Rheumatology

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• Rheumatology
• Summer Board Review
• Session 1
• Mashkur Husain

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Question 1

• A 47-year-old man is evaluated in the emergency
  department for a 5-day history of acute swelling
  and pain of the right knee. He has a 15-year
  history of gout, with multiple attacks annually
  he also has diabetes mellitus and chronic kidney
  disease. Medications are enalapril, glipizide,
  and allopurinol.
• On physical examination, temperature is 38.2 C
  (100.8 F), blood pressure is 146/88 mm Hg, pulse
  rate is 96/min, and respiration rate is 15/min.
  BMI is 27. Several nodules are noted on the
  metacarpophalangeal and proximal interphalangeal
  joints and within the olecranon bursa. The right
  knee is swollen, erythematous, warm, tender, and
  fluctuant.

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Question 1

• Laboratory studies
• Hemoglobin 10.1 g/dL (101 g/L)
• Leukocyte count 13,000/µL (13 109/L, 85
  neutrophils)
• Serum creatinine 2.8 mg/dL (247.5 µmol/L)
• Serum uric acid 9.2 mg/dL (0.54 mmol/L)
• Radiographs of the knee reveal soft-tissue
  swelling.
• Aspiration drainage of the right knee is
  performed. Synovial fluid leukocyte count is
  110,000/µL (110 109/L, 88 neutrophils).
  Polarized light microscopy of the fluid
  demonstrates extracellular and intracellular
  negatively birefringent crystals. Gram stain is
  negative for bacteria. Culture results are
  pending.

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Answer Choice

• Which of the following is the most appropriate
  initial treatment?
• A Intra-articular methylprednisolone
• B prednisone
• C Surgical debridement and drainage
• D Vancomycin plus piperacillin-tazobactam

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Answer Choice

• Which of the following is the most appropriate
  initial treatment?
• A Intra-articular methylprednisolone
• B prednisone
• C Surgical debridement and drainage
• D Vancomycin plus piperacillin-tazobactam

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Explanation

• This patient requires empiric therapy with
  vancomycin plus piperacillin-tazobactam, pending
  the results of synovial fluid cultures. Based on
  his history of gout as well as the presence of
  tophi and intracellular and extracellular
  negatively birefringent (urate) crystals, the
  patient is currently having a gout attack.
  However, an excessively high synovial fluid
  leukocyte count of the joint (gt50,000/µL 50
  109/L) requires that the acute joint process be
  presumed infectious until proved otherwise. In
  this setting, a negative Gram stain is of
  insufficient sensitivity to rule out infection.
  Patients with chronic joint damage such as that
  seen in gout and other arthritides are at greater
  risk for joint infection. This patient also has
  diabetes mellitus and is presumed to be
  immunocompromised and susceptible not only to
  gram-positive, but also to gram-negative and
  anaerobic, organisms. Therefore, empiric
  combination therapy with vancomycin and
  piperacillin-tazobactam is an appropriate
  approach.
• Although intra-articular methylprednisolone is an
  appropriate approach to treat an acute gout
  attack while minimizing systemic corticosteroid
  effects, corticosteroids should never be injected
  into potentially infected joints.

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Explanation

• Prednisone is also an effective treatment for
  acute gout, particularly if polyarticular
  however, use in this patient with diabetes and a
  potential joint infection would not be
  justifiable unless and until infection were ruled
  out.
• In this patient, infection is empirically assumed
  but not proved, and the joint has been adequately
  drained percutaneously for the time being.
  Surgical debridement and drainage can be
  considered for a definitively infected joint,
  particularly if the percutaneous approach is
  inadequate to fully drain the entire joint, but
  is premature at this time.

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Key Points

• Manage infectious arthritis in a patient with
  concurrent gout.
• Bacterial infectious arthritis and gout can occur
  concomitantly in the same joint and should be
  suspected when there is a very high (gt50,000/µL
  50 109/L) synovial fluid leukocyte count.

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Septic Arthritis

• Diagnosis
• Septic arthritis should be considered in any
  patient who presents with
• sudden onset of monoarthritis
• acute worsening of chronic joint disease
• previously painless joint prosthesis that is now
  painful
• radiographic loosening or migration of a cemented
  prosthetic device
• The risk for infection is increased in persons
  with previously damaged joints (e.g., patients
  with rheumatoid arthritis), in older adults, and
  in immunosuppressed patients. In patients with
  underlying rheumatologic disorders, a sudden
  joint flare that is not accompanied by other
  features of the preexisting disorder and is
  unresponsive to usual therapy suggests a
  diagnosis of infectious arthritis.

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Septic Arthritis

• The hallmark of a septic joint is pain on passive
  range of motion in the absence of trauma, and an
  infected joint typically appears swollen and warm
  with overlying erythema.
• Gonococcal arthritis is the most common form of
  bacterial arthritis in young sexually active
  persons in the United States. This condition
  manifests as either a purulent arthritis or a
  syndrome of disseminated gonococcemia. The
  arthritis usually involves one or two joints
  sequentially, most commonly the knees, wrists,
  ankles, or elbows. Disseminated gonococcemia is
  characterized by a prodrome of tenosynovitis,
  polyarthralgia, and cutaneous lesions that
  progress from papules or macules to pustules and
  usually are sterile on culture. Fever and rigors
  are common

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Septic Arthritis

• Most patients with purulent gonococcal arthritis
  do not have systemic features or cutaneous
  involvement therefore, gonococcal arthritis
  should be considered in all sexually active
  patients. Blood cultures for Neisseria
  gonorrhoeae are positive in 50 of infected
  patients. Obtaining culture specimens from the
  pharynx, genitals, and rectum in addition to
  synovial fluid cultures increases the diagnostic
  yield.
• Other less common causes of septic arthritis
• Gram-negative infections are more common in
  older, immunosuppressed, and postoperative
  patients and those with IV catheters.
• Tuberculous arthritis typically is indolent, does
  not cause systemic features, and is not
  associated with positive TST synovial fluid is
  usually inflammatory with a predominance of
  polymorphonuclear cells and a negative Gram
  stain.
• Fungal arthritis typically manifests as subacute
  monoarthritis in patients with a systemic fungal
  infection.

