Spondyloarthropathies

Suggested Alternatives for Differential Diagnosis Influenza, infectious mononucleosis, hepatitis, leptospirosis, infective endocarditis, malaria, tuberculosis, typhoid fever, cryptococcosis, histoplasmosis, ankylosing spondylitis and undifferentiated spondyloarthropathy, collagen vascular disease, chronic fatigue syndrome, malignancy, and osteomyelitis. 

The NSAIDs have a number of commonalities. Although not all NSAIDs are approved by the FDA for the whole range of rheumatic diseases, most are probably effective in rheumatoid arthritis, seronegative spondyloarthropathies (eg, psoriatic arthritis and arthritis associated with inflammatory bowel disease), osteoarthritis, localized musculoskeletal syndromes (eg, sprains and strains, low back pain), and gout (except tolmetin, which appears to be ineffective in gout). 

The sulfasalazine molecule comprises sulfa-piridine and 5-aminosalicylic acid linked by an azo-bond which is split by colonic bacteria, releasing the component parts. Sulfapiridine, as a sulphonamide, has an antifolate action which is believed to benefit rheumatoid arthritis, while it is the salicylate moiety that is thought to be effective in inflammatory bowel disease a fuller description appears on page 64. Sulfasalazine is used as a DMARD for rheumatoid arthritis, spondyloarthropathy with peripheral joint involvement, and psoriatic arthritis. 

Only some autoimmune diseases are almost exclusively associated with MHC class I alleles of the HLA-A, HLA-B, or HLA-C locus. One of the strongest MHC disease associations is between HLA-B27 and the spondyloarthropathies, especially ankylosing spondylitis and reactive arthritis. B27 molecules seem to play a direct role in disease pathogenesis (David, 1997). Although the exact mechanism is unknown, it has been shown that HLA-B27 is capable of presenting potentially arthritogenic peptides to cytotoxic T cells (Bowness, 2002). 

Spondylo- arthropathies HLA-B27 is a very strong disease susceptibility marker. The relative risk for ankylosing spondylitis is up to 150. Under the influence of environmental and other inherited factors (e.g. MHC class II alleles), HLA-B27 seems to be directly involved in the development of spondyloarthropathies (Westman et al., 1996 David, 1997 Khan, 2000 Bowness, 2002). The HLA-linked LMP2 gene is involved in the expression of ankylosing spondylitis (Maksymowych et al., 1995). 

HLA-B27 Spondyloarthropathy arises spontaneously in HLA-B27 transgenic rats. In contrast, HLA-B27 transgenic mice have usually remained healthy Breban et al. (2004)... 

Bukulmez H, Colbert R A (2002). Juvenile spondyloarthropathies and related arthritis. Curr Opin Rheumatol 14 531-535. 

Two studies have suggested that the IR spectra of synovial fluid specimens provide the basis to diagnose arthritis and to differentiate among its variants.A NIR study demonstrated that osteoarthritis, rheumatoid arthritis, and spondyloarthropathy could be distinguished on the basis of the synovial fluid absorption patterns in the range 2000-2400 nm.< In that case, the pool of synovial fluid spectra was subject to principal component analysis, and eight principal component scores for each spectrum were employed as the basis for linear discriminant analysis (LDA). On that basis, the optimal LDA classifier matched 105 of the 109 spectra to the correct clinical designation (see Table 7). 

The IR-based diagnoses are from principal component analysis and LDA of synovial fluid NIR spectra (see text) SA = spondyloarthropathy RA = rheumatoid arthritis OA = osteoarthritis. The table indicates, for example, that of the 29 spectra corresponding to patients with osteoarthritis, 27 were classified correctly but two were misdassified as rheumatoid arthritis, (see Shaw et al. ). 

Skin Cutaneous adverse reactions to TNF antagonists have been studied in 252 patients with rheumatoid arthritis (146 treated with infliximab, 72 with adalimumab, and 34 with etanercept) and in 183 with spondyloarthropathies (138 treated with infliximab, 37 with etanercept, and 8 with... 

Fouache D, Goeb V, Massy-Guillemant N, Avenel G, Bacquet-Deschryver H, Kozyr-eff-Meurice M, Menard J-F, Muraine M, Savoye G, Le Loet X, Tharasse C, Vittecoq O. Paradoxical adverse events of anti-tumour necrosis factor therapy for spondyloarthropathies a retrospective study. Rheumatology 2009 48(7) 761-4. 

Lehtinen A, Taavitsainen M, Leirisalo-Repo M (1994) Sonographic analysis of enthesopathy in the lower extremities of patients with spondyloarthropathy. Clin Exp Rheumatol 12 143-148... 

The first question to ask to the patient with knee complaints is whether the symptoms are chronic or acute. In chronic abnormalities, the possible occurrence of systemic articular disorders such as rheumatoid and psoriatic arthritis, seronegative spondyloarthropathy, and degenerative and metabolic disorders should be considered. Close coop-... 

The tibialis posterior tendon is the most commonly injured tendon on the medial side of the ankle. Its rupture is typically encountered in middle-aged obese women or as a result of systemic disease, such as rheumatoid arthritis or seronegative spondyloarthropathy (Johnson 1983). Acute fractures of the ankle may also be responsible for some cases of rupture of this tendon. In most cases, tibialis posterior tendon tears occur around the medial malleolus, but they may also be encountered at the navicular insertion. Rupture of the is frequently overlooked clinically because it often develop with no history of trauma. Initially, the patient complains of pain and swelling around the affected tendon. Then, as the severity of the lesion gradually progresses toward rupture elongation, gradual collapse... 

Chronic posterior ankle pain may also be related to bursal pathology, which may occur as an isolated disorder but is more often secondary to inflammatory disorders, such as rheumatoid arthritis and seronegative spondyloarthropathies, or repetitive trauma, usu-... 

A detailed history of the patient and a careful physical examination are of the utmost importance in narrowing the list of differential diagnoses. Systemic inflammatory arthritis and spondyloarthropathies, previous local trauma, a sudden increase or change in training strategies for sportsmen. 

US can assess plantar fascia involvement related to inflammatory disorders, such as spondyloarthropathy (Lehtinen et al. 1994 D Agostino et al. 2003 Borman et al. 2005). Subclinical enthesitis in the feet of these patients is not rare and can easily be detected with US. At gray-scale US and Doppler imaging, the large majority of these patients have at least one sign of active enthesitis that typically presents with symmetric distribution in the extremities. 

Borman P, Koparal S, Babaoglu S et al (2005) Ultrasound detection of entheseal insertions in the foot of patients with spondyloarthropathy. Clin Rheumatol 1 1-5 Boutry N, Larde A, Lapegue F et al (2003) Magnetic resonance imaging appearance of the hands and feet in patients with early rheumatoid arthritis. J Rheumatol 30 671-679 Boutry N, Flipo RM, Cotten A (2005) MR imaging appearance of rheumatoid arthritis in the foot. Semin Musculoskelet Radiol 9 199-209... 

These observation open up the possibility of TM therapy for human diseases of excessive inflammation and/or excessive fibrosis, both of which are very numerous, and some of which are quite common. A clinical trial in idiopathic pulmonary fibrosis has been initiated and others are being planned for psoriasis, primaiy biliaiy cirrhosis, scleroderma, and spondyloarthropathies. 

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