Cortex rheumatology - Inflammatory arthropathies 2

Question 1

What are the 4 main seronegative inflammatory arthropathies ?

Answer 1

• Ankylosing spondylitis
• Psoriatic arthritis
• Enteropathic arthritis
• Reactive arthritis.

Think REAP your joints

Question 2

Describe what ankylosing spondilitis is

Answer 2

It is a chronic inflammatory disease of the spine and sacro‐iliac joints which can lead to eventual fusion of the intervertebral joints and SI joints.

Question 3

Who are more commonly affected by ankylosing spondilitis (M or F?) and what age group does it typically occur in ?

Answer 3

• More common in men - 3:1
• Typically occuring between 20-40

Think matty turner

Question 4

What are the common symptoms of ankylosing spondilitis ?

Answer 4

Back pain and stiffness are usually the main symptoms of AS. You may find:

• The pain gets better with exercise, but doesn’t improve or gets worse with rest
• The pain and stiffness is worse in the morning and at night – you may wake up regularly during the night because of the pain
• You have pain in the area around your buttocks

Question 5

What is the characteristic appearance people with ankylosing spondilitis can develop ?

Answer 5

Over time there is loss of spinal movement and development of a “question mark” spine, with loss of lumbar lordosis and increased thoracic kyphosis

Question 6

What test can be done to assess lumbar spine flexion ?

Answer 6

Schobers test - should have flexion of over 20cm

Question 7

What are some of the associated conditions of ankylosing spondilitis ?

Answer 7

• Anterior uveitis - inflam of middle layer of the eye
• Aortitis - inflam of the aorta
• Pulmonary fibrosis - a group of diseases which lead to interstitial lung damage and ultimately fibrosis and loss of the elasticity of the lungs.
• Amyloidosis - a group of rare but serious conditions caused by deposits of abnormal protein, called amyloid, in tissues and organs throughout the body

Question 8

What are some of the radiological features of ankylosing spondilitis ?

Answer 8

Xrays may show sclerosis and fusion of the sacroiliac joints and bony spurs from the vertebral bodies, known as syndesmophytes which can bridge the intervertebral disc resulting in fusion, producing a “bamboo spine”

Think pic shows them on left side of the spine where it shows briding from one vertebral body to the next

Question 9

What are 90% of suffers from ankylosing spondilitis positive for ?

Answer 9

HLA-B27

Question 10

What investigations should you do for ankylosing spondylitis ?

Answer 10

• Bloods + inflam markers
• HLA-B27
• X-ray lumbar spine (later & AP)

2nd line if still suspecting but normal x-ray = MRI spine

Question 11

What is the treatment of ankylosing spondilitis ? (this needs to be done from BMJ best practice)

Answer 11

• 1st line = NSAID’s + Physio/exercise
• 2nd line = anti-TNF inhibitors e.g. etanercept and adalimumab for more aggressive disease.

Question 12

What is psoriatic arthritis ?

Answer 12

A form of arthritis that affects some people who have psoriasis

Question 13

Where does psoriatic arthritis commonly affect ?

Answer 13

Often affects the hands, feet, knees, neck, spine and elbows.

Question 14

What commonly occurs in psoriatic arthritis ?

Answer 14

• Spondylitis - inflammation of the joints of the backbone
• Dactylitis - inflammation of the digits
• Enthesitis - inflammation at tendon, ligament or joint capsule insertions
• Patients usually have nail changes including pitting and onycholysis (lifting of the nail from its nailbed) - pic shows this

Question 15

What is the treatment of psoriatic arthritis ?(check with BMJ)

Answer 15

Similar to RA:

• 1st line: disease-modifying antirheumatic drugs (DMARDs) - methotrexate
• plus: non-steroidal anti-inflammatory drugs (NSAIDs)
• plus: physiotherapy
• plus: intra-articular corticosteroid injection

TNF-alpha inhibitor if don’t respond to DMARD

Question 16

What is enteropathic arthritis ?

Answer 16

It is an inflammatory arthritis involving the peripheral joints and sometimes spine, occurring in patients with inflammatory bowel disease (Crohn’s disease and UC).

Question 17

What is the treatment of enteropathic arthritis (use BMJ)

Answer 17

Treatment usually involves finding medication to manage both the underlying condition and the arthritis

Question 18

What is reactive arthritis ?

Answer 18

Arthritis occuring in reaction to an infection in another part of the body, most commonly gentiurinary or GI infections

Large joints eg the knee become inflamed around 1‐3 weeks following the infection.

Question 19

What is the most common areas affected by reactive arthritis ?

Answer 19

• the joints (arthritis), which can cause pain, stiffnessand swelling
• the eyes (conjunctivitis), which can cause eye pain and redness
• the urethra (non-gonococcal urethritis), which can cause pain when urinating

Question 20

What is the treatment of reactive arthritis ?

Answer 20

• Most cases self-limiting but can be chronic

Acute - symptomatic relief:

• 1st line: non-steroidal anti-inflammatory drugs (NSAIDs)
• 2nd line: corticosteroids

Ongoing - persisting or chronic reactive arthritis

• 1st line: DMARD - methotrexate