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Question 2

• A 36-year-old man is evaluated for a 5-month
  history of left knee pain and swelling. He is a
  gardener and frequently scrapes his knees while
  working in the soil. He has mild but chronic
  discomfort when walking and at rest. The patient
  reports no diarrhea or urethral discharge and has
  been sexually inactive for 2 years. He has a
  10-year history of type 2 diabetes mellitus that
  is managed with insulin.
• On physical examination, temperature is 38.0 C
  (100.4 F), blood pressure is 135/77 mm Hg, pulse
  rate is 78/min, and respiration rate is 12/min.
  BMI is 20. The left knee is warm and swollen with
  a palpable effusion. The knee has decreased
  flexion, and increasing discomfort is noted at
  the limits of range of motion.
• Laboratory studies reveal a leukocyte count of
  11,000/µL (11 109/L, 35 lymphocytes) and an
  erythrocyte sedimentation rate of 48 mm/h.

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Question 2

• Radiographs of the left knee reveal soft-tissue
  swelling and diffuse joint-space narrowing, with
  periarticular osteopenia. Aspiration of the knee
  is performed. Synovial fluid leukocyte count is
  6500/µL (6.5 109/L, 65 lymphocytes).
  Polarized light microscopy reveals no crystals.
  Gram stain is negative.
• Subsequent bacterial cultures, Lyme disease
  titers, rheumatoid factor, and anticyclic
  citrullinated peptide antibody titers are
  negative. Tuberculin skin test results are
  negative.

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Answer Choice

• Which of the following is the most appropriate
  diagnostic test to perform next?
• A Alizarin red staining of synovial fluid
• B Antistreptolysin O antibody titers
• C MRI of the knee
• D Synovial biopsy

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Answer Choice

• Which of the following is the most appropriate
  diagnostic test to perform next?
• A Alizarin red staining of synovial fluid
• B Antistreptolysin O antibody titers
• C MRI of the knee
• D Synovial biopsy

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Explanation

• Synovial biopsy is indicated for this patient
  with probable fungal arthritis. Fungal arthritis
  is rare, typically occurs in patients who are
  immunocompromised, and manifests as subacute
  monoarthritis. This patient has long-standing,
  indolent, chronic monoarticular arthritis a
  history of diabetes mellitus and recurrent skin
  breaks with likely soil exposure. In this
  setting, infection with a fungus, particularly
  Sporothrix schenckii, is the likely cause. S.
  schenckii is associated with plant litter and
  other organic materials. S. schenckii arthritis
  usually manifests as progressive joint pain,
  swelling, and loss of range of motion. The
  diagnosis of fungal arthritis requires a high
  degree of suspicion and is most commonly made by
  synovial biopsy and/or culture of joint fluid.
  Because joint fluid culture may take weeks,
  obtaining a synovial biopsy is appropriate at
  this time.
• Alizarin red staining of synovial fluid is not
  done routinely but is theoretically helpful for
  identifying basic calcium phosphate (BCP)
  crystals, which are invisible under polarized
  light microscopy. However, the chronic nature of
  the patient's condition, along with his
  relatively young age and an absence of
  calcification seen on radiographs, makes a
  diagnosis of BCP arthritis unlikely.

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Explanation

• Obtaining antistreptolysin O antibody titers
  aids in the diagnosis of rheumatic fever
  however, this patient lacks the systemic signs
  (such as cardiac and/or neurologic involvement)
  that warrant consideration of rheumatic fever.
• MRI of the knee would help delineate the extent
  of the joint damage but would not provide insight
  into the nature of the infectious process.
• Key Point
• Fungal arthritis is rare, typically occurs in
  patients who are immunocompromised, and manifests
  as subacute monoarthritis

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Question 3

• A 52-year-old man is evaluated for a 5-year
  history of gradually progressive left knee pain.
  He has 20 minutes of morning stiffness, which
  returns after prolonged inactivity. He has
  minimal to no pain at rest. He reports no
  clicking or locking of the knee. Over the past
  several months, the pain has limited his
  ambulation to no more than a few blocks.
• On physical examination, vital signs are normal.
  BMI is 25. The left knee has a small effusion and
  some fullness at the back of the knee the knee
  is not erythematous or warm. Range of motion of
  the knee elicits crepitus. There is medial joint
  line tenderness to palpation, bony hypertrophy,
  and a moderate varus deformity. There is no
  evidence of joint instability on stress testing.
• Radiographs of the knee reveal bone-on-bone
  joint-space loss and numerous osteophytes

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Answer Choice

• Which of the following is the most appropriate
  next diagnostic step for this patient?
• A CT of the knee
• B Joint aspiration
• C MRI of the knee
• D No diagnostic testing

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Answer Choice

• Which of the following is the most appropriate
  next diagnostic step for this patient?
• A CT of the knee
• B Joint aspiration
• C MRI of the knee
• D No diagnostic testing

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Explanation

• No additional diagnostic testing is indicated for
  this patient who has osteoarthritis, which is a
  clinical diagnosis. According to the American
  College of Rheumatology's clinical criteria, knee
  osteoarthritis can be diagnosed if knee pain is
  accompanied by at least three of the following
  features age greater than 50 years, stiffness
  lasting less than 30 minutes, crepitus, bony
  tenderness, bony enlargement, and no palpable
  warmth. These criteria are 95 sensitive and 69
  specific but have not been validated for clinical
  practice. Additional diagnostic testing is not
  appropriate, because it has no impact on the
  management of advanced disease.
• CT of the knee is very sensitive for pathologic
  findings in bone and can be used to look for
  evidence of an occult fracture, osteomyelitis, or
  bone erosions. However, none of these are
  suspected in this patient.
• Small- to moderate-sized effusions can occur in
  patients with osteoarthritis, and the fluid is
  typically noninflammatory. Joint aspiration in
  this patient without evidence of joint
  inflammation and evident osteoarthritis is not
  useful diagnostically but is often done in the
  context of intra-articular corticosteroid
  injection or viscosupplementation.

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Explanation

• MRI is useful to evaluate soft-tissue structures
  in the knee such as meniscal tears. Patients with
  meniscal tears may report a clicking or locking
  of the knee secondary to loose cartilage but
  often have pain only on walking, particularly
  going up or down stairs. Patients with
  degenerative arthritis often have MRI findings
  that indicate meniscus tears. These tears are
  part of the degenerative process but do not
  impact management arthroscopic knee surgery for
  patients with osteoarthritis provides no clinical
  benefit. The one exception may be in patients
  with meniscal tears that result in a free flap or
  loose body, producing painful locking of the
  joint. These symptoms are not present in this
  patient.
• Key Point
• Osteoarthritis is diagnosed clinically and does
  not require advanced imaging to establish the
  diagnosis.

