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Spondyloa rth ritis Ankylosing Spondylitis PsoriaticArthritis EnteropathicArthritis ReactiveArthritis Musculoskeletal Axial involvement Axial involvement is May occur at any level; May have Less common than in hallmark; initially may start in the cervical asymptomatic or other forms of symmetric involvement spine; may skip regions asymmetric Sl joint spondyloarthritis but o{ Sl joints and lower disease or have typical may be asymmetric spine, progressing ankylosing spondylitis; cranially axial disease does not parallel bowel activity Peripheral Enthesitis; may have Clinical subtypes of PsA: Pauciarticular large and Enthesitis, tenosynovitis involvement asymmetric large-joint medium joints; and asymmetric large- 1. Oligoarthritis peripheral arthritis can joint oligoarthritis; oligoarthritis, including 2. Polyarthritis parallel IBD activity usually self-limited and hips and shoulders; hip 3. DlP-predominant nonerosive; persistent involvement can cause 4. Arthritis mutilans Polyarticular peripheral arthritis in up to 25olo si gnifica nt functional 5. Axial spine involvement arthritis of small and and may develop MTP limitation; dactylitis large joints does not Enthesitis, dactylitis, and erosions parallel bowel disease; tenosynovitis are dactylitis; enthesitis commonly seen Dermatologic Psoriatic-like lesions Psoriasis typically hToderma Keratoderma may rarely occur precedes joint gangrenosum; blennorrhagicum and involvement; nail erythema nodosum circinate balanitis (rare) pitting; onychodystrophy

Ankylosing Spondylitis PsoriaticArthritis EnteropathicArthritis ReactiveArthritis Musculoskeletal Axial involvement Axial involvement is May occur at any level; May have Less common than in hallmark; initially may start in the cervical asymptomatic or other forms of symmetric involvement spine; may skip regions asymmetric Sl joint spondyloarthritis but o{ Sl joints and lower disease or have typical may be asymmetric spine, progressing ankylosing spondylitis; cranially axial disease does not parallel bowel activity Peripheral Enthesitis; may have Clinical subtypes of PsA: Pauciarticular large and Enthesitis, tenosynovitis involvement asymmetric large-joint medium joints; and asymmetric large- 1. Oligoarthritis peripheral arthritis can joint oligoarthritis; oligoarthritis, including 2. Polyarthritis parallel IBD activity usually self-limited and hips and shoulders; hip 3. DlP-predominant nonerosive; persistent involvement can cause 4. Arthritis mutilans Polyarticular peripheral arthritis in up to 25olo si gnifica nt functional 5. Axial spine involvement arthritis of small and and may develop MTP limitation; dactylitis large joints does not Enthesitis, dactylitis, and erosions parallel bowel disease; tenosynovitis are dactylitis; enthesitis commonly seen Dermatologic Psoriatic-like lesions Psoriasis typically hToderma Keratoderma may rarely occur precedes joint gangrenosum; blennorrhagicum and involvement; nail erythema nodosum circinate balanitis (rare) pitting; onychodystrophy Ophthalmologic Anterior uveitis Conjunctivitis more Anterior uveitis most Conjunctivitis more (unilateral, recurrent) common than anterior common; conjunctivitis, common than anterior uveitis keratitis, and episcleritis uveitis are rare G astrointestina I 60% with ileocolitis on Dysbiosis may play a Gl inflammation is Preceding Gl infection colonoscopy role in inflammation hallmark common Genitourinary Urethritis (rare) Prior GU infection in some patients; sterile urethritis; prostatitis; cervicitis; salpingitis Cardiovascu lar lncrease in CAD; aortic lncrease in CAD Thromboembolism Rare aortic valve disease valve disease; aortitis; and conduction conduction abnormalities abnormalities Pulmonary Restrictive lung disease Rare cases of large from costovertebral airway stenosis rigidity; apical fibrosis (rare) Bone quality Falsely elevated bone lncreased risk for High risk for vitamin D Localized osteopenia mineral density from fracture (multifactorial) deficiency, low bone syndesmophytes; density, and fracture increased risk for spine fractu re

