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Spondyloarthropathies

Contributor: Nancy Liu, MD

CASE 1:

A 25 year old female is referred for evaluation of back pain.  She has had chronic back pain since high school and thought it was related to injuries since she was active in numerous sports, including field hockey and soccer.  During college, she was less physically active in sports, but the back pain persisted.  She describes her back stiffness as most severe in the morning upon awakening and after prolonged inactivity, such as sitting in the classroom for an hour.  The symptoms last at least for 60 minutes and improve if she stretches, moves, or participates in physical exercise.  Her pain is mostly in the lower thoracic region and she describes muscle spasms.  Occasionally, she will have alternating buttock pain as well.  Naproxen OTC reduces her stiffness but she is afraid to take them regularly due to concern for toxicity.

  • Past Medical History: None.
  • Family and Social History: Unmarried elementary school teacher.  No family history of back pain; brother with psoriasis.
  • Medications:  None.
  • Review of Systems:  One episode of iritis in college that resolved with topical steroid eye drops.
  • General Physical Exam: Vital signs stable.  HEENT normal; skin without lesions; pulmonary, cardiac, GI and neurologic exams are all normal.
  • Musculoskeletal Exam:  Cervical spine with normal range of motion.  No evidence of peripheral arthritis or enthesitis; no point tenderness in thoracic or lumbar regions. There is loss of lumbar lordosis and the Schober's exam is 10 to 13 cm on full flexion (normal is >15 cm on full flexion).

What are the typical features of inflammatory back pain?

The characteristics features of inflammatory back pain include onset of back pain before age 40; insidious in onset lasting greater than 3 months; pain that improves with exercise but not with rest; nocturnal pain, especially the second half of the night; and alternating buttock pain.

What are other commonly associated features in this diagnosis that should be sought?

Aside from inflammatory back pain, other manifestations include: enthesitis, particularly in the Achilles tendon, plantar fascia, anterior chest wall or iliac crest; shoulder or hip joint involvement; uveitis or iritis; aortitis; IgA nephropathy; rarely neurologic involvement; and apical pulmonary fibrosis.

What is the best approach to classify and confirm the diagnosis?

  • Aside from the history and physical exam, laboratory data has limited utility. Although elevations in inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are often present, these are nonspecific. Radiographic imaging in early disease can be normal but obtaining sacroiliac (SI) joint, thoracic and lumbar spine films can sometimes reveal characteristic changes (enthesitis at the vertebral body, syndesmophytes, sacroiliac erosions or sclerosis) if symptoms have been of longer duration. MRI with STIR images of the spine and SI joints are more sensitive for early inflammatory changes and bone marrow edema. The utility of HLA B27 testing is debatable since nearly 8% of Caucasians are B27 positive and only 0.2% of Caucasian population has ankylosing spondylitis. However, the presence of HLA B27 in a patient with classic inflammatory back symptoms or other associated features supports the diagnosis if radiographic changes are not yet present.
  • A new classification criteria proposed by the Assessment of Spondyloarthritis International Society (ASAS) advocates separation of this group of diseases into only two main clinical classifications: axial spondyloarthritis and peripheral spondyloarthritis. Thus, in this case, the patient would have axial spondyloarthritis  

Case 2:

A 40 year old male with longstanding psoriatic arthritis on adalimumab for management of skin and joint disease develops increasingly severe mid-back pain. The pain started after lifting a heavy box at work. He describes the pain as constant, unrelieved by positional change and worse with activity. He has tried ibuprofen 800mg three times daily without symptomatic relief. The pain has been increasing in severity. His psoriatic arthritis and skin disease have been in excellent control for the past 6 years on therapy. He denies any fevers but describes malaise for the past week and mild anorexia. He has no radicular symptoms.