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Question 4

• A 76-year-old woman is evaluated for a 3-month
  history of left knee pain of moderate intensity
  that worsens with ambulation. She reports minimal
  pain at rest and no nocturnal pain. There are no
  clicking or locking symptoms. She has tried
  naproxen and ibuprofen but developed dyspepsia
  acetaminophen provides mild to moderate relief.
  The patient has hypertension, hypercholesterolemia
  , and chronic stable angina. Medications are
  lisinopril, metoprolol, simvastatin, low-dose
  aspirin, and nitroglycerin as needed.
• On physical examination, vital signs are normal.
  BMI is 32. Range of motion of the left knee
  elicits crepitus. There is a small effusion
  without redness or warmth and tenderness to
  palpation along the medial joint line. Testing
  for meniscal or ligamentous injury is negative.

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Question 4

• Laboratory studies, including complete blood
  count and erythrocyte sedimentation rate, are
  normal.
• Radiographs of the knee reveal medial
  tibiofemoral compartment joint-space narrowing
  and sclerosis small medial osteophytes are
  present.

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Answer Choice

• Which of the following is the next best step in
  management?
• A Add celecoxib
• B Add glucosamine sulfate
• C MRI of the knee
• D Weight loss and exercise

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Answer Choice

• Which of the following is the next best step in
  management?
• A Add celecoxib
• B Add glucosamine sulfate
• C MRI of the knee
• D Weight loss and exercise

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Explanation

• Weight loss and exercise are indicated for this
  patient with knee osteoarthritis. Her knee pain,
  which is worse with weight bearing, is suggestive
  of tibiofemoral knee osteoarthritis, a diagnosis
  supported by the presence of medial joint line
  tenderness and radiographic findings of medial
  tibiofemoral compartment joint-space narrowing.
  The strongest risk factors for osteoarthritis are
  advancing age, obesity, female gender, joint
  injury (caused by occupation, repetitive use, or
  actual trauma), and genetic factors. Obesity, in
  particular, is the most important modifiable risk
  factor for knee osteoarthritis. Several trials
  have demonstrated that weight loss and/or
  exercise programs can offer relief of pain and
  improved function comparable to the benefits of
  NSAID use. In long-term studies, sustained weight
  loss of approximately 6.8 kg (15 lb) has resulted
  in symptomatic relief.
• Celecoxib carries an increased myocardial risk
  and is therefore not appropriate for this patient
  who has coronary artery disease. Although
  celecoxib has a lower risk of gastrointestinal
  ulcers than other NSAIDs, it can still cause
  dyspepsia, which occurred in this patient after
  taking naproxen and ibuprofen.

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Explanation

• There have been several contradictory studies
  regarding glucosamine sulfate in the management
  of osteoarthritis. After several favorable
  smaller studies, a trial sponsored by the
  National Institutes of Health showed no
  effectiveness in reducing pain. A recently
  conducted meta-analysis also found negative
  results for the use of glucosamine sulfate.
• MRI of the knee would be indicated to evaluate
  for meniscal or other ligamentous injuries, none
  of which is suggested by this patient's history
  (the knee locking or giving way) or examination
  findings (negative examination for tendinous or
  ligamentous injury).
• Key Point
• Obesity is the most important modifiable risk
  factor for knee osteoarthritis, and weight loss
  and exercise are recommended to reduce pain and
  improve function

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Osteoarthritis

• Diagnosis
• Age is the most important risk factor for
  developing primary OA in women and men.
  Additional risk factors include genetics,
  obesity, and trauma-induced mechanical joint
  instability. OA most often affects the lower
  cervical and lumbar spine hips knees DIP, PIP,
  and first carpometacarpal joints.
• Characteristic findings include
• morning joint stiffness lasting lt30 minutes
• gelling (brief stiffness after inactivity)
• crepitus
• tenderness along the joint line
• reduced joint motion
• bony enlargement (including Heberden and Bouchard
  nodes)
• involvement of the first carpometacarpal joint
  results in squaring at the base of the thumb

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Osteoarthritis

• Two important variants are erosive OA of the hand
  and DISH.
• Erosive inflammatory OA is characterized by pain
  and palpable swelling of the soft tissue in the
  PIP and DIP joints. This condition also may be
  associated with disease flares during which these
  joints become more swollen and painful.
• DISH is an often asymptomatic form of OA that
  causes significant radiographic changes similar
  to those associated with degenerative spondylosis
  or ankylosing spondylitis. X-rays of the spine in
  patients with DISH reveal flowing ossification
  that develops along the anterolateral aspect of
  the vertebral bodies, particularly the anterior
  longitudinal ligament. However, neither
  disk-space narrowing nor syndesmophytes are
  visible in this setting, as they are in lumbar
  spondylosis or ankylosing spondylitis,
  respectively.

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Osteoarthritis

• Secondary OA results from previous joint injury
  or metabolic diseases such as hemochromatosis.
  Consider metabolic causes when OA develops in
  atypical joints (e.g., MCP joints, shoulder,
  wrist).
• Be alert for an acutely painful calf mimicking a
  DVT, which represents a ruptured Baker cyst
  (herniation of fluid-filled synovium of the
  posterior knee) or ruptured gastrocnemius muscle.
• No pathognomonic laboratory tests are available
  for OA. An x-ray is not helpful in the diagnosis
  of symptomatic hand OA (clinical examination is
  more specific) but is the gold standard for hip
  and knee OA. X-rays show joint-space narrowing,
  subchondral sclerosis, and osteophytes. Synovial
  fluid is usually noninflammatory, with a
  leukocyte count lt2000/microliter. Ultrasonography
  is useful in the diagnosis of Baker cyst.

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Bony enlargement of the DIP joints and squaring
of the first carpometacarpal joint characteristic
of osteoarthritis.
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Don't Be Tricked

• Typical OA radiographic changes do not exclude
  other diagnoses. Be alert for
• septic arthritis superimposed on OA
• trochanteric and anserine bursitis causing hip
  and knee pain
• de Quervain tenosynovitis mimicking
  carpometacarpal OA
• hemochromatosis, particularly if involving the
  second and third metacarpophalangeal joints
• gout or CPPD deposition disease

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Therapy

• Medical therapy includes
• acetaminophen as first-line therapy for hip and
  knee OA
• NSAIDs in patients who do not respond to
  acetaminophen or as initial therapy for severe
  pain
• tramadol if NSAIDs are contraindicated or
  ineffective
• intra-articular corticosteroids for acute
  exacerbations of knee OA
• intra-articular hyaluronan injection, which has
  comparable efficacy to NSAID therapy for knee OA
• glucosamine sulfate, although data for its use
  are conflicting
• Patients with hip and knee OA benefit from weight
  loss patients with knee OA benefit from
  quadriceps-strengthening exercises. Joint
  arthroplasty of the hip or knee is indicated for
  pain that does not respond to nonsurgical
  treatment, especially when lifestyle or
  activities of daily living are affected.

