SPONDYLOARTHROPATHIES

I. Definition--a heterogeneous family of chronic inflammatory arthritides affecting both spinal and non-spinal joints with the following common features:

  1. Involvement of spinal ("spondylitis") and SI joints
  2. When present, non-spinal involvement usually asymmetric, migratory, or oligoarticular
  3. Involvement of tendon insertion sites (enthesopathy)
  4. "Sausage digits"
  5. Extra-articular features include uveitis and aortitis
  6. Male predominance (for some subsets)
  7. Us. negative for rheumatoid factor
  8. Strong association w/Class I HLA antigens, e.g. HLA-B27
  9. Infectious agents appear to be involved in pathogenesis (for some subsets)

II. Specific syndromes

  1. Ankylosing spondylitis
    1. Prevalence 0.1%; male: female 3:1; rare in people of African descent
    2. Predominantly afects the spine; can get fusing of vertebrae
  2. Reiter's syndrome
    1. Often follows with nongonococcal urethritis, esp. chlamydia
    2. Oligoarticular arthritis
    3. Often accompanied by conjunctivitis and mucocutaneous or skin lesions
    4. Usually self-limited, lasting 3-12mos
    5. Chronic sx occur in 15-20%
  3. Psoriatic arthritis
    1. Usually peripheral arthritis
    2. Seen in about 7% of pts with cutaneous psoriasis
    3. Usually accompanied by nail pitting
  4. Reactive arthritis
    1. Clinically similar to Reiter's
    2. Follows enteritis from Shigella, Salmonella, Yersinia, or Campylobactor
    3. Usually self-limited, lasting 3-12mos
    4. Chronic sx occur in 15-20%
  5. Enteropathic arthritis
    1. Associated with inflammatory bowel disease (20% get arthropathy; 10% get spondylitis)
    2. Arthropathy sx us. not correlated w/bowel sx
  6. "Undifferentiated spondyloarthropathy"
    1. For pts without evident coexisting psoriasis, enteric infection, or enteropathy and without clinical features of Reiter's or ankylosing spondylitis

III. Pathophysiologic features

  1. Mononuclear inflammation of synovium, periarticular bone, cartilage, and joint capsule
  2. Ossification of tendon entheses
  3. Radiographs may be normal but can show narrowing or irregularity of SI joint
  4. Lab abnormalitis include increased ESR and CRP and occasionally, mild anemia

IV. Treatment

  1. Similar to treatment of Rheumatoid Arthritis: NSAIDs alone in mild cases, DMARD's when more severe, systemic steroids for brief periods in flares or chronically as a last resort
    1. Note that hydroxychloroquine in psoriatic arthritis may in rare cases lead to flare of cutaneous psoriasis
  2. Physical therapy for spine ROM

 

(Source: Chapter by Phil Mease in handout form dated 1994)