Definition
A.Spondyloarthropathies are a group of inflammatory conditions that affect the axial skeleton and also may have multisystem effects.
B.Inflammatory arthritis of the spine and sacroiliac joints, asymmetric oligoarthritis of the peripheral joints, and inflammation at sites where tendon and ligament insert into bone (enthesopathy) characterize spondyloarthropathies.
C.Spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and arthritis associated with inflammatory bowel disease.
D.Also known as seronegative spondyloarthropathies.
E.Clinical presentation and diagnostic evaluation are similar for the seronegative spondyloarthropathies.
Incidence
A.Males are more often affected.
B.Onset is typically before age 40.
C.Ankylosing spondylitis is common to manifest in late teens and early 20s.
Pathogenesis
A.The cause of spondyloarthropathies is not well understood.
B.It appears to be a genetic relationship to human leukocyte antigen (HLA)-B27.
C.Some theories exist that attribute microbial exposure as a possible cause; for example, chlamydia-induced arthritis, psoriatic arthritis, and the development of arthritis in patients with Crohn’s disease and ulcerative colitis.
Predisposing Factors
A.Male.
B.Genetic predisposition.
C.Bacterial infections.
Subjective Data
A.Common complaints/symptoms.
1.Low back pain more than 3 months’ duration.
a.Back pain may also have an inflammatory pattern,
which is insidious onset often before age 40. It improves with exercise, but not rest and nocturnal pain.
b.Also characteristic can be relief of pain within 24 to 48 hours of taking nonsteroidal anti-inflammatory drugs (NSAIDs).
2.Peripheral arthritis will affect the knees and ankles predominantly, and will often be asymmetrical, affecting one to three joints.
3.Ocular complaints include redness, pain, and photophobia. These may be the first presenting symptoms of spondyloarthropathy.
B.Common/typical scenario.
1.Ankylosing spondylitis will progress in cephalad direction with limited chest expansion.
2.Heart disease characterized by atrioventricular conduction defects and aortic regurgitation will manifest in severe disease.
3.Constitutional symptoms are typically absent.
4.Psoriatic arthritis may present with symmetric polyarthritis similar to rheumatoid arthritis. Pitting of the nails and onycholysis is common.
5.Reactive arthritis (formerly Reiter syndrome) will present with oligoarthritis, conjunctivitis, urethritis, and mouth ulcers. Patients will often report a history of gastrointestinal (GI) or sexually transmitted infections. Systemic symptoms such as fever and weight loss are more common.
C.Family/social history.
1.Family history.
a.Spondyloarthropathies.
b.Inflammatory bowel disease.
2.Social history.
a.Sexual activity.
b.Exercise.
D.Review of systems.
1.Back pain.
2.Joint pain.
3.Swelling.
4.Eye pain.
5.Eye redness.
6.Mucosal ulcers.
7.Rashes.
8.Changes in nails.
9.Vomiting.
10.Bowel changes.
11.Diarrhea.
12.Dysuria.
13.Genital discharge.
14.Fever.
15.Weight loss.
Physical Examination
A.Musculoskeletal findings include the following.
1.Decreased range of motion in the back over time.
2.Edema in peripheral arthritis.
3.Enthesitis most commonly in the heel or Achilles tendon, but can be seen at the following.
a.Iliac crests.
b.Greater trochanters.
c.Epicondyles, tibial plateaus.
d.Costochondral junctions of the sternum.
e.Humeral tuberosities, manubrial-sternal joints.
f.Occiput.
g.Spinous processes.
4.Dactylitis is a characteristic feature of spondyloarthropathies, especially psoriatic arthritis and less frequently reactive arthritis. The physical finding is also known as sausage toe or sausage finger
and is characterized by swelling of the entire digit without pain or tenderness.
5.Ocular findings include nonpurulent conjunctivitis and anterior uveitis.
6.Dermatologic findings include psoriasis and pitting nails, particularly in patients with peripheral joint manifestations.
Diagnostic Tests
A.No laboratory tests are specific for spondyloarthropathies.
B.HLA-B27: 90% of patients with ankylosing spondylitis and 50% to 70% of patients with other types of spondyloarthropathies will be positive.
C.Negative rheumatoid factor.
D.Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are elevated in 35% to 50% of patients. They are also used to assess radiographic progression and response to therapy.
E.Uric acid levels may be high with psoriatic arthritis.
F.Synovial fluid cultures in reactive arthritis are negative.
G.Axial radiographs: Findings of sacroiliitis including erosions, ankylosis, changes in joint width, or sclerosis, are specific for spondyloarthropathies; however, it takes several years to be visible on radiograph. Syndesmophytes can develop on the spine.
H.MRI can be useful in patients with nonradiographic evidence of spondyloarthropathies.
I.Ultrasound has been used to confirm enthesitis.
Differential Diagnosis
A.Degenerative disc disease.
B.Kyphosis.
C.Spine fractures, dislocations.
D.Osteoarthritis.
E.Spinal stenosis.
Evaluation and Management Plan
A.General plan.
1.Reduce swelling and pain.
2.Treat infectious processes and skin disorders.
B.Patient/family teaching points.
1.Encourage exercise.
C.Pharmacotherapy.
1.NSAIDs (use in caution in patients with inflammatory bowel disease).
2.Tumor necrosis factor (TNF) inhibitors have been used for NSAID refractory cases for ankylosing spondylitis and methotrexate refractory cases of psoriatic arthritis. Both may also be used for reactive arthritis.
3.Methotrexate is used in psoriatic arthritis to treat both cutaneous and arthritic manifestations.
4.Monoclonal antibody therapy has been used in psoriatic arthritis patients who do not respond to TNF inhibitors.
5.Sulfasalazine for peripheral arthritis.
6.Psoralen and ultraviolet A (PUVA) therapy for psoriasis skin lesions.
7.Antibiotics may be needed to treat GI or genitourinary infections in patients with reactive arthritis.
Follow-Up
A.Interval follow-up is necessary to monitor medication safety and patient’s response to therapy.
Consultation/Referral
A.Physical therapy for exercise regimens.
B.Dermatology for skin manifestations.
C.Gastroenterology for GI manifestations.
D.Ophthalmology for ocular manifestations.
E.Infectious disease for sexually transmitted infections or other infectious diseases.
Special/Geriatric Considerations
A.Markers of disease progression and treatment do not appear to be age-related.
B.Standard precautions in the elderly related to pharmacokinetics still apply.
Bibliography
Hannon, R. A., & Porth, C. M. (2017). Porth pathophysiology: Concepts of altered health states (2nd ed.). Philadelphia, PA: Wolters Kluwer.
Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2016). Current medical diagnosis & treatment 2016. New York, NY: McGraw Hill Education.
Yu, D. T., & van Tubergen, A. (2018, September 7). Overview of the clinical manifestations and classification of spondyloarthritis. In P. L. Romain (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-clinical-manifestations-and-classification-of-spondyloarthritis?source=search_result&search=spondyloarthropathy&selectedTitle=1
Yu, D. T., & van Tubergen, A. (2019, January 1). Pathogenesis of spondyloarthritis. In P. L. Romain (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/pathogenesis-of-spondyloarthritis?source=search_result&