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Don't Be Tricked

• Patients with signs of inflammation should not
  undergo intra-articular corticosteroid therapy
  until synovial fluid analysis excludes infection.
• Do not select arthroscopic lavage, debridement,
  or closed lavage for knee OA.

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Medial compartment joint space-narrowing and
subchondral sclerosis consistent with
osteoarthritis are shown.
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Question 5

• A 52-year-old man is evaluated for an 8-week
  history of pain and 2 hours of morning stiffness
  of the hands that improves with activity. The
  patient has no pertinent personal or family
  medical history. He takes no medications.
• On physical examination, vital signs are normal.
  Synovitis is noted at the metacarpophalangeal
  joints of the second through fifth digits
  bilaterally with swelling, tenderness, and pain
  on range of motion. The remainder of the
  examination is normal.
• Laboratory studies, including complete blood
  count, chemistries, liver chemistry tests,
  thyroid-stimulating hormone, C-reactive protein,
  and urinalysis, are normal erythrocyte
  sedimentation rate is 13 mm/h, and rheumatoid
  factor is negative. Parvovirus serology results
  are negative.
• Radiographs of the hands are normal

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Answer Choice

• Which of the following antibody assays is most
  helpful in establishing this patient's diagnosis?
• A Anticyclic citrullinated peptide antibodies
• B Antimitochondrial antibodies
• C Antineutrophil cytoplasmic antibodies
• D Antinuclear antibodies

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Answer Choice

• Which of the following antibody assays is most
  helpful in establishing this patient's diagnosis?
• A Anticyclic citrullinated peptide antibodies
• B Antimitochondrial antibodies
• C Antineutrophil cytoplasmic antibodies
• D Antinuclear antibodies

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Explanation

• An anticyclic citrullinated peptide (CCP)
  antibody assay is warranted for this patient in
  whom rheumatoid arthritis is suspected. Anti-CCP
  antibodies are present in approximately 40 to
  60 of patients with early rheumatoid arthritis,
  including some patients with a negative
  rheumatoid factor. These antibodies are 95
  specific for rheumatoid arthritis. The presence
  of higher titers of either rheumatoid factor or
  anti-CCP antibodies or the presence of both
  increases the likelihood of disease. Although
  this patient's rheumatoid factor is negative and
  his acute phase reactants are normal, rheumatoid
  arthritis remains a significant concern because
  he has synovitis of eight small joints and
  morning stiffness lasting more than 1 hour,
  common symptoms of rheumatoid arthritis. An
  anti-CCP antibody assay is therefore appropriate
  to determine whether this patient's symptoms are
  caused by rheumatoid arthritis.
• Antimitochondrial antibodies are present in
  patients with autoimmune hepatitis. Patients with
  this disease can develop arthralgia and arthritis
  similar to this patient however, he does not
  have liver chemistry test abnormalities that are
  characteristic of autoimmune hepatitis.

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Explanation

• Antineutrophil cytoplasmic antibodies are
  typically associated with vasculitis such as
  granulomatosis with polyangiitis (also known as
  Wegener granulomatosis), microscopic
  polyangiitis, Churg-Strauss syndrome,
  antiglomerular basement membrane antibody
  disease, and drug-induced vasculitis. Arthritis
  and arthralgia can be associated with these
  syndromes however, the presence of these
  vascular inflammatory disorders would be unusual
  in the absence of other system involvement.
• Antinuclear antibodies (ANA) can be clinically
  useful when there is clinical suspicion for
  autoimmune conditions associated with these
  antibodies such as systemic lupus erythematosus
  (SLE). SLE may present with arthritis but, in
  this case, SLE is less likely than rheumatoid
  arthritis. SLE typically occurs in women of
  childbearing age, with additional clinical and/or
  laboratory abnormalities rather than isolated
  arthritis. ANA are present in some patients with
  rheumatoid arthritis but are not specific for
  this disorder.
• Key Point
• Anticyclic citrullinated peptide antibodies are
  a highly specific marker for rheumatoid
  arthritis.

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Question 6

• A 36-year-old woman is evaluated for a 5-week
  history of pain and swelling of the fingers
  accompanied by morning stiffness lasting more
  than 1 hour. Her only medication is ibuprofen,
  which provides minimal relief.
• On physical examination, vital signs are normal.
  Musculoskeletal examination reveals tenderness
  and swelling of the right second, third, and
  fourth metacarpophalangeal joints and the left
  third, fourth, and fifth metacarpophalangeal
  joints. There is no bony enlargement, ulnar
  deviation, or other abnormalities.
• Radiographs of the hands and wrists are normal.

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Labs
Erythrocyte sedimentation rate 40 mm/h
Rheumatoid factor 43 units/mL (43 kU/L)
Antinuclear antibodies Negative
Anticyclic citrullinated peptide antibodies Positive
IgM antibodies against parvovirus B19 Negative
Hepatitis B surface antigen Negative
Hepatitis B surface antibodies Positive
Hepatitis C virus antibodies Negative
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Answer Choice

• Which of the following is the most appropriate
  next step in management?
• A Etanercept
• B Hydroxychloroquine
• C Methotrexate
• D Reevaluate in 6 weeks

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Answer Choice

• Which of the following is the most appropriate
  next step in management?
• A Etanercept
• B Hydroxychloroquine
• C Methotrexate
• D Reevaluate in 6 weeks

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Explanation

• Methotrexate is indicated for this patient with
  early rheumatoid arthritis. Experts recommend
  that patients begin disease-modifying
  antirheumatic drug (DMARD) therapy within 3
  months of onset. The sooner DMARDs are
  instituted, the more likely that damage will be
  limited. Methotrexate is the gold standard DMARD
  therapy for rheumatoid arthritis and is central
  to most treatments for the disease. This agent
  can be effective as initial monotherapy for
  patients with rheumatoid arthritis of any
  duration or degree of activity. This patient has
  synovitis of six metacarpophalangeal joints with
  a symmetric distribution not involving the distal
  interphalangeal joints, which is consistent with
  rheumatoid arthritis. She has swelling, prolonged
  morning stiffness, an elevated erythrocyte
  sedimentation rate (ESR), and positive rheumatoid
  factor, which further support the diagnosis of
  rheumatoid arthritis, and initial treatment with
  methotrexate is warranted at this time.
• Etanercept is a tumor necrosis factor a inhibitor
  used for initial therapy in some patients with
  high disease activity and poor prognostic
  features. This agent may be necessary for this
  patient if her disease does not respond to
  methotrexate.
• Hydroxychloroquine as monotherapy may be
  effective only in mild cases early in the disease
  course for patients without poor prognostic
  features. This patient has evidence of moderate
  disease activity, given the extent of her
  synovitis and elevated ESR therefore,
  hydroxychloroquine as a single agent is unlikely
  to control this degree of inflammation and is
  more beneficial as an adjunctive agent.

