Page 811 - Clinical Immunology_ Principles and Practice ( PDFDrive )

782 Part six Systemic Immune Diseases

A B

C D
FiG 57.5 Grading of radiographic sacroiliitis, including (A) grade 0–1 (normal); (B) grade 2–3, with
sclerosis and small erosions; (C) advanced grade 3, with joint space narrowing and large erosions;
and (D) grade 4 (total sacroiliac fusion).

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Hip involvement is a predictive factor for severe disease. Other general, the prognosis of ReA is fairly good. Most cases appear
factors that may suggest severe disease and severe outcome include to remit within 6 months of onset. Given the introduction of
ESR >30 mm/hr; unresponsiveness to NSAIDs; limitation of highly effective biological agents, such as anti-TNF blockers, it
lumbar spine; “sausage” digits; oligoarthritis; or onset at <16 is likely that the long-term prognosis in ReA will improve even
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years. Longitudinal studies in patients with AS revealed that further.
deformities and disability occurred during the first 10 years of
disease and correlated significantly with the occurrence of Psoriatic Arthritis
peripheral arthritis, radiographic changes of AS in the spine, Recent studies—although before the introduction of biological
and the development of “bamboo” spine. 33 treatments—showed that the prognosis of PsA is worse than
Significant risk factors for work disability from several studies previously suggested. 29,37 In one large cohort, 40–57% of patients
3
include older age, longer disease duration, lower level of education, had deforming arthritis, 17% had five deformed joints, and up
reduced physical functioning, pain, and more physically demand- to 19% of patients had disability. Overall, more rapidly progressive
ing jobs. Patients with AS have an overall frequency of disability disease was associated with a greater number of actively inflamed
and economic costs similar to that of RA, with a threefold greater joints, the early use of disease-modifying agents, and the presence
rate of disability than the general population, a higher rate of of HLA-B27 and -B39. Patients with PsA have also been shown
sick leave episodes (up to 50% more), and an overall 8% loss of to have increased mortality, which is associated with a high ESR,
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productivity. Moreover, a growing body of data has shown that high “advanced” medication use, and early radiographic damage.
patients with AS are at risk for early mortality as a result of
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cardiovascular disease. However, the impact of newer agents, Juvenile Spondyloarthritis
such as anti-TNF and anti–IL-17 drugs, on the natural history Although not extensively studied, the prognosis in JSpA is
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of this disease remains to be seen. guarded. Available data suggest that children with disease activity
for >5 years are more likely to be disabled. In fact, the probability
Reactive Arthritis of remission was only 17% after 5 years of disease. Nearly 60%
Early studies of outcome in ReA suggested a relatively poor of children with JSpA have moderate to severe limitation after
prognosis. More recent studies, however, have found that, in 10 years of disease. What is not clear is the extent to which the