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What are the Seronegative Spondyloarthropathies?
The seronegative spondyloarthropathies are a heterogeneous group of disorders that consist of ankylosing spondylitis, reactive arthritis (formerly known as Reiter syndrome), enteropathic arthritis, and psoriatic arthritis. Manifestations vary widely among these conditions, but common features include a genetic predisposition, the potential for an infectious trigger, the presence of enthesitis (inflammation at the attachment site of tendon to bone), and extra-articular involvement. The results of serologic studies, including rheumatoid factor assays, are characteristically negative in affected patients.
What is a characteristic pathogenesis of the spondyloarthropathies?
T-cell activation is characteristic of the pathogenesis of the spondyloarthropathies, particularly psoriatic arthritis.
What is a good test to monitor loss of lumbar flexion in ankylosing spondylitis?
The Schober test
The Schober test is performed by locating the bilateral indentations of Venus in the posterior area, and measure 10 cm above and 5 cm below. When pt bends forward, this 15 cm line should extend by 5 cm. A decrease in this extension should make you suspicious of decreased L-spine flexion
What is the cardinal feature of the spondyloarthropathies?
The cardinal feature of the spondyloarthropathies is enthesitis with subsequent reactive new bone and spur formation.
A pt who is less than 40 years of age, now presenting with persistent low back pain accompanied by morning stiffness should raise suspicion for what?
Spondyloarthropathy, particularly ankylosing spondylitis
Describe the onset and diagnosis of ankylosing spondylitis
- The onset of ankylosing spondylitis is marked by persistent low back pain and occurs in the teenage years or 20s. The inflammatoryspinal disease typically progresses cephalad and results in a characteristic stooped posture and loss of spinal mobility seen in late disease
- Early in the disease course, plain radiographs of the pelvis and spine are normal. At this stage, patients with suspected disease should undergo MRI of the sacroiliac joints to detect early inflammatory and erosive changes.
What is reactive arthritis?
- Reactive arthritis is an inflammatory arthritis that presents within 2 months of an episode of bacterial gastroenteritis or nongonococcal urethritis or cervicitis in a genetically susceptible patient.
- Acute episodes of reactive arthritis typically resolve within 4 to 6 months. In some patients, these episodes recur or evolve into a chronic destructive arthritis or progressive spinal disease. Approximately 10% to 50% of affected patients have recurrent or progressive disease.
What are other extra-articular manifestations of enteropathic arthritis?
Additional extra-articular manifestations of enteropathic arthritis include inflammatory eye disease and cutaneous lesions (particularly erythema nodosum) and occur in up to 20% of patients with this condition. The course of these extra-articular manifestations typically parallels peripheral joint and bowel inflammation.
What is the first-line therapy in ankylosing spondylitis?
- Tumor necrosis factor (TNF) α inhibitors are currently first-line therapy in ankylosing spondylitis. These agents are the first therapy to significantly suppress inflammation in the axial skeleton and therefore improve back pain and potentially halt progressive ankylosis with the subsequent loss of mobility and function.
- Traditional immunosuppressants, such as methotrexate or sulfasalazine, benefit patients with peripheral joint and extra-articular disease but are not effective for spinal involvement.
- Exercise (including physical therapy) and NSAIDs, once the primary therapeutic options in ankylosing spondylitis, are still indicated for symptomatic and functional improvement.
What is the treatment for Reactive arthritis?
- Despite the association between reactive arthritis and bacterial infection, antibiotics are indicated primarily for acute infection and generally are of dubious benefit for reactive joint disease.
- In some studies, a 3-month trial of minocycline or a similar agent was shown to improve the clinical course of reactive arthritis, particularly when this condition was associated with Chlamydia infection.
- NSAIDs are first-line therapy for symptom management in reactive arthritis. Corticosteroid therapy (topical, intralesional, or intra-articular) is useful for skin lesions, eye involvement, and acute arthritis or enthesitis in this setting.
- Disease-modifying agents such as sulfasalazine or methotrexate can be beneficial in recurrent or chronic inflammatory disease.
- TNF-α inhibitors should be considered only if other interventions are ineffective or if patients have significant axial skeleton involvement or severe disease.
What is the treatment for enteropathic arthritis?
- The immunosuppressive therapies that benefit intestinal disease in enteropathic arthritis also have efficacy in the treatment of the associated peripheral joint and extra-articular manifestations. These therapies include corticosteroids, sulfasalazine, azathioprine, methotrexate, and the TNF-α inhibitors infliximab and adalimumab. Etanercept has not shown efficacy in treating bowel symptoms in this setting.
- In patients with predominantly axial skeleton disease, TNF-α inhibition should be considered even if the bowel disease is quiescent.
What is the treatment for psoriatic arthritis?
Methotrexate is beneficial for both skin and joint disease and has dominated therapy for many years. TNF-α inhibitors increasingly have been shown to be effective in psoriatic arthritis and are the preferred intervention for patients with predominant spondylitis. Leflunomide, sulfasalazine, and cyclosporine also have been used to treat psoriatic arthritis. Rarely, hydroxychloroquine has been associated with flares in skin disease.