  • Past Medical History: Hypertension, mild asthma
  • Family and Social History: Brother with psoriasis and sister with Crohn’s disease; works full time in a factory’s shipping and receiving department. Non-smoker. Rare alcohol use on the weekend
  • Medications: Adalimumab 40mg sc every 14 days; hydrochlorothiazide 25mg daily; albuterol inhaler as needed; topical steroids as needed
  • Review of Systems: Weight loss of 4 lbs; no rash; minimal shortness of breath; no chest pain; no diarrhea or constipation; recent mild abrasion of elbow at work.
  • General Physical Exam: Temperature 99.7; pulse 100; normal respirations; blood pressure 100/60. Skin shows left olecranon abrasion with surrounding erythema. Heart with tachycardia but no murmurs. Lungs clear. Abdomen is normal without rebound or tenderness. Neurologic exam is normal.
  • Musculoskeletal exam: Prominent DIP enlargement; synovial thickening at left 3rd MCP; other peripheral joints are normal without tenderness. Percussion tenderness at T12 level.

What is your differential diagnosis?

Although psoriatic arthritis is one of the spondyloarthropathies that can have associated involvement in the axial spine, it is important to consider the entire history. The patient’s joint disease has been in very good control with adalimumab and it would be unusual to develop new inflammatory back pain on adequate therapy. The sudden onset of pain after lifting a box is concerning for possible mechanical injury or compression fracture. The latter would be unusual in this 40 year old male. However, he also has more generalized symptoms of fever, malaise and has low grade fever on ibuprofen. Given his immunosuppression with adalimumab and evidence of skin breakdown at his elbow, workup for possible infectious cause is strongly indicated.

How would you proceed to evaluate this patient?

General evaluation includes CBC with differential, electrolytes, creatinine, ESR, CRP, blood and urine cultures. Start with plain radiographs of area of point tenderness but likely will need further imaging with MRI or CT scan to exclude vertebral osteomyelitis, discitis or paravertebral abcess. Cardiac echo is needed to exclude endocarditis.

Patient Care

  • Learn the approach in evaluation of patients with axial or oligoarticular complaints through specific history, family information and physical exam details (aside from peripheral joint exam, review the back exam with Schober’s testing and other maneuvers )
  • Distinguish characteristic features of inflammatory back pain from mechanical back pain
  • Distinguish the symptoms and physical findings of spondyloarthritis patients from other inflammatory joint diseases or connective tissue disorders
  • Learn the appropriate approach for evaluation of the spondyloarthritis patient, including laboratory studies, imaging modalities and the utility of HLA B27 testing
  • Determine the need for further subspecialty evaluations with gastroenterology, dermatology or ophthalmology
  • Discuss the need for physical and occupational therapy (1, 2) and explore the impact of the specific diagnosis on the patient’s professional and personal lifestyle.
  • Review the risks and benefits of various treatment modalities for each of the spondyloarthropathies and their limitations
  • Understand the potential complications of the various spondylarthropathies

Medical Knowledge

Interpersonal and Communications Skills

Professionalism

  • Recognize the importance of patient privacy, informed consent and equal care
  • Respect the patient’s decisions and opinions even when they are divergent with the standard of care
  • Recognize and address the patient’s concerns and fears when a diagnosis is uncertain or when the diagnosis is established

Practice Based Learning

  • Recognize the of current classification of spondyloarthritis
  • Apply the information from the patient’s history, physical exam, laboratory and radiographic findings to make informed approach in further management of patients with different spondyloarthropathies
  • Set learning goals in comparing and contrasting the types of treatment and expected outcomes reported/recommended in the current literature for each of the spondyloarthropathies
  • Recognize current assessment tools for monitoring disease activity in AS and psoriatic arthritis

System Based Practice

  • Demonstrate the ability to work with consultants (dermatology, gastroenterology, ophthalmology, and orthopedics) and allied health professionals in the management of patients with inflammatory back disease or peripheral arthritis

  • Provide supporting information for patient’s health plan or employers when issues concerning medications, work accommodations or disability arise

  • Demonstrate an awareness of the impact of diagnostic and pharmacologic recommendations on the health care system, including insurance companies, physician and patient

  • Identify barriers to the delivery of optimal patient care for patients with spondyloarthritis and offer improved ideas for delivering care

Keywords: Spondyloarthropathy, ankylosing spondylitis, reactive arthritis, psoriatic arthritis, inflammatory bowel disease associated arthritis, inflammatory back pain, enthesitis, anti-TNF therapies

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