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Explanation

• Reevaluation in 6 weeks is not indicated for this
  patient whose laboratory studies reveal no
  evidence of acute parvovirus or hepatitis B
  infection. Such viral infections can cause an
  acute polyarthritis syndrome that mimics
  rheumatoid arthritis. The diagnosis of rheumatoid
  arthritis previously was predicated on symptoms
  lasting more than 6 weeks to exclude many
  self-limiting viral syndromes. However,
  classification criteria no longer require
  symptoms to occur for 6 weeks to avoid delays in
  treatment. The likelihood of rheumatoid arthritis
  is now calculated on the distribution of joints
  involved, rheumatoid factor, anticitrullinated
  peptide antibodies, acute phase reactants, and
  duration of symptoms.
• Key Point
• Methotrexate is the gold standard
  disease-modifying antirheumatic drug therapy for
  rheumatoid arthritis and is central to most
  treatments for the disease

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Rheumatoid Arthritis

• Diagnosis
• RA is a symmetric inflammatory polyarthritis that
  primarily involves the small joints of the hands
  and feet. Characteristic findings include
• morning stiffness lasting gt1 hour
• seven classic sites of symmetric joint pain (PIP,
  MCP, wrist, elbow, knee, ankle, and MTP joints)
• synovitis characterized by soft-tissue swelling
  or effusion
• subcutaneous nodules over bony prominences or
  extensor surfaces

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• Laboratory findings include
• positive rheumatoid factor (sensitivity 80
  specificity 87)
• elevated ESR or CRP level
• normocytic anemia
• positive anti-CCP antibody assay (sensitivity
  76 specificity 96)
• An x-ray can reveal periarticular osteopenia,
  erosions, and symmetric joint-space narrowing.
  MRI and ultrasonography are more sensitive for
  detecting early RA.

52

• Don't Be Tricked
• Negative rheumatoid factor does not exclude RA
  anti-CCP antibody assay may be positive.
• A positive rheumatoid factor alone is not
  diagnostic of RA.
• Not all symmetric arthritis is RA.

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54

• RA extra-articular manifestations
• arm paresthesias and hyperreflexia ? C1-C2
  subluxation (increased risk of cord compression
  with tracheal intubation)
• cough, fever, pulmonary infiltrates ? BOOP
• foot drop or wrist drop ? mononeuritis multiplex
  (vasculitis)
• hoarseness ? cricoarytenoid involvement
• multiple basilar pulmonary nodules ? Caplan
  syndrome
• dry eyes and/or mouth ? Sjögren syndrome
• pleural effusion with low plasma glucose (lt30
  mg/dL) ? rheumatoid pleuritis
• pulmonary fibrosis ? rheumatoid interstitial lung
  disease
• skin ulcers, peripheral neuropathy ? rheumatoid
  vasculitis
• splenomegaly and granulocytopenia ? Felty
  syndrome
• red, painful eye ? scleritis
• HF ? rheumatoid disease or anti-TNF therapy
• Other complications include increased risk of CAD
  and osteoporosis.

55
Carpal, metacarpal, and PIP joints show
periarticular osteopenia, joint-space narrowing,
and marginal erosions, all characteristic of
rheumatoid arthritis.
56
Therapy

• Early treatment with one or more DMARDs is
  essential. Choose NSAIDs and low-dose oral and
  intra-articular corticosteroids for quick
  symptomatic relief, but recognize these agents do
  not alter the course of the disease.
• Monotherapy with hydroxychloroquine or
  sulfasalazine or combination therapy with these
  agents is indicated to manage early, mild, and
  nonerosive disease.
• In the absence of contraindications, methotrexate
  with or without the addition of another DMARD
  should be instituted immediately in patients with
  erosive disease.
• In some patients, combination therapy with
  hydroxychloroquine, sulfasalazine, and
  methotrexate has been shown to be more effective
  than monotherapy with methotrexate or
  sulfasalazine plus hydroxychloroquine.
• Initiate biologic therapy when adequate disease
  control is not achieved with oral DMARDs. The
  initial biologic therapy should be a TNF-a
  inhibitor
• add a TNF-a inhibitor to baseline methotrexate
  therapy
• screen for TB before starting therapy
• treat for latent TB if TST is positive before
  beginning any biologic therapy

57
Therapy

• perform periodic TST screening while the patient
  continues to receive biologic therapy
• Common toxicities of TNF-a inhibitor therapy
  include pancytopenia, positive ANA formation
  associated with lupus-like syndromes, and
  demyelinating disorders. Combination therapy with
  multiple biologic therapies is not recommended.
• Indications for surgical intervention include
  intractable pain or severe functional disability
  from joint destruction. Patients may also require
  surgical repair of ruptured tendons.
• All patients taking corticosteroids require
  osteoporosis screening and serum calcium and
  vitamin D level measurement. If osteopenia or
  osteoporosis is diagnosed, prescribe a
  bisphosphonate. Annual influenza vaccination is
  indicated for all patients using
  immunosuppressants, and pneumococcal vaccination
  is indicated before beginning treatment with
  methotrexate, leflunomide, or a biologic agent.

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Therapy

• The most common cause of death in patients with
  RA is CAD. Begin aggressive coronary risk factor
  reduction in all patients. Also, begin adjuvant
  physical and occupational therapy.
• Don't Be Tricked
• Hydroxychloroquine and sulfasalazine can be used
  during pregnancy.
• Test Yourself
• A 46-year-old man has a 3-month history of
  swelling of the PIP and MCP joints and 90 minutes
  of morning stiffness. Rheumatoid factor is
  negative.
• ANSWER The probable diagnosis is RA. Select
  anti-CCP antibody assay.

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Question 7

• A 56-year-old woman is evaluated during a
  follow-up visit for a 6-year history of Sjögren
  syndrome treated with low-dose hydroxychloroquine
  and cyclosporine eyedrops. She has had two
  episodes of cutaneous vasculitis, which resolved
  with corticosteroids.
• On physical examination, temperature is 36.4 C
  (97.6 F), blood pressure is 116/64 mm Hg, pulse
  rate is 72/min, and respiration rate is 18/min.
  Oral mucous membranes are dry. There is a new
  firm, left parotid gland enlargement without
  tenderness or warmth, reported by the patient to
  be progressive over several months, with
  asymmetry of the parotid glands.
• Laboratory studies at the time of diagnosis
  revealed elevated serum immunoglobulin levels
  positive mixed monoclonal cryoglobulin levels
  and positive rheumatoid factor, antinuclear
  antibodies, and anti-Ro/SSA antibodies.

