ARTRITI POST-INFETTIVE O REATTIVE 3.pdf · • (Artrite Reattiva Post-streptococcica) •...

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ARTRITI POST-INFETTIVE O REATTIVE

POST-FARINGITICHE

POST-URETRITICO / DISSENTERICHE

MALATTIA REUMATICA ACUTA

SEQUELA RITARDATA (1-5 settimane; media 19 giorni)

NON SUPPURATIVA

DI UNA FARINGITE DA STREPTOCOCCO β-EMOLITICO

DI GRUPPO A

scaricato da www.sunhope.it

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MALATTIE POST-STREPTOCOCCICHE

POST-FARINGITICHE

POST-PIODERMITICHE

MALATTIA REUMATICA ACUTA

ERITEMA NODOSO

ARTRITE POST-STREPTOCOCCICA

GLOMERULONEFRITE POST-STREPTOCOCCICA


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CRITERI DIAGNOSTICIvs

CRITERI CLASSIFICATIVI

• Diagnostici: utili per la diagnosi nel singolopaziente( comprendono manifestazioni frequentianche se aspecifiche)

• Classificativi: utili per assicurare la comparabilità fra casistiche raccolte in centridiversi( si fondano su manifestazioni specifiche)


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To measure the overall impact of a disease

Outcome criteria

To assess present disease activity or accumulated damage from the disease

Disease status criteriaActivity indices

Damage indices

To separate subjects with a good or potentially favourable outcome from those with a poor outcome

Prognostic criteria

To separate those with a subset of disease within a disease cluster

Subclassification criteria

To distinguish those with a specific disease from those without it

Classification criteria

TYPES OF CRITERIA IN THE RHEUMATIC DISEASESJ.Fries et al 1994


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ARTRITE (75%)

Poliartrite migrante aggiuntiva a carico prevalentemente delle grosse articolazioni

Gomito dx

Ginocchio sx

Caviglia dx

Gomito sx

Spalla dx

21 76543 8 109 11

Giorni12

CARDITE (40%)

Soffi

Cardiomegalia

Pericardite

Scompenso cardiaco congestizio


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CLINICAL MANIFESTATIONS OF CARDITIS IN ACUTE REUMATIC FEVER

Murmurs

Apical systolic

Apical mid-diastolic (Carey Coombs murmur)

Basal diastolic

Pericarditis

Cardiomegaly

Congestive heart failure


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• Corea di Sydenham

(15%)

?

Post-streptococcal autoimmuneneuropsychiatric disorder

(PANDAS)

Noduli sottocutanei

(10%)


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THE MANY FACES OF ACUTE REUMATIC FEVER:

POSSIBLE FEATURES

High fever, prostration, crippling polyarthritis

Lassitude, tachycardia, new cardiac murmurs

Acute pericarditis

Fulminant heart failure

Sydenham’s chorea without fever or toxicity

Acute abdominal pain mimicking appendicitis

Varying combinations of the above


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months

ETIOPATOGENESI1

Infezione faringea da streptococco β emolitico di gruppo A reumatogeni (3,5,18,24)

+

Predisposizione genetica

( Alloantigene B linfocitario non-HLA nel 100%)


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LESIONE ELEMENTARE


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ETIOPATOGENESI2

• Tossine streptococciche

• Immunocomplessi

• Superantigeni

• MIMETISMO MOLECOLARE


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• (Artrite Reattiva Post-streptococcica)

• Endocardite Infettiva

• Artrite Cronica Giovanile ad esordio sistemico

• Cardiopatie congenite

• Soffi funzionali

• Lupus Sistemico

• Altre

DIAGNOSI DIFFERENZIALE


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TERAPIA

ACIDO ACETILSALICILICO 100 mg/Kg/die

CORTICOSTEROIDI 1 mg/Kg/die

PENNICILLINA G ritardo 600.000-1.200.000 U.

