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HLA-B27
MANIFESTARI CLINICE
1.Manifestari axiale
Teste de evaluare a mobilitatii coloanei vertebrale :Testul Schober modificat-pozitiv cand distanta dintre
pct e mai mica de 4 cm
2.Manifestari periferice
Artrita periferica:hip,shoulder,knee
Dactilita:
3.Manifestari extrascheletale
Generale:
Investigatii :
Testul Chest expansion measurement:in full expiration and inspiration :diferenta fiziologica peste 5
cm,cea patologica sub 2cm
Diagnostic pozitiv:
1.Criterii clinice:
2.Criteriul radiologic
Tratament:
Non-farmacologic:kinetoterapie,masaj,cure-cel mai important tratament
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Epidemiology
References: [1][2]
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Etiology
References: [1]
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Clinical features
Articular symptoms
Most common presenting symptoms: back and neck pain
Gradual onset of dull pain that progresses slowly
Morning stiffness that improves with activity
Pain is independent of positioning, also appears at night
Tenderness over the sacroiliac joints
Limited mobility of the spine (especially reduced forward lumbar flexion)
Inflammatory enthesitis (e.g., of the Achilles tendon, iliac crests, tibial tuberosities):
painful on palpation
Dactylitis
Arthritis outside the spine: hip, shoulder, and knee joint
Extra-articular manifestations
Most common: acute, unilateral anterior uveitis (∼ 25% of cases)
Gastrointestinal symptoms: associated with chronic inflammatory bowel disease (∼ 5–
10% of cases, see also: colitis ulcerosa or Crohn's disease)
Prostatitis
Fatigue, weakness, fever, weight loss
Restrictive pulmonary disease due to decreased mobility of the spine and thorax
Rare
Cardiac: aortic valve insufficiency, atrioventricular blocks
Kidney: IgA-nephropathy
References: [1][2]
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Diagnostics
Diagnostic approach
1. Physical examination, patient history, and pelvic x-ray: If results are conclusive, no
additional testing is required!
2. If inconclusive → HLA-B27 testing
3. If still inconclusive → pelvic MRI
Clinical tests
Chest expansion measurement: in full expiration and inspiration
Pathological difference: < 2 cm
Physiological difference: > 5 cm
Spine mobility tests
Examination of the hip[3]
Mennell sign: tenderness to percussion and pain on displacement of the sacroiliac joints
FABER test: FABER (Flexion, ABduction, and External Rotation) provokes pain in
the ipsilateral hip
Laboratory findings
↑ CRP and ESR
Auto-antibodies (e.g., rheumatoid factor, antinuclear antibodies) are negative
HLA-B27 positive in 90–95% of cases
However, < 5% of HLA-B27 positive individuals have ankylosing spondylitis.
Imaging
X-ray
Can help confirm a diagnosis or evaluate the severity of disease, but is not required for
the diagnosis
Changes are generally more evident in later disease
Sacroiliac joints: signs of sacroiliitis, including ankylosis of sacroiliac joints
Spine
Loss of lordosis with increasing abnormal straightening of the spine
Sclerosis of the vertebral ligamentous apparatus
Syndesmophytes resulting in a so-called 'bamboo spine' in anteroposterior radiograph in
the later stages (see the table in “Differential diagnosis” below)
Signs of spondyloarthritis, including ankylosis of intervertebral joints[4]
Mild courses may only exhibit inflammatory changes in the sacroiliac joints on x-ray after a
number of years.
MRI[5]
References: [1][6][7]
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Differential diagnoses
Disc prolapse
Vertebral osteomyelitis
Other spondyloarthritides (e.g., reactive arthritis, psoriasisarthritis, arthritis associated
with inflammatory bowel disease)
Diffuse idiopathic skeletal hyperostosis (DISH; also called Forestier's
disease or hyperostotic spondylosis)
Definition: degenerative disease of the vertebral column(especially the thoracic and
lumbar spine), which is characterized by calcification and ossification of spinal ligaments
and entheses
Epidemiology
Not related to HLA-B27[8]
Mostly affects men
Common in patients with diabetes
Clinical presentation
Limited mobility
Mild or even no pain at all
Diagnosis:
X-ray of the spine
Formation of osteophytes (see table below)
No sacroiliitis
Treatment: symptomatic
Osteophytes of the spine
Syndesmophytes Osteophytes
Ossification or calcification of the annulus
Definition Lipping of vertebral bodies
fibrosus or a spinal ligament
Radiograp Symmetrical, vertical growth, directly from Horizontal growth
hic vertebral body to vertebral body
features Full manifestation: "bamboo spine”
Etiology Inflammatory spinedisease (e.g., ankylosing sp Degenerative spinedisease (e.g., d
ondylitis) iffuse idiopathic skeletal
hyperostosis)
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Treatment
Physical therapy
Consistent and rigorous physical therapy
Independent exercises
Medical therapy
First choice: NSAIDs (e.g., indomethacin)
Additional options
Tumor necrosis factor-α inhibitors (e.g., etanercept) [12]
In case of peripheral arthritis: DMARDs (especially sulfasalazine)
In severe cases: temporary, intra-articular glucocorticoids
Surgery: in severe cases to improve quality of life
Indication:
Severe deformity of the spinal column
Instability of the spine
Neurologic deficits
Procedures:
Osteotomy
Joint replacement
Spinal fusion
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Complications
References: [1][2]
Manifestari clinice:
Sindrom SAPHO(synovitis,acne,pustulosis,hypersostosis,osteomyelitis)
2.musculo-scheletale
Entezita
Tenosinovita
Dactilita
3.extrascheletale
Complicatii metabolice(DZ,obezitate),boli CV
Investigatii
PCR,VSH crescute
HLA-B27-limitata
Rx maini si picioare:pencil-in-cup
Rx coloana:sacroileita unilaterala/asimetrica,parasindesmofite,sindesmofite
ECO:artrite periferice,dactilita,entezite
Tratament
Artrita reactiva
Autoimuna care apare in urma unei infectii bacteriene pe TGI sau urinar.
Etiologie
Post-veneriana:Chlamydia
Post-enterala:Shigella,Yersinia,Salmonella,Campylobacter
Manifestari clinice
Musculoscheletale:
Entezita
Sacroiliita,spondilita
Tendinite,tenosinovite
Extraarticulare:
Oculare:conjunctivita,uveita
Gastrointestinale:diaree
Renale:proteinuria,microhematuria,nefropatia cu IgA
Cardiac
Diagnostic
VSH.CRP crescute
Leucocite crescute
HLA-B27 limitata
ECO,IRM RX
Antibiotice
Artrita enterale
Apare in BII
2 FORME:
Spondilita:Colita ulceroasa
Tratament
CORTICOSTEROIZI-intraarticular
DMADS
ANTI-TNF alpha