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Labs
Complete blood count Normal
Alkaline phosphatase Normal
Calcium Normal
Rheumatoid factor Negative
C3 Normal
C4 Decreased
Antinuclear antibodies Positive
Anti-Ro/SSA antibodies Positive
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Answer Choice

• Which of the following is the most appropriate
  management?
• A Add pilocarpine
• B Add prednisone
• C Bone marrow biopsy
• D Increase hydroxychloroquine
• E Parotid gland biopsy

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Answer Choice

• Which of the following is the most appropriate
  management?
• A Add pilocarpine
• B Add prednisone
• C Bone marrow biopsy
• D Increase hydroxychloroquine
• E Parotid gland biopsy

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Explanation

• Parotid gland biopsy is indicated for this
  patient who has Sjögren syndrome and progressive
  parotid swelling suggesting possible non-Hodgkin
  lymphoma. Patients with Sjögren syndrome have up
  to a 44-fold increased incidence of lymphoma,
  which may be confined to glandular tissue. Risk
  factors for the development of lymphoma include
  disappearance of rheumatoid factor, the presence
  of mixed monoclonal cryoglobulinemia, cutaneous
  vasculitis, and low C4 levels, all of which are
  seen in this patient. Although benign parotid
  gland swelling can occur and be unilateral or
  bilateral in patients with Sjögren syndrome, this
  patient's high-risk profile and new asymmetric
  parotid enlargement should prompt a biopsy to
  evaluate for extranodal lymphoma in the parotid
  gland. Extranodal marginal zone B-cell lymphomas
  of the mucosa-associated lymphoid tissue (MALT)
  are the most common lymphomas in patients with
  Sjögren syndrome, and salivary glands are the
  most common location other extranodal sites
  include the stomach, nasopharynx, skin, liver,
  and lungs. The risk of nodal lymphoma is also
  increased in Sjögren syndrome. Although benign
  lymphadenopathy is a common disease
  manifestation, the presence of new or rapidly
  enlarging lymph nodes may indicate development of
  nodal lymphoma and should prompt biopsy.
• Pilocarpine is effective for reducing dry mouth
  symptoms but is not used to treat parotid
  enlargement.

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Explanation

• Prednisone is generally used to treat
  inflammatory symptoms of Sjögren syndrome,
  including arthritis, vasculitis, and cytopenias,
  but does not reduce parotid swelling or treat
  symptoms of keratoconjunctivitis sicca and
  xerostomia (dry eyes and dry mouth).
• Patients with Sjögren syndrome often have
  elevated immunoglobulin levels with monoclonal
  gammopathy stability of this during the
  patient's disease course, as well as normal
  hemoglobin, calcium, and alkaline phosphatase
  levels, suggests that bone marrow biopsy to
  evaluate for myeloma is not warranted. Extranodal
  lymphoma in Sjögren syndrome involves the bone
  marrow in less than 10 of patients.
• Hydroxychloroquine is used to treat arthritis
  associated with Sjögren syndrome however, it is
  unclear if this agent has efficacy in reducing
  sicca symptoms or parotid swelling.
• Key Point
• Patients with Sjögren syndrome have up to a
  44-fold increased incidence of lymphoma, which
  may be confined to glandular tissue

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Sjögren Syndrome

• Diagnosis
• Sjögren syndrome is an autoimmune disease
  characterized by keratoconjunctivitis sicca and
  xerostomia. Salivary gland enlargement occurs in
  nearly half of patients during the course of the
  disease and is most obvious in the parotid
  glands. This condition may occur as a primary
  disease process or may be associated with another
  autoimmune disease, most commonly rheumatoid
  arthritis. A cardinal feature of Sjögren syndrome
  is the presence of antibodies to Ro/SSA and
  La/SSB. A positive ANA, RF, and
  hypergammaglobulinemia are also frequently found.
  Diagnosis is established by biopsy of a labial
  minor salivary gland. Patients with Sjögren
  syndrome are up to 44 times more likely than the
  general population to have a B-cell lymphoma.
  Careful follow-up is therefore required.

66
Bilateral parotid gland enlargement in a patient
with Sjögren syndrome.
67
Therapy

• Treatment is symptomatic. Choose artificial tear
  replacement and artificial saliva and mouth
  lubricants. Systemic immunosuppressive therapy is
  indicated only in patients with severe systemic
  manifestations.

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Spondyloarthritis

• Key Considerations
• Spondyloarthritis comprises several systemic
  inflammatory joint disorders that share distinct
  clinical, radiographic, and genetic features.
  These disorders are
• psoriatic arthritis
• reactive arthritis (formerly Reiter syndrome)
• ankylosing spondylitis
• IBD-associated arthritis
• Characteristics include
• inflammatory spine and sacroiliac disease
• asymmetric inflammation in four or fewer
  peripheral joints (typically large joints)
• inflammation at the sites of ligament and tendon
  insertion (enthesitis)
• the presence of HLA-B27
• extra-articular conditions, such as uveitis,
  colitis, urethritis, aortitis, and psoriasis

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Question 8

• A 42-year-old man is evaluated for a 1-month
  history of a painful, swollen right finger and a
  swollen left toe.
• On physical examination, vital signs are normal.
  The right third distal interphalangeal joint is
  swollen, with localized tenderness to palpation
  and pain with active and passive range of motion.
  The appearance of the nails
• is shown
• The left second toe is remarkable for fusiform
  swelling and mild diffuse tenderness, with
  decreased active and passive range of motion.
  There is onycholysis of several toenails,
  including the left second toenail. The remainder
  of the physical examination is normal.