PROFILASSI DELLE RECIDIVE

PENICILLINA G ritardo


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SECONDARY PREVENTION OF RHEUMATIC FEVER(PREVENTION OF RECURRENT ATTACKS)

AGENT DOSE MODEBenzathine penicillin G 1.200.000 U every 4 wkIntramuscular

or

Penicillin V 250 mg twice daily Oral

or

Sulfadiazine 0.5 g once daily for patients Oral ≤ 27 Kg (60 lb)

1,0 g once daily for patients > 27 Kg (60 lb)

For individuals allergic to Penicillin and Sulfadiazine

Erytrhomycin 250 mg twice daily Oral

DURATION OF SECONDARY RHEUMATIC FEVER PROPHYLAXIS

CATEGORY DURATION

Rheumatic fever with carditis At least 10 yr since last episode and residual heart disease and at least until age 40 yr (persistent valvular disease) sometimes lifelong prophilaxis

Rheumatic fever with carditis 10 yr or well into adulthood but no residual heart disease whichever is longer

(no valvular disease)

Rheumatic fever without carditis 5 yr or until age 21 yr, whichever is longer


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PROPHYLACTIC REGIMENS FOR BACTERIAL ENDOCARDITIS

Dental, Oral, Respiratory Tract, and Esophageal Procedures in Patients at High and Moderate Risk

Standard regimen

Amoxicillin 2,0 g orally 1 hr before procedure

Amoxicillin/Penicillin-allergic patients

Azithromycin or Clarithromycin 500 mg orally 1 hr before procedure

Standard regimen

Ampicillin, Amoxicillin, Gentamicin

IV or IM administration of ampicillin, and 2 g plus gentamicin, 1,5 mg/kg (not to exceed 12 mg), within 30 min of starting procedure; 6hr later, ampicillin, 1,0 g IV/IM, or amoxicillin, 1 g orally.

Ampicillin/amoxicillin/penicillin-allergic patients

Vancomycin ± Gentamicin

IV or administration of vancomycin, 1,0 g over 1-2 hr, plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete infusion or injection within 30 min of starting procedure.

Genitourinary/Gastrointestinal (excluding Esophageal) Procedures in Patients at High and Moderate Risk

PROPHYLACTIC REGIMENS FOR BACTERIAL ENDOCARDITIS


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ARTRITI REATTIVE

POST-URETRITICHE/DISSENTERICHE

SINDROME DI REITER

URETRITE

CONGIUNTIVITE

ARTRITE


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INFECTIOUS ORGANISM ASSOCIATED WITH THE ONSET OF REITER’S SYNDROME

ENTERIC PATHOGENES UROGENITAL PATHOGENES

Shigella flexneri (serotypes 2a, 1b) Chlamydia trachomatisSalmonella typhimurium Chlamydia psittaciSalmonella enteritidis Ureaplasma urealyticumSalmonella paratyphiSalmonella heidelbergYersinia enterocolitica (serotypes 0:3, 0:8, 0:9)Yersinia pseudotuberculosisCampylobacter jejuniCampylobacter fetus


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SPONDILARTRITI SIERONEGATIVE

Reumatismi infiammatori accomunati da aspetti :

Clinici

Sierologici

Radiologici

Genetici


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SPONDILARTRITI SIERONEGATIVE

Spondilartrite anchilosante

Artriti reattive (Sindrome di Reiter)

Artrite psoriasica

Artriti associate a malattie infiammatorieintestinali

COMPARISON OF THE SPONDYLOARTHROPATHIES

FEATURE ANKYLOSING POST-URETHRAL POST-DYSSENTERIC ENTEROPATHIC PSORIATIC SPONDYLITIS REACTIVE REACTIVE ARTHRITIS ARTHRITIS

ARTHRITIS ARTHRITIS

Sacroiliitis +++++ +++ ++ + ++

Spondylitis ++++ +++ ++ ++ ++

Peripheral Arthritis + ++++ ++++ +++ ++++

Articular Course Chronic Acute or chronic Acute>Chronic Acute or chronic Chronic

HLA-B27 95% 60% 30% 20% 20%

Enthesopathy ++ ++++ +++ ++ ++

Common Eye Eye GU GI Skin extra- articular Heart GU Eye Eye Eyemanifestation Oral/GI

Heart

Other names von Bechterev’s Reiter’s syndrome Reiter’s syndrome Crohn’s diseaseMarie-Strümpell SARA, NGU ulcerative colitis

chlamydial arthritis


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Sottogruppi di artrite psoriasica

Oligoartrite

Poliartrite simmetrica similreumatoide

Artrite delle DIP

Spondilartrite

Arthritis Mutilans.