Ophthalmologic Anterior uveitis Conjunctivitis more Anterior uveitis most Conjunctivitis more (unilateral, recurrent) common than anterior common; conjunctivitis, common than anterior uveitis keratitis, and episcleritis uveitis are rare G astrointestina I 60% with ileocolitis on Dysbiosis may play a Gl inflammation is Preceding Gl infection colonoscopy role in inflammation hallmark common Genitourinary Urethritis (rare) Prior GU infection in some patients; sterile urethritis; prostatitis; cervicitis; salpingitis Cardiovascu lar lncrease in CAD; aortic lncrease in CAD Thromboembolism Rare aortic valve disease valve disease; aortitis; and conduction conduction abnormalities abnormalities Pulmonary Restrictive lung disease Rare cases of large from costovertebral airway stenosis rigidity; apical fibrosis (rare) Bone quality Falsely elevated bone lncreased risk for High risk for vitamin D Localized osteopenia mineral density from fracture (multifactorial) deficiency, low bone syndesmophytes; density, and fracture increased risk for spine fractu re CAD = coronary artery disease; DIP = distal interphalangeal; Gl = gastrointestinal; GU = genitourinary; IBD = inflammatory bowel disease; MCP = metacarpophalangeal; MTP = metatarsophalangeal; PIP = proximal interphalangeal; PsA = psoriatic arthritis; Sl = sacroiliac.

Ophthalmologic Anterior uveitis Conjunctivitis more Anterior uveitis most Conjunctivitis more (unilateral, recurrent) common than anterior common; conjunctivitis, common than anterior uveitis keratitis, and episcleritis uveitis are rare G astrointestina I 60% with ileocolitis on Dysbiosis may play a Gl inflammation is Preceding Gl infection colonoscopy role in inflammation hallmark common Genitourinary Urethritis (rare) Prior GU infection in some patients; sterile urethritis; prostatitis; cervicitis; salpingitis Cardiovascu lar lncrease in CAD; aortic lncrease in CAD Thromboembolism Rare aortic valve disease valve disease; aortitis; and conduction conduction abnormalities abnormalities Pulmonary Restrictive lung disease Rare cases of large from costovertebral airway stenosis rigidity; apical fibrosis (rare) Bone quality Falsely elevated bone lncreased risk for High risk for vitamin D Localized osteopenia mineral density from fracture (multifactorial) deficiency, low bone syndesmophytes; density, and fracture increased risk for spine fractu re CAD = coronary artery disease; DIP = distal interphalangeal; Gl = gastrointestinal; GU = genitourinary; IBD = inflammatory bowel disease; MCP = metacarpophalangeal; MTP = metatarsophalangeal; PIP = proximal interphalangeal; PsA = psoriatic arthritis; Sl = sacroiliac. entheses, and peripheraljoints. Ankylosing spondylitis is also Articular Manifestations known as a radiographic axial spondyloarthritis. Prevalence Ankylosing spondylitis initially presents with subacute onset is 0.32% in North America but only O.O7ok in Africa, largely of inflammatory low back pain, including pain and stiffness of following the population prevalence of HLA-B27. Ankylosing the low back and/or buttocks at night and in the morning that spondylitis is more frequent in men than women (ratio, improves with activity. The synovial facet joints are also 2 3:1). The penetrance of ankylosing spondylitis is 12'lu lrom involved, and back extension may be painful. Over time, the father to son and 5'2, from father to daughter, highlighting the thoracic and cervical spine can become involved. The disease protective effect of female sex. The disorder usually begins in has three phases: inflammation; fibrosis; and ossification, the third to fourth decades (typically before age 45 years). It which can drastically limit range of spinal motion. If untreated, can occur as early as the teen years and as late as the sixties patients can assume a kyphotic stance and may only be able to in rare cases. look at their shoes as they walk. This is due to the 40'l" flexion

entheses, and peripheraljoints. Ankylosing spondylitis is also Articular Manifestations known as a radiographic axial spondyloarthritis. Prevalence Ankylosing spondylitis initially presents with subacute onset is 0.32% in North America but only O.O7ok in Africa, largely of inflammatory low back pain, including pain and stiffness of following the population prevalence of HLA-B27. Ankylosing the low back and/or buttocks at night and in the morning that spondylitis is more frequent in men than women (ratio, improves with activity. The synovial facet joints are also 2 3:1). The penetrance of ankylosing spondylitis is 12'lu lrom involved, and back extension may be painful. Over time, the father to son and 5'2, from father to daughter, highlighting the thoracic and cervical spine can become involved. The disease protective effect of female sex. The disorder usually begins in has three phases: inflammation; fibrosis; and ossification, the third to fourth decades (typically before age 45 years). It which can drastically limit range of spinal motion. If untreated, can occur as early as the teen years and as late as the sixties patients can assume a kyphotic stance and may only be able to in rare cases. look at their shoes as they walk. This is due to the 40'l" flexion 34

