004. Spondyloarthritides

Question 1

What are the spondyloarthritidies?

Give some examples of the different conditions?

Answer 1

Group of related chronic inflammatory conditions that typically affect the axial (midline) skeleton. They are linked by common features

Ankylosing spondylitits
Enteric arthropathy
Psoriatic arthritis
Reactive arthritis

Question 2

What are the shared features the spondyloarthritidies exhibit?

Answer 2

Seronegativity (Rf-ve)

HLA B27 associations

Axial arthritis (sacroiliac and spine)

Asymmetrical large joint osteoarthritis (<5 joints)

Enthesitis (inflammation of insertion point e.g. plantar fascitis)

Dactilytis- inflammation of an entire digit

Extra-articular diseases e.g.g uveitis, oral ulcers, IBD

Question 3

What is ankylosing spondylitis?

Answer 3

Chronic inflammatory disease of the spine and sacroiliac joints with unknown aetiology

Question 4

How does ankylosing spondylitis typically present

Answer 4

Typical patient is a man under 30 with lower back pain that has a gradual onset.

Worse during the night with with spinal stiffness relieved by exercise

Pain radiates from sacroiliac joint to hips/buttocks and usually improves towards the end of the day.

Progressive loss of spinal movement

Question 5

What features may ankylosing sponylitits progress to?

Answer 5

Kyphosis

Neck hyperextension

Spino-cranial ankylosis

Question 6

What other features are associated with AS?

Answer 6

Enthesitis (achilles tendonitis, plantar fascitis)

Anterior mechanical chest pain

Fatigue

Anterior iririts

Osteoperosis, aortic valve incompetance, pulmonary apicla fibrosis (rare)

Question 7

What investigations are undertaken when AS is suspected?

Answer 7

Clinical assessment

MRI scan to see active inflammation and destructive changes

Bloods (ESR, FBC, normocytic anaemia, CRP)

HLA B27

Question 8

How is ankylosing spondylitits managed?

Answer 8

Exercise for back ache and physio

NSAIDS

TNF a blockers

Local steroid injections

Surgery ? hip replacement if severe hip involvement

Question 9

What is enteric arthropathy?

Answer 9

Joint inflammations associated with IBD, GI bypass and Whiplle’s disease

Arthropathy usually improves with treatment of bowelsymptoms (beware NSAIDS)

Question 10

Psoriatic arthritis can present in between 10 and 40% of people with arthritis. What are the patters of the disease?

Answer 10

Symmetricla polyarthritis

DIP joint involvement

Asymetricla oligoarthritis

Spinal involvment (similar to AS)

Question 11

What radiological feature would you expect to see with psoriatic arthritis?

Answer 11

Pencil in cup deformity

Question 12

What other symptoms are classic with psoriacic arhtritis

Answer 12

Nail changes

Acneifrom rashes

Palmo-plantar pustulosis

Question 13

What is the management of psoriatic arhtritis?

Answer 13

NSAIDS

Sulfasalazine, methotrexate

Anti TNF may also be effective

Question 14

What is reactive arthritis?

Answer 14

Condition in which arthritis and other clincial manifestations occur as an autoimmune response to infection

Question 15

Aside form the shared features that occur in spondyloarthritides, what features occur in reactive arthritis?

(all occur outside joints)

Answer 15

Iritis

Keratoderma blenorrhagica (raised bits on the soles and palms)

Circinate balantis (penis ulceration)

Mouth ulcers

Question 16

What tests are undertaken in reactive arthritis?

Answer 16

ESR and CRP raised

Culture stool if diarrhoea

Sexual health review

Question 17

What is the management of reactive arthritis?

Answer 17

Splint joints acutely

NSAIDS/local joint injections will relieve pain

Consider sulfasalazine or methotrexate if symptoms last >6 months

Treating original infection may make little difference