Spondyloarthropathies

Ankylosing spondylitis:

• Most common form of SpA, Males > Females

• Morning stiffness + pain improves with exercise + pain awakening at night +
alternating buttock pain → Inflammatory back pain
• Pre-radiographic stage (non-radiographic axial SpA) → Back pain only
Radiographic stage (AS) → Back pain + radiographic sacroiliitis + syndesmophytes
• MRI detects active SI joint inflammation + bone marrow oedema (BMO)
• Untreated uveitis can lead to synechia (iris stuck to cornea/lens), glaucoma,
blindness. [Uveitus can be presenting symptom of AS]
• Also: IBD, aortitis, heart block, restrictive lung disease, apical fibrosis, osteoporosis

Reactive Arthritis:

• Occurs within 1 month of infection (GU → M>F) (GI → M=F); lasts 4-5 months
• Arthritogenic peptide hypothesis (molecular mimicry) → activated T-cells cross-react
with self antigen peptides (Cartilage, PGs) after bacteria is cleared
• Environmental bacterial trigger is necessary for HLA-B27 to develop SA
• Triad + inflammatory eye disease, circinate balanitis, oral ulceration, keratodermia
blennorhagica (similar to psoriasis), enthesopathy, sacroiliitis, reiter’s nails
• Inflammation in GU tract has tendency to relapse

Psoriatic Arthritis:

• No sex predominance; type I (familial; <40yo) vs type II (non-familial; >40yo)

• Patterns: oligo/polyarticular asymmetric arthritis; symmetric polyarthritis (RA-like
pattern); predominant DIP joint involvement; arthritis mutilans
• Can develop sacroiliitis (bilateral, asymmetric) and/or spondylitis (no
syndesmophytes or squaring) → radiologically similar to Reiter’s syndrome
• Also: ocular inflammation (conjunctivitis, iritis), urethritis, aortic valve disease
• Associated with HIV (sudden onset, rapid evolution, severe arthritis)
[HIV → Reactive arthritis, psoriatic arthritis, undifferentiated SpA)
Enteropathic Arthritis:

• AS more common with Chron’s than UC

• Pathogenic link between gut inflammation and AS
• Peripheral arthritis predominates in lower limbs (usually pauciarticular, asymmetric)
NO HLA-B27 ASSOCIATION
• Axial arthritis (similar to AS, M>F) → silent sacroiliitis
• Also: acute anterior uveitis, erythema nodosum, apthous stomatitis, pyoderma
gangrenosum, secondary amyloidosis
• Arthritis in other GI conditions: whipple’s disease (NO HLA-B27), celiac disease (NO
HLA-B27), collagenous colitis (thickening of subepithelial collagen in elderly female)

Treatment of SA:

• Exercise / physical therapy / hydrotherapy

• Avoid splints, braces, corsets
• Smoking cessation
• NSAIDs
• Muscle relaxants
• Local steroid injections
• DMARDs: Sulfasalazine, MTX, anti-TNF