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Spondilita anchilozanta

Boala inflamatorie cronica-debut insidios

Duce la o fuziune partiala/totala a scheletului axial

Frecvent,barbatii

HLA-B27

Manifestarea caracteristica:durere si redoare la nivelul gatului si coloanei lombare

Factori de prognostic negativ:

MANIFESTARI CLINICE

1.Manifestari axiale

Lombalgia inflamatorie(datorita sacroileitei)

Limitarea progresiva a coloanei vertebrale in toate planurile

Teste de evaluare a mobilitatii coloanei vertebrale :Testul Schober modificat-pozitiv cand distanta dintre
pct e mai mica de 4 cm

Modificari de postura caracteristice:stergerea lordozei lombare,aplatizarea toracelui,bombarea


abdomenului,cifoza dorsala inalta,protruzia capului.

Dureri torace anterior cu limitarea expansiunii toracice

2.Manifestari periferice

Artrita periferica:hip,shoulder,knee

Entezite:durere la palpare:tendonul lui Achille,crestele iliace,tuberozitatea tibiala

Dactilita:

3.Manifestari extrascheletale

Commune:oculare(uveita anterioara),cutanate(psoriazis,eritem nodos,pyoderma


gangrenosum),intestinale(BII)

Rare:cardiace,pulmonare(boala pulmonara restrictive),renale,neurologice

Generale:
Investigatii :

Ex.obiectiv,istoric si Rx pelvic:diagnostic fara alte investigatii

Daca rezultatul nu e concluziv :atunci HLA-B27

Daca rezultatul nu e concluziv:atunci IRM pelvin

PCR,VSH –valoare limitata

Autoanticorpii sunt negativi

HLA-B27 pozitivi in maj cazurilor

Rx:sacroileita bilaterala,simetrica merge spre anchiloza

Coloana vertebrala:vertebra patrata,vertebra cu colturi stralucitoare,sindesmofite,coloana de bambus

Nu e util in stadiul precoce!!!

IRM:utila in stadiile precoce

Edem osos-leziune definitorie pt sacroileita

CT:metoda de electie pt diagnosticul complicatiilor

ECOGRAFIA:articulatii periferice, enteze

Testul Chest expansion measurement:in full expiration and inspiration :diferenta fiziologica peste 5
cm,cea patologica sub 2cm

Teste de mobilitate spinal

Examinarea coapsei:Mennell sign:

FABER test:flexion,abduction,external rotation:provoaca durere in coapsa de aceeasi


parte

Diagnostic pozitiv:

Criteriile de la New York

1.Criterii clinice:

2.Criteriul radiologic

Tratament:
Non-farmacologic:kinetoterapie,masaj,cure-cel mai important tratament

Medicamentos:AINS(indomethacin,diclofenac)+/-corticosteroizi(cazuri severe),sulfasalazine(pt artrita


periferica)

Terapie biologica:TNF-alpha(reduc durerea,dar nu progresia bolii),IL-17

Chirurgical:artroplastia totala de sold

Ankylosing spondylitis (spondyloarthritis) is a chronic inflammatory disease of the axial


skeleton that leads to partial or even complete fusion and rigidity of the spine. Males are
disproportionately affected and upwards of 90% of patients are positive for the HLA-
B27 genotype, which predisposes to the disease. The most characteristic early finding is pain and
stiffness in the neck and lower back, caused by inflammation of the vertebral column and
the sacroiliac joints. The pain typically improves with activity and is especially prominent at
night. Other articular findings include tenderness to percussion and displacement of
the sacroiliac joints (Mennell's sign), as well as limited spine mobility, which can progress
to restrictive pulmonary disease. The most common extra-articularmanifestation is acute,
unilateral anterior uveitis. Diagnosis is primarily based on symptoms and x-ray of the sacroiliac
joints, with HLA-B27 testing and MRI reserved for inconclusive cases. There is no curative
treatment, but regular physiotherapy can slow progression of the disease.
Additionally, NSAIDs and/or tumor necrosis factor-α inhibitors may improve symptoms. In
severe cases, surgery may be considered to improve quality of life.

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Epidemiology

 Sex: ♂ > ♀ (3:1)


 Age: 15–40 years
 Lifetime prevalence in the US: ∼0.5%

References: [1][2]

Epidemiological data refers to the US, unless otherwise specified.

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Etiology

 Genetic predisposition: 90–95% of patients are HLA-B27positive.

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]

 More sensitive method of detecting sacroiliitis


 Best method for early detection

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)

Syndesmophytes grow vertically, as opposed to osteophytes, which grow horizontally!


References: [9][10][11]

The differential diagnoses listed here are not exhaustive.

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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

Physical therapy is the most important treatment modality!


