Page 809 - Clinical Immunology_ Principles and Practice ( PDFDrive )

780 Part six Systemic Immune Diseases

TABLE 57.4 Extraintestinal Manifestations TABLE 57.5 Frequencies of Different
of inflammatory Bowel Disease symptoms and signs in Patients With
Undifferentiated spondyloarthritis
Crohn Disease Ulcerative Colitis
Feature (%) (%) Feature Percent (%)
Peripheral arthritis 15 10 Demographic
Axial arthritis 15–20 10–15 Males 62–88
Septic arthritis Rare No association Mean age at onset (years) 16–23
Skin <9 <1
Aphthous ulcers Rare 8 Clinical
Nephrolithiasis <15 No association Low-back pain 52–80
Liver disease 3–5 7
Uveitis 13 4 Peripheral arthritis 60–100
Polyarthritis
40
Vasculitis Takayasu arteritis <5
Clubbing of fingers 4–13 1–5 Enthesopathy 56
Heel pain 20–28
Mucocutaneous involvement 16
Conjunctivitis 33
Genitourinary disease 28
involvement may precede the development of IBD, has no gender Inflammatory bowel disease 4
predilection, and resembles the development of AS. The axial Cardiac abnormalities 8
symptoms do not parallel activity of IBD. In addition to spon-
dylitis, an isolated sacroiliitis occurs that is often asymmetric Laboratory
and not associated with HLA-B27. Elevated erythrocyte sedimentation rate 19–30
Mucocutaneous complications of IBD include erythema Human leukocyte antigen (HLA)-B27 positive 80–84
nodosum, which occurs in fewer than 10% of those with CD radiographic
and is rare in UC; pyoderma gangrenosum, seen in slightly over Sacroiliitis 16–30
1% of those with CD and rarely occurring in those with UC; Spinal radiographic changes 20
and, rarely, erythema multiforme. Painful aphthous ulcers occur
in about 8% of those with UC and are rare in CD. Adapted from Chen CH, Lin KC, Yu DT, et al. Serum matrix metalloproteinases and
The uveitis with IBD that is bilateral, posterior, insidious in tissue inhibitors of metalloproteinases in ankylosing spondylitis: MMP-3 is a
reproducibly sensitive and specific biomarker of disease activity. Rheumatol (Oxf)
onset, and/or chronic in duration contrasts with the uveitis 2006; 45: 414–420.Table 56.6 Measurements of disease outcome in spondyloarthritis.
associated with other types of SpA, which is predominantly
anterior, unilateral, sudden in onset, and limited in duration.
Only 46% of patients with uveitis associated with IBD are
HLA-B27 positive, as opposed to 89% of the patients with SpA. AS is not excluded by normal ESR and/or CRP levels. Synovial
Episcleritis, scleritis, and glaucoma are more common among fluid does not differ in appearance or cytology from that of any
patients with IBD than in those with SpA. inflammatory joint disease.
Undifferentiated Spondyloarthritis
Patients who do not meet criteria or clinical features of the DIAGNOSIS
“classic” spondyloarthritides are regarded as having undifferenti-
ated SpA. Generally, at presentation, about 40% of patients will In most cases, SpA is largely diagnosed, or at least initially
30
be classified as having undifferentiated SpA, and the frequency suspected, on clinical grounds. Current criteria for AS demand
of HLA-B27 reaches around 80% in Caucasians (Table 57.5). that the patient have radiographic sacroiliitis (at least grade II
Follow-up studies suggest that over time about one-third will bilaterally or grade III unilaterally) in conjunction with clinical
go into remission and more than half will develop a “classic” signs of inflammatory back pain and limitation of spinal mobility.
SpA, usually AS. 30 However, given that up to 10 years can pass from the onset of
inflammatory back pain and the development of radiographic
sacroiliitis, many of those with inflammatory back pain might
LABORATORY INVESTIGATIONS not have radiographic evidence of sacroiliitis. With the develop-
ment of effective treatments (i.e., anti-TNF blockers), criteria
The most useful investigations in SpA come from musculoskeletal have been developed for earlier diagnosis of axial SpA that take
imaging, but some laboratory tests are informative. into account recent advances in MRI scanning as well as the
Data on the correlation of erythrocyte sedimentation rate added benefit provided in HLA-B27 testing. 5,6
(ESR) and cross-reactive protein (CRP) in the assessment of
disease activity in SpA show ambiguous results, although most Measures of SpA Activity and Severity
studies suggest that CRP performs better. A recent literature In the past few years, outcome measures have been developed
review on the validity of ESR and CRP in AS concluded that and validated to quantitate disease activity and severity; these
ESR and CRP do not comprehensively represent the disease are summarized in Table 57.6. These instruments are extensively
process and thus do not have the same validity as in RA. 13,30 validated and easy to administer in clinical practice and have
Generally, it is felt that patients with peripheral joint involvement been shown to perform well in clinical trials. The Ankylosing
or with IBD more often have elevated ESR and CRP than patients Spondylitis Disease Activity Scale (ASDAS) has recently been
13
with axial disease. However, the presence of clinically active developed to gauge disease activity.