Rheumatology [SPONDYLOARTHROPATHIES]

Introduction
This group of diseases are unique in that they show a predilection HLA-B27 doesn’t help - DON’T order it.
for the spine, particularly the sacroiliac joints, and have a higher UNLESS you have a clear diagnosis of ankylosing
incidence in men (much unlike the majority of rheumatologic spondylitis despite negative films (x-ray and MRI)
diseases). There’s a correlation to HLA-B27 but it isn’t useful for
diagnosis. These patients are seronegative: they have no RF, RF, CCP, ANA don’t help - DON’T order them.
CCP, or ANA reactive antibodies. What separates them from each
other is their extra-articular involvement and links to other
inflammatory conditions.

1) Ankylosing Spondylitis 32 year old man with lumbar stiffness in the morning who
Ankylosing spondylitis is the most commonly tested seronegative gets an x-ray showing ‘any positive finding’ of the lumbar
arthropathy. It occurs in men in their 20s and 30s. They will have spine. The vignette should NOT include something about
lower back pain with morning stiffness that improves with use. diarrhea.
It’s caused by sacroiliitis with fusion of the sacral joints and
calcification of tendons, which produces the bamboo spine on X- Start him on NSAIDs and escalate to Methotrexate.
ray. Other tendons can calcify as well - especially the Achilles Monoclonal antibodies CAN be used to treat the pain (unlike
tendon. It can be associated with inflammatory bowel disease all other seronegatives).
(distracting towards enteropathic) but its course is different. The
treatment is based on severity and presence of axial vs peripheral TNF-Alpha-Inhibitors
joint involvement. Therapy generally starts with NSAIDs, Etanercept
escalates to Methotrexate, and if all else fails moves to Infliximab
monoclonal antibodies (TNF-alpha inhibitors) like Etanercept. Adalimumab

2) Reactive Arthritis
People with HLA-B27 who also get nongonococcal urethritis Gonococcal Urethritis = Septic Arthritis (one joint)
(usually Chlamydia) will “react” and develop an asymmetric
bilateral arthritis of the lower back and hands as well as a Non-Gonococcal Urethritis + Arthritis = Reactive Arthritis
conjunctivitis. Treating the underlying infection will prevent this (back and hands)
acute disease from transforming into chronic. Treat the
Chlamydia with doxycycline and arthritis with NSAIDs. Urethritis + Arthritis + Uveitis = Reiter’s Syndrome

3) Psoriatic Arthritis
Psoriasis + Arthritis is psoriatic arthritis. The main joint involved NSAIDs: Mild arthritis and no / ‘meh’ skin findings
will be in the hands. It’s a symmetric PIP and DIP arthritis with Methotrexate: Severe arthritis and real skin findings
erosive pitting of the nails. The arthritis may precede the TNF-a Inhibitors: Nonresponsive to Methotrexate
psoriatic plaques (making the diagnosis difficult). The goal is
symptom control with NSAIDs if there’s mild arthritis and NO Steroids: no... Steroids bad and lead to flare of psoriasis
skin disease. Use Methotrexate if it’s severe or there are skin
findings, Anti-TNF if Methotrexate resistant.

4) Enteropathic / IBD-Associated
While ankylosing spondylitis is associated with, but independent
of IBD’s course, this disease directly correlates with IBD. See how this is different from Ankylosing Spondylitis?
Treating the IBD fixes the arthritis. The arthritis is symmetric Treating IBD makes this better. Treating IBS in AS does not.
and bilateral, non-deforming, peripheral (fingers), and
migratory. It also involves the lower back. The person will have
some history of diarrhea to tell you they have IBD.
Disease Presentation Diagnosis Extraarticular Treatment
Ankylosing Back Pain + Morning Stiffness Bamboo spine IBD but independent of NSAIDs
Spondylitis relieved by exercise on X-ray IBD course Steroids
(Sacroiliitis) Anti-TNF
Reactive Nongonococcal Urethritis Ø Nongonococcal Doxycycline
Arthritis Conjunctivitis PCR/DNA Chlamydia Urethritis and
Asymmetric Bilateral Arthritis (usually Chlamydia) NSAIDs
Psoriatic Psoriatic Patches Ø Psoriasis UV light
Arthritis Erosive pitting of nails Arthritis may appear NSAID (no skin)
MCP, DIP, PIP Arthritis first Methotrexate (skin)
Enteropathic Non-deforming, migratory, Ø IBD and dependent of Tx IBD with ASA
Arthritis symmetric Bilateral Arthritis IBD course compounds
In a patient with IBD (mesalamine)