References: [1][13]

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Complications

 Complete fusion of the spine → severely limited mobility


 Increased risk of osteoporosis → pathological fractures
 Restricted chest expansion and spine mobility → breathing difficulties

References: [1][2]

We list the most important complications. The selection is not exhaustive.


Artrita psoriazica

=inflamatia articulatiiilor(in principal maini,picioare,coloana) care insoteste psoriazisul

Manifestari clinice:

1.cutanate:apar inaintea manifestarilor articulare in majoritatea cazurilor

Leziuni psoriazice:placi eritematoase localizate : pe suprafetele extensoare genunchi,coate

Sindrom SAPHO(synovitis,acne,pustulosis,hypersostosis,osteomyelitis)

Leziuni unghiale:se asociaza cu afectarea IFD si cu o forma de artrita progresiva

2.musculo-scheletale

Majoritatea au afectare periferica,oligoartrita asimetrica:tipic cu implicarea IFD si IFP(fata de artrita


reumatoida ,articulatiile metacarpofalangiene nu sunt implicate)

Entezita

Tenosinovita

Dactilita

3.extrascheletale

Uveita anterioara acuta,recurenta/uveita anterioara si posterioara,cronica,bilaterala

Complicatii metabolice(DZ,obezitate),boli CV

Investigatii

PCR,VSH crescute

FR,anticorpi anti-CCP negative

HLA-B27-limitata

Rx maini si picioare:pencil-in-cup

Rx coloana:sacroileita unilaterala/asimetrica,parasindesmofite,sindesmofite

IRM:pt stadiul precoce al sacroileitei,pt dactilita,entezita,artrita

ECO:artrite periferice,dactilita,entezite
Tratament

Predominant periferica:boala usoara-AINS

Boala moderata-severa:AINS,corticosteroizi topic,DMARDs,Terapia biologica:TNF-


alpha,anti IL-17,anti-IL23/IL-12

Axiala:boala usoara:masuri generale,AINS

Boala moderata-severa:masuri generale,AINS,anti TNF-alpha,anti-IL17

Artrita reactiva

Autoimuna care apare in urma unei infectii bacteriene pe TGI sau urinar.

Este asociata cu HLA-B27=spondilartrita seronegativa

Afecteaza barbatii tineri

Se prezinta cu simptome musculoscheletale si extraarticulare

Triada caracteristica:artrita,conjunctivita si uretrita(un nr mic de pacienti au triada clasica)

Nu exista teste specifice pt artrita reactiva

Tratament este symptomatic si consta in AINS,majoritatea se vindeca spontan.

Infectia HIV este asociata cu un risc crescut de artrita reactiva

Etiologie

Post-veneriana:Chlamydia

Post-enterala:Shigella,Yersinia,Salmonella,Campylobacter

Manifestari clinice

Perioada de latenta:1-4 sapt

Musculoscheletale:

Poliartrita/oligoartrita asimetrica ,migratorie a mb.inf


Dactilita

Entezita

Sacroiliita,spondilita

Tendinite,tenosinovite

Extraarticulare:

Oculare:conjunctivita,uveita

Cutanate:keratoderma blenorrhagicum,leziuni cutanate psoriazis-like,afte bucale,eritem


nodos,hiperkeratoza unghiala

Simptome ale infectiei:genitourinare:disurie,durere pelvina,uretrita,prostatita

Gastrointestinale:diaree

Renale:proteinuria,microhematuria,nefropatia cu IgA

Cardiac

Diagnostic

Se pune clinic,nu exista niciun test de confirmare

VSH.CRP crescute

Leucocite crescute

HLA-B27 limitata

Investigatii pt a gasi bacteria:culturi bacteriene din scaun,urina,faringe

Chlamydia trachomatis din urina,secretie ureterala,cervicala prin PCR

Anticorpi anti Yersinia,Salmonella,Campylobacter,Chlamydia

ECO,IRM RX

Artrocenteza:pt a face diferenta cu alte diagnostic:in lichidul synovial gasim:leucocite peste 10


000/microl,majoritatea neutrofile,culture negative

Diagnostic diferential cu:artrita septica,Lyme


Tratament

Nu exista tratament curative

Scopul este de a controla simptomele pt ca boala se autolimiteaza

AINS,Crioterapie,fizioterapieglucocorticoizi intraarticulari,oraliDMARDs(forme cornice),anti-TNF-


alpha

Antibiotice

Artrita enterale

Apare in BII

2 FORME:

Oligoartrita periferica:in boala Crohn

Asociere cu manifestari extraarticulare

Spondilita:Colita ulceroasa

Asociere cu uveita si cu HLA-B27

Tratament

AINS-Induce reactivari ale BII,eficienta pt manifestari articulare

CORTICOSTEROIZI-intraarticular

DMADS

ANTI-TNF alpha