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DIAGNOSTIC CRITERIA FOR THE SPONDYLOARTHROPATHIES Slide a

Rome Criteria Reiter’s Syndrome

Low back pain and stiffness >3 Peripheral arthritis >1 mo association mo, not relieved by rest with Urethritis and/or cervicitis

Pain and stiffness in the thoracicregion

Limited motion of the lumbarspine

Limited chest expansion

History of iritis

Radiographic evidence of bilateral sacroiliitis

Criteria for Psoriatic Arthritis Cutaneous evidence of psoriasis plus inflammatory peripheral arthritis or spondylitis ≥6 wk

Diagnosis required 4 of the 1st 5 criteria or sacroiliitis plus 1 of the clinical criteria

ESSG Criteria for spondyloarthropathy (1992)

Inflammatory spinal pain or peripheral synovitis (asymmetrical or lower limbs)

Plus one or more of the following: Alternate buttock pain Sacroiliitis EnthesopathyPositive family history Psoriasis Inflammatory bowel disease Urethritis, cervicitis, or acute diarrhea occurring within 1 mo of the onset of arthritis

DIAGNOSTIC CRITERIA FOR THE SPONDYLOARTHROPATHIES


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Criteria for Diagnosing Spondyloarthropathies by Amoret al. (1993)

Lumbar pain at night or morning stiffness

Asymmetrical oligoarthtritis

Buttock painAlternating buttock pain

Sausage-like toe or digt(s)

Heel pain or enthesitis

Iritis

Non-gonococcal urethritis/cervicitis within 1 mo of onset

Acute diaeehrea within 1 mo of arthritis onset

Psoriasis, balanitis, or inflammatory bowel disease

Sacroiliitis (bilateral grade 2 or unilateral grde 3)

HLA-B27+ or positive family history of a spondyloarthropathy

Rapid (<48 hr ) response to NSAIDs

1

2

1

2

2

2

2

1

1

2

2

2

2

ScoreDiagnosis requires score ≥6

DIAGNOSTIC CRITERIA FOR THE SPONDYLOARTHROPATHIES

Is there:

Inflammatory arthritis that is asymmetric or predominantly lower extremity?

and/or

Back pain of insidious onset of > 3 mo duration associated with morning . stiffness and improvement with activity

Unlikely to be a spondyloarthropathy

NO Yes

Is there evidence of psoriasis or inflammatory bowel disease

Yes

Consider enteropathicor psoriatic arthritis

Slide b

NO

ALGORITHM FOR DIAGNOSIS OF SPONDYLOARTHROPATIES


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Is there one or more of the following?

Radiographic evidence of sacroiliitis

Enthesopathy

Dactylitis (sausage digits)

Buttock pain (bilateral or alternating)

Urethritis or cervicitis or acute diarrhea within 1 month of arthritis onset

Family history of spondyloarthropathy

Iritis

HLA-B27 (+)

Unlikely to be a spondyloarthropathy

No Yes

Likely to be a spondyloarthropathy

Slide c


Is there evidence of spondylitis ?

Inflammatory spinal pain and limitation of movement or

Radiographic sacroiliitis or

Vertebral ankylosis

No Yes

Probably ankylosingsspondylitis

Probably reactive arthritis/Reiter’s

syndrome

Is there evidence of clamydial infection?

(ie, elevated antichlamydialantibody titers)

No Yes

Reactive arthritis/Reiter’s

syndrome

Chlamydialassociated

reactive arthritis


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TREATMENT ALGORYTHM IN PATIENTS WITH A SPONDYLOARTHROPATHY

Diagnosis of spondyloarthropathy

Is there evidence of Chlamydial infection or infectious diarrhea?

Consider:

•NSAIDs

•Physical therapy

Consider:

•Antibiotic therapy

•NSAIDs

•Physical therapy

No Yes

Patient evaluation:

Slide a

TREATMENT ALGORITHM PATIENTS WITH A SPONDYLOARTHROPATHYSlide b

Patient evaluation:Is there NSAID unacceptable toxicity?

Can side effects be controlled by other ?

Consider therapy with second-line agent, such as:

•Sulfasalazine

•Methotrexate

•Anti-TNF alfa

Is there adequate control of symptoms?

Continue therapeutic program Patient evaluation

Has NSAID therapy been optimized?

Optimize NSAID therapy

Is there adequate control of symptoms?

Continue therapeutic program

Patient evaluation

Yes

Yes No

No

No

No

Yes

Yes

No

NSAID


ARTRITI POST-INFETTIVE O REATTIVE 3.pdf · • (Artrite Reattiva Post-streptococcica) •...

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