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71
Answer Choice

• Which of the following is the most likely
  diagnosis?
• A Lyme arthritis
• B Osteoarthritis
• C Psoriatic arthritis
• D Rheumatoid arthritis

72
Answer Choice

• Which of the following is the most likely
  diagnosis?
• A Lyme arthritis
• B Osteoarthritis
• C Psoriatic arthritis
• D Rheumatoid arthritis

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Explanation

• This patient has psoriatic arthritis, a systemic
  chronic inflammatory arthritis associated with
  numerous clinical manifestations. Typically,
  psoriasis predates the arthritis by years,
  whereas arthritis develops before skin disease in
  15 of patients. Although there is a poor
  correlation between the severity of skin and
  joint disease, there is a good correlation
  between the severity of nail disease and the
  severity of both skin and joint disease.
  Psoriatic findings may also be limited to nail
  pitting and onycholysis. There are five patterns
  of joint involvement in psoriatic arthritis
  involvement of the distal interphalangeal joints
  asymmetric oligoarthritis symmetric
  polyarthritis (similar to that of rheumatoid
  arthritis) arthritis mutilans (extensive
  osteolysis of the digits with striking
  deformity) and spondylitis. Characteristic
  features of psoriatic arthritis include
  enthesitis, dactylitis, and tenosynovitis. This
  patient has findings characteristic of psoriatic
  arthritis, including inflammation of a distal
  interphalangeal joint and dactylitis of a toe. He
  also has nail changes, including pitting and
  onycholysis.
• Lyme arthritis typically involves medium- or
  large-sized joints rather than distal
  interphalangeal joints and does not typically
  cause tenosynovitis. Furthermore, this disorder
  does not cause nail changes, as seen in this
  patient.
• Osteoarthritis can involve the distal
  interphalangeal joints but does not cause
  dactylitis or nail changes.

74
Explanation

• Rheumatoid arthritis can initially present with
  an asymmetric pattern, although it classically
  takes on a symmetric distribution with time. In
  contrast to this case, rheumatoid arthritis
  typically spares the distal interphalangeal
  joints, involving the proximal interphalangeal
  joints and metacarpophalangeal joints
  preferentially. Finally, this condition does not
  cause nail changes
• Key Point
• Psoriatic arthritis is associated with various
  patterns of joint involvement, most notably
  distal interphalangeal joint involvement, and is
  characterized by enthesitis, dactylitis,
  tenosynovitis, and cutaneous involvement such as
  nail pitting

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Psoriatic Arthritis

• Characteristic findings are classic psoriasis
  (thick silvery scale on a well-demarcated red
  patch) and nail pitting in a patient with joint
  pain and stiffness. Skin involvement commonly
  precedes joint inflammation, although 15 of
  patients first develop joint inflammation.
• Patterns of joint involvement are various.
  Approximately 40 of patients present with
  symmetric oligoarthritis of the large joints of
  the lower extremities, and 25 of these patients
  develop small-joint polyarthritis, similar to RA.
  Spinal involvement occurs in almost 50 of
  patients with psoriatic arthritis. A
  sausage-shaped finger or toe (dactylitis) may be
  found and the DIP joints are often involved,
  which helps distinguishes psoriatic arthritis
  from RA.
• Patients with psoriatic arthritis tend to be
  seronegative for rheumatoid factor, but at least
  15 are seropositive, as are a similar percentage
  of patients with uncomplicated psoriasis. Serum
  uric acid levels may be elevated in patients with
  psoriatic arthritis because of rapid turnover of
  skin cells. X-rays may show a pencil-in-the-cup
  appearance of one or more involved joints. Other
  radiographic findings include syndesmophytes and
  sacroiliitis of the axial skeleton.

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• Don't Be Tricked
• No relationship exists between the extent of skin
  and joint disease in patients with psoriatic
  arthritis.
• Do not make a diagnosis of gout based solely on
  joint pain and elevated serum uric acid levels.
• Use NSAIDs for mild joint inflammation and
  minimal skin involvement prescribe methotrexate
  for severe skin and erosive peripheral joint
  disease. A TNF-a inhibitor is indicated for
  methotrexate-resistant peripheral disease and may
  be indicated as first-line treatment for patients
  with axial involvement and for those with
  dactylitis or enthesitis that does not respond to
  NSAIDs and locally injected corticosteroids.
  NSAIDs, antimalarial drugs, and (withdrawal from)
  oral corticosteroids may exacerbate psorias

77
Diffuse swelling of the left third and fourth
toes and right fourth toe characteristic of
dactylitis.
78
Tiny pits scattered over the nail plate resulting
from psoriatic involvement of the nail matrix.
79
Question 9

• A 24-year-old woman is evaluated for a 3-week
  history of pain and swelling of the right knee
  and left ankle. She also has urinary frequency
  and urgency. The patient has no history of tick
  exposure, skin rash, diarrhea, or abdominal pain.
  She has not been sexually active in the past
  month. She takes no medications.
• On physical examination, vital signs are normal.
  Musculoskeletal examination reveals swelling,
  tenderness, warmth, pain on active and passive
  range of motion, and a palpable effusion of the
  right knee the left ankle is swollen and tender,
  with pain at the extremes of active range of
  motion and no significant pain with passive range
  of motion.
• Serologic test results for Borrelia burgdorferi
  are negative. Urinalysis reveals 2 leukocyte
  esterase, 18 leukocytes/hpf, and no protein,
  bacteria, squamous epithelial cells, or
  erythrocytes.
• Aspiration of the right knee is performed
  synovial fluid analysis reveals an erythrocyte
  count of 150/µL and a leukocyte count of 7500/µL
  (7.5 109/L). Gram stain is negative. Synovial
  fluid culture results are pending.

80
Answer Choice

• Which of the following is the most appropriate
  next step in management?
• A Antinuclear antibody testing
• B Rheumatoid factor testing
• C Synovial fluid polymerase chain reaction
  testing for Borrelia burgdorferi
• D Urine nucleic acid amplification testing for
  Chlamydia trachomatis and Neisseria gonorrhoeae

81
Answer Choice

• Which of the following is the most appropriate
  next step in management?
• A Antinuclear antibody testing
• B Rheumatoid factor testing
• C Synovial fluid polymerase chain reaction
  testing for Borrelia burgdorferi
• D Urine nucleic acid amplification testing for
  Chlamydia trachomatis and Neisseria gonorrhoeae

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Explanation

• This patient requires urine nucleic acid
  amplification testing for Chlamydia trachomatis
  and Neisseria gonorrhoeae. She has acute
  arthritis of the right knee, enthesitis of the
  left ankle, and urethritis, all of which can be
  seen with disseminated gonorrheal infection
  however, in the absence of any recent history of
  sexual activity, these findings are more
  suggestive of reactive arthritis as can be seen
  after C. trachomatis infection. Reactive
  arthritis occurs in both men and women, and
  enthesitis and oligoarthritis are common. The
  classic triad of arthritis, urethritis, and
  conjunctivitis occurs in only one third of
  patients. Symptoms typically develop 2 to 4 weeks
  after an infection.
• Classic pathogens associated with reactive
  arthritis include C. trachomatis as well as
  several enteric pathogens. C. trachomatis
  infection may be asymptomatic. Urine sample
  evaluation with ligase reaction can establish a
  diagnosis of C. trachomatis infection at that
  time, antibiotic treatment (azithromycin or
  levofloxacin) is warranted to prevent potential
  sequelae of untreated disease. Sexual partners
  should also be counseled and treated.
• Antinuclear antibody testing can be helpful in
  the diagnosis of systemic lupus erythematosus
  (SLE). Although arthritis and pyuria can be seen
  in SLE, the pyuria typically results from
  glomerulonephritis and is therefore not
  associated with the lower urinary tract symptoms
  of frequency and urgency. The patient does not
  have any other symptoms or signs of SLE.