Spondyloarthritis Back pain >3 months and Age at onset <45 years Sacroiliitis on plain radiography or MRI Yes No 1 or more features of spondyloarthritis HLA-B27 positivity meet criteria for radiographic plus axial spondyloarthritis 2 or more features of spondyloarthritis meet criteria for nonradiographic axial spondyloarthritis Features of spondyloarthritis . lnflammatory back pain . Arthritis . Enthesitis o Uveitis . Dactylitis . Psoriasis . lnflammatory bowel disease . Good response to NSAIDs . Family history of spondyloarthritis . HIA-B.27 positivity . Elevated C-reactive protein level FIGURE 1 5. AssessmentofSpondyloArthritis international Societyclassification criteria foraxial spondyloarthritis.

Features of spondyloarthritis . lnflammatory back pain . Arthritis . Enthesitis o Uveitis . Dactylitis . Psoriasis . lnflammatory bowel disease . Good response to NSAIDs . Family history of spondyloarthritis . HIA-B.27 positivity . Elevated C-reactive protein level FIGURE 1 5. AssessmentofSpondyloArthritis international Societyclassification criteria foraxial spondyloarthritis. rule of swollen synovial joints: Patients are most comfortable Arthritis or enthesitis or dactylitis when the spinal facet joints are in the 40% flexed position plus when swollen; when lying down, patients will prop their back 1 or more additional spondyloarthritis feature

rule of swollen synovial joints: Patients are most comfortable Arthritis or enthesitis or dactylitis when the spinal facet joints are in the 40% flexed position plus when swollen; when lying down, patients will prop their back 1 or more additional spondyloarthritis feature with two or three pillows to be comfortable. Fibrosis and ossi- fication of the spine then occur in this position. Ossification of the spine occurs at the vertebral entheses and is visible radio- graphically as syndesmophytes and ossification of the spinal Spondyloarthritis features: o Uveitis ligaments. o Psoriasis Enthesitis is most commonly appreciated in the feet at the o Preceding infection plantar fascia and where the Achilles tendon inserts into the . lnflammatory bowel disease heel (Figure 17). Enthesitis of the costovertebral joints can also . HLA-827 positivity o Sacroiliitis on imag;ng affect the chest wall, leading to pain at night and in the morn- ing that improves with movement. Peripheral joint involvement may include the hips (Figrre 18), shoulders, knees, and, less commonly, other joints. The synovial fluid is inflammatory with a predominance of neu- lf none of the above spondyloarthritis features are present, patient must trophils and cell counts ranging from 10,000/pL to 50,000/pL have 2 or more of the following: (ro to so x loell). . Arthritis o Enthesitis . Dactylitis Extra-Articular Manifestations . History of inflammatory back pain Anterior uveitis occurs in up to 27% of patients with ankylos . Family history of spondyloarthritis ing spondylitis. It is episodic, unilateral, and typically self- limited. It generally does not cause permanent visual tIGURE l6.AssessmentofSpondyloArthritisinternationalSocietyclassification damage. criteria for peripheral spondyloarthritis.

with two or three pillows to be comfortable. Fibrosis and ossi- fication of the spine then occur in this position. Ossification of the spine occurs at the vertebral entheses and is visible radio- graphically as syndesmophytes and ossification of the spinal Spondyloarthritis features: o Uveitis ligaments. o Psoriasis Enthesitis is most commonly appreciated in the feet at the o Preceding infection plantar fascia and where the Achilles tendon inserts into the . lnflammatory bowel disease heel (Figure 17). Enthesitis of the costovertebral joints can also . HLA-827 positivity o Sacroiliitis on imag;ng affect the chest wall, leading to pain at night and in the morn- ing that improves with movement. Peripheral joint involvement may include the hips (Figrre 18), shoulders, knees, and, less commonly, other joints. The synovial fluid is inflammatory with a predominance of neu- lf none of the above spondyloarthritis features are present, patient must trophils and cell counts ranging from 10,000/pL to 50,000/pL have 2 or more of the following: (ro to so x loell). . Arthritis o Enthesitis . Dactylitis Extra-Articular Manifestations . History of inflammatory back pain Anterior uveitis occurs in up to 27% of patients with ankylos . Family history of spondyloarthritis ing spondylitis. It is episodic, unilateral, and typically self- limited. It generally does not cause permanent visual tIGURE l6.AssessmentofSpondyloArthritisinternationalSocietyclassification damage. criteria for peripheral spondyloarthritis. 35