Brief Overview of Polyarticular Arthritis and Spondyloarthropathy
June 22, 2006 GM 3
Definitions
Monoarticular = 1 Oligoarticular = > 1 and = 4 Polyarticular….guess
H&P
History - preceding illness/trauma? - prior episodes? - family history of arthritis or back pain? - pattern of evolution? - which joints? Symmetrical? - additive vs migratory? - pattern of pain?
Physical - Soft tissue swelling/effusion - Normal joints - Systemic findings - Spine & muscles in addition to joints
Labs - Hematologic & biochemical - ESR/CRP - Antibody tests for exposure - Autoantibody tests Other - Synovial fluid analysis - Imaging studies - Biopsy of the synovium
Acute Inflammatory
Rheumatic Fever 2. Septic Arthritis 3. Gonococcal/Meningococcal 4. Lyme disease 5. Bacterial Endocarditis 6. Mycobacterial/Fungal 7. Viral 8. Crystal Induced 9. Palindromic Rheumatism and FMF 10. RS3PE syndrome 11. Acute Leukemia in Children 12. Sarcoid Arthritis
1.
Subacute/Chronic
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Rheumatoid arthritis Seronegative Spondyloarthropathy Juvenile Chronic Polyarthritis and Still’s Disease Whipple’s disease Intestinal Bypass Surgery SLE Drug-induced Lupus Other systemic Rheumatic diseases Behcet’s Disease Relapsing Polychondritis
Seronegative Spondyloarthropathies
“Spondyloarthropathy” family/spectrum of diseases that share certain clinical features a. predilection for axial inflammation b. asymmetric arthritis c. enthesitis d. genital and skin lesions e. eye and bowel inflammation f. association w/ preceding or current infection g. strong association w/ HLA B27
Family
1. 2. 3. 4. 5. 6. 7.
“Undifferentiated Spondyloarthropathy” Ankylosing spondylitis Reactive Arthritis Reiter’s Syndrome Spondyloarthropathy Associated w/ Psoriasis “ “ “ Crohn’s Dz & UC Juvenile Onset Ankylosing Spondylitis
Clinical Manifestations
MUSCULOSKELETAL: 1. Peripheral Arthritis: asymmetric oligoarthritis 2. Enthesopathy: insertions sites, highly vascular New Bone Formation Sausages Achilles Chest Wall 3. Inflammatory Spine Pain GENITAL, SKIN, MUCOSA: 1. Circinate Balanitis 2. Keratoderma Blennorrhagica 3. Nonspecific Urethritis 4. Superficial Oral Ulcers
Cont.
INFLAMMATORY EYE: 1. Conjunctivitis 2. Iritis INFLAMMATION OF THE BOWEL MUCOSA: 1. 2/3’rds, usually clinically silent 2. Acute vs Chronic 3. Similarities w/ Crohn’s CARDIOVASCULAR: 1. Aortic regurg 2. Prolongation of the PR
Cont.
AMYLOIDOSIS, SECONDARY: 1. Life threatening 2. Control Inflammation
EVIDENCE OF INFECTION: 1. Reactive: within 4-6 wks 2. 2. GU: Chlamydia Trachomatis 3. 3. Diarrhea: Shigella, Salmonella, Campylobacter, Yersinia
LABS & IMAGING
1. Bacterial Infection 2. HLA B-27 - 20-fold increased risk 3. HIV 1. Peripheral Joints 2. Sacroiliac Joints 3. Syndesmophytes
Criteria:
SPONDYLOARTHROPATHY: ESSG 1. Inflammatory Spinal Pain or, 2. Synovitis: asymmetric or predominately in lower limbs and 1 or more: Positive Family History Psoriasis IBD Urethritis, cervicitis, or acute diarrhea w/in 1 mo Alternating buttock pain Enthesopathy Sacroiliitis
EARLY DIAGNOSIS!
1.
2.
IS INFLAMMATORY SPINE PAIN PRESENT? -insidious -3 mo duration -AM stiffness -improved w/ exercise -onset before 40 y/o ARE THERE 2 OR MORE OTHER FEATURES? -alternating buttock pain -enthesitis, arthritis, dactylitis -acute anterior uveitis, IBD -psoriasis, acute phase markers -HLA-B27 -spondylitis or sacroiliitis on films -family history
TREATMENTS
1.
2. 3. 4. 5. 6.
STEROIDAL AND NSAIDs ANTIBIOTICS SULFASALAZINE MTX OTHER DMA’s ANTI-TNF