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What are the main bacterial agents that can trigger a reactive arthritis?
SSYC + Chlamydia
Salmonella, Shigella, Yersinia, Campy J

but the full list is long
Epidemiology of reactive arthritis/Reiter's
young adults 20-40
enteric infection, M=F
urogenital infection M > F
What is the most common type of inflammatory arthritis in young males?
Reiter's
Main extra-articular features of Reiter's
PROSTATITIS, urethritis, hemorragic cystitis, salpingitis, vulvovaginitis

circinate balantis (30%), keratoderma blennorrhagicam (15%)
painless oral ulcers (25%)
hyperkeratotic nails (10%)


sterile CONJUNCTIVITIS, uveitis

ILEITIS/ COLITIS, sterile


rare cardiac AR, heart block, pericarditis; neuropathy; igA nephropathy, livedo
What FOOT symptoms are seen in Reiter's?

What HAND symptoms?
Achilles tendonitis, plantar fasciitis

sausage digits, dactilitis
T/F: ankylosing spondylitis is seen in 20% of Reiter's patients.
true. The syndesmophytes are thicker than in AS, so called "jug-handle"
T/F: Joint-space narrowing and calcifications are seen in Reiter's.
False. Joint space narrowing is see uniformly across the joint space, but calcifications are rarely seen.
What is the distribution of peripheral arthritis in Reiter's vs. psoriatic arthritis?
Reiter's: mainly in lower extremity

psoriatic: mainly in upper extremity
What is the nonpharm tx of Reiter's?
1. Bed rest and splinting at first
2. Then passive strengthening and ROM exercises
3. Then active exercises.

Avoid behavior promoting reinfection.
What is the pharm tx of Reiter's?
Eliminate trigger infection with antibiotics, especially if Chlamydia.
Topicals for skin; refer to ophtho if uveitis
arthritic: Indomethacin 150 mg/day, do not use aspirin or ibuprofen
steroids injections for SI, but systemic steroids are ineffective
if refractory the drug of choice is SULFASALAZINE
T/F: Antibiotics are not necessary in the treatment of Reiter's.
True, usually; treating the infection will not change the course of the arthropathy, and the disease is usually past when the arthropathy starts. However, Chlamydia is a possible exception.
What are typical labs for IBD arthropathy?
ESR elevated
ANA, RF negative (seronegative, remember)
ANCA is positive in 50-60%: UC is often pANCA+, but there are NOT antibodies against myeloperoxidase
50% of Crohn's have ABs against Saccharomyces cerevisiae.
What is the relation between IBD arthropathy and sacroiliitis?
It is pretty much the same as in AS.
What is the treatment for IBD arthropathy?
NSAIDs
intra-articular injections (for SI, etc.)
sulfasalazine, immunosuppressives, anti-TNF agents
How is celiac disease diagnosed?

How is the arthritis ass/w celiac treated?
autoantibody to endomysial and transglutaminase (90% sn/sp)

gold standard is villous atrophy on bx

gluten free diet also treats arthritis
What arthritis signs might be seen in cancer of esophagus and colon? What labs would you expect?
acute onset, asymmetric, mainly lower extremity joints, sparing of small joints of hands and wrists.
Elevated ESR and negative RF.l
What symptoms would distinguish anklyosing spondylitis from mechanical lower back pain?
SACROILIAC TENDERNESS
insidious rather than acute onset
frequent NOCTURNAL pain
Loss of flexibility in all planes, not just flexion
Decreased chest expansion
Pain improves with exercise
What are five clinical tests for ankylosing spondylitis?
occiput to wall test: stand with back to wall, heels, scapulae, and occiput should all be able to touch if normal
chest expansion: > 5 cm
Gaenslen's test: one knee to chest, one leg dropped over side of table, sacroiliac pain on side of dropped leg
Patrick's test: heel on knee in "4" position, press bent knee down to table; "F-AB-ER", flexion, abduction, external rotation, will cause contralateral SI joint pain if there is sacroiliitis.
sacrioiliac joints TTP in posterior.
Which peripheral joints are most commonly involed in AS?
hips, shoulders
What are the radiographic signs of anklyosing spondylitis?
sacroiliitis, bilateral and symmetric, lower two thirds of joint
whiskering of iliac crests, etc.
syndesmophytes, bamboo spine