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Toronto Notes 2019 Seronegative Rheumatic Disease Rheumatology RH23 Enteropathic Arthritis
• seeGastroenterology,InflammatoryBowelDisease,G19
• MSKmanifestationsinthesettingofeitherulcerativecolitisorCrohn’sdiseaseincludeperipheral
arthritis (large joint, asymmetrical), spondylitis, and hypertrophic osteoarthropathy
• non-arthriticMSKmanifestationscanoccur2otosteroidtreatmentofbowelinflammation(arthralgia,
myalgia, osteoporosis, AVN)
• NSAIDsshouldbeusedcautiouslyastheymayexacerbateboweldisease
Table 28. Comparing Features of Spondylitis vs. Peripheral Arthritis in EA
Parameter
HLA-B27 Association Gender
Onset Before IBD Parallels IBD Course Type of IBD
Spondylitis Peripheral Arthritis
Yes No M>F M=F Yes No No Yes UC=CD CD
Psoriatic Arthritis
Definition
• arthriticinflammationassociatedwithpsoriasis
Etiology and Pathophysiology
• unclearbutmanygenetic,immunologic,andsomeenvironmentalfactorsinvolved(e.g.bacterial,viral, and trauma)
Epidemiology
• psoriasisaffects1%ofpopulation
• arthropathyin15%ofpatientswithpsoriasis
• 15-20%ofpatientswilldevelopjointdiseasebeforeskinlesionsappear
Signs and Symptoms
• dermatologic
■ well-demarcated erythematous plaques with silvery scale
■ nail involvement: pitting, transverse or longitudinal ridging, discolouration, subungual
hyperkeratosis, onycholysis, and oil drops • musculoskeletal
■ 5 general patterns
◆ asymmetric oligoarthritis (most common – 70%)
◆ arthritis of DIP joints with nail changes
◆ symmetric polyarthritis (similar to RA)
◆ sacroiliitis and spondylitis (usually older, male patients) ◆ arthritis mutilans - destructive small joint polyarthritis
■ other findings: dactylitis, enthesopathy • ophthalmic
■ conjunctivitis, iritis (anterior uveitis) • cardiacandrespiratory(latefindings)
■ aortic insufficiency
■ apical lung fibrosis • neurologic
■ cauda equina syndrome • radiologic
■ floating syndesmophytes
■ pencil-in-cup appearance at IP joints ■ osteolysis, periostitis
Treatment
• treatskinlesions(e.g.steroidcream,salicylicand/orretinoicacid,tar,UVlight) • NSAIDsorIAsteroids
• DMARDstominimizeerosivedisease(useearlyinperipheraljointinvolvement) • non-biologicDMARDs(methotrexate,sulfasalazineorleflunomide)
• biologictherapiesincludeanti-TNFagents,anti-IL-17(secukinumab)andanti-IL-12/23(ustekinumab)
Check “hidden” areas for psoriatic lesions (ears, hair line, umbilicus, gluteal cleft, nails) TNF-α inhibitors are effective treatments for PsA with no important added risks associated with their short-term use