deck_Spondylo and crystaline arthropathies

Question 1

What are the Major features of spondylarthropathies ?

Answer 1

• Inflammation of the axial joints especially sacroiliitis.
• *Asymmetrical oligoarthritis
• • Dactylitis
• • Enthesitis
• • HLA-B27

Question 2

What is Ankylosing Spondylitis?

Answer 2

It is a seronegative spondylarthropathy of unknown aetiology with strong correlation to HLAB-27 gene positivity. The inflammatory process is mediated by CD4+ and CD8+ T-Lymphocytes and macrophages inducing cytokine response through TNFα, TGF-β, and IL-17, which manifest as sacroiliitis and enthesitis along the spine causing the stiffness and bamboo spine appearance on X-Ray.

Question 3

What is the epidemiology of ankylosing spondylitis ?

Answer 3

90% of the patients are HLAB-27 positive with 50% concordance rate. It is 3 times more common in men than in woman with a peak onset age range of 20-40.

Question 4

What is the clinical presentation of ankylosing spondylitis ?

Answer 4

The hallmark is axial involvement which manifest as nocturnal back pain and stiffness that improves with exercise and not with rest. patients often have peripheral arthritis involving shoulder, hip , knee and ankle. The physical examination of the spine will often show kyphosis or kyphoscoliosis.

Question 5

What are the systemic manifestations of ankylosing spondylitis ?

Answer 5

The patients often have constitutional symptoms, dactylitis, recurrent acute uveitis, IBD, and Achiliis tendinitis. The cardiovascular involvement may manifest as aortitis, Aortic regurgitation, and conduction abnormalities.

Question 6

What are the Lab findings in Ankylosing spondylitis ?

Answer 6

Elevated ESR and CRP. All other markers of autoimmune or inflammatory diseases has to be negative ( seronegative).

Question 7

What is the Tx of ankylosing spondylitis ?

Answer 7

• PT ,OT interventions and smoking cessation. * NSAIDs * steroid injections* Anti-TNF alpha agents such as Infliximab. * IL-