83
Explanation

• Rheumatoid factor is present in approximately 70
  of patients with rheumatoid arthritis. This
  disorder typically presents with a symmetric,
  small joint polyarthritis and does not explain
  this patient's urinary symptoms and pyuria.
• This patient's negative Lyme disease serology
  results indicate that she does not have Lyme
  arthritis, and testing the synovial fluid for
  Borrelia burgdorferi infection is not needed. In
  patients with Lyme arthritis, testing by
  polymerase chain reaction (PCR) can detect B.
  burgdorferi DNA in synovial fluid. Unlike B.
  burgdorferi serology, synovial fluid PCR testing
  becomes negative after successful antibiotic
  treatment. However, synovial fluid PCR testing
  has not been validated for wide use.
• Key Point
• Detection of pathogens such as Chlamydia
  trachomatis in patients with arthritis,
  urethritis, conjunctivitis, and/or enthesitis
  supports a diagnosis of reactive arthritis.

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Reactive Arthritis

• Reactive arthritis is an acute aseptic
  inflammatory arthritis that occurs 1 to 3 weeks
  after an infectious event originating in the GU
  or GI tract. A high prevalence of HIV infection
  is found in patients with symptoms of reactive
  arthritis.
• Characteristic findings include
• acute asymmetric oligoarthritis (usually in
  weight-bearing joints)
• dactylitis
• mouth ulcers
• inflammatory eye conditions
• Patients may also have keratoderma
  blennorrhagicum (a psoriasis-like skin lesion on
  the palms and soles) or circinate balanitis
  (shallow, moist, serpiginous ulcers with raised
  borders on the glans penis).

85

• Diagnostic studies include throat culture for
  Streptococcus, urogenital culture for Chlamydia,
  and serologic studies for Salmonella, Yersinia,
  Campylobacter, Neisseria, and HIV. Obtain
  urinalysis for protein, blood, and leukocytes.
• If the causative organism can be isolated
  (ß-hemolytic streptococci, N. gonorrhoeae,
  Chlamydia), begin specific antibiotics. If
  infection is ruled out, treat with an
  intra-articular corticosteroid injection in the
  acutely inflamed joint. If arthritis persists for
  longer than 3 to 5 months, begin DMARDs.
  Sulfasalazine is a common first-line choice.
• Don't Be Tricked
• The classic triad of arthritis, conjunctivitis,
  and urethritis (or cervicitis) is found in only
  one third of patients with reactive arthritis.
• Do not prescribe chronic antibiotic therapy for
  patients with reactive arthritis.

86
A papular and pustular rash of the palms and
soles is associated with reactive arthritis.
87
Ankylosing Spondylitis

• Ankylosing spondylitis primarily affects the
  spine and sacroiliac joints. It also may involve
  the shoulders and hips, although the small
  peripheral joints are not affected. Ankylosing
  spondylitis occurs most often in patients lt40
  years of age and presents as chronic low back
  pain. Characteristic findings are pain and
  stiffness that worsen at night and are relieved
  with physical activity or heat.
• Physical examination findings include
• decreased hyperextension, forward flexion,
  lateral flexion, and axial rotation
• diminished chest expansion
• asymmetric peripheral arthritis involving the
  large joints
• painful heels (enthesitis)
• X-rays show subchondral bony sclerosis, vertebral
  body squaring, and bony ankylosis (bamboo
  spine). When radiographic findings are equivocal
  or absent, MRI can detect the early changes of
  sacroiliitis. HLA-B27 testing is neither
  sensitive nor specific for ankylosing spondylitis
  and does not distinguish ankylosing spondylitis
  from other spondyloarthropathies.

88

• Extra-articular manifestations include acute
  anterior uveitis (most common), aortic valvular
  regurgitation and cardiac conduction defects,
  apical pulmonary fibrosis and cavitation, and
  cauda equina syndrome.
• A patient with ankylosing spondylitis with
  increased pain and mobility of the neck following
  a minor accident may have a fracture and requires
  an urgent CT of the cervical spine.
• Don't Be Tricked
• Ankylosing spondylitis occurs in both men and
  women.
• NSAIDs, not aspirin, are the mainstay of
  management. Use corticosteroid injections for
  recalcitrant enthesitis and persistent synovitis.
  Prescribe sulfasalazine for patients with
  primarily peripheral arthritis and a TNF-a
  inhibitor for primarily axial disease. Calcium
  and vitamin D supplements and exercise to retain
  good posture, spinal mobility, and chest
  expansion are beneficial. Begin a bisphosphonate
  if osteopenia or osteoporosis is present.
• Don't Be Tricked
• Do not prescribe traditional DMARDs for patients
  with axial disease because they are ineffective.
  Select a TNF-a inhibitor.

89
Sclerosis and erosions of sacroiliac joints and
bridging of the intervertebral disks by
syndesmophytes are characteristic of ankylosing
spondylitis.
90
IBD-Associated Arthritis

• Inflammatory arthritis can complicate Crohn
  disease and ulcerative colitis. Up to 20 of
  patients with IBD develop a peripheral arthritis,
  which manifests as either a polyarticular
  arthritis resembling RA or an asymmetric
  oligoarthritis predominantly of the lower
  extremities resembling reactive arthritis. The
  course of arthritis often fluctuates with the
  activity of the underlying bowel involvement.
  Another 20 of patients have spinal involvement
  ranging from asymptomatic sacroiliac disease to a
  clinical presentation identical to that of
  ankylosing spondylitis. Unlike peripheral
  arthritis, the progression of spinal involvement
  is independent of the course of the bowel
  disease.
• The therapies that benefit intestinal disease
  also have efficacy in the treatment of the
  associated peripheral joint and extra-articular
  manifestations. These therapies include
  corticosteroids, sulfasalazine, azathioprine,
  methotrexate, infliximab, and adalimumab.
• Don't Be Tricked
• Etanercept has not shown efficacy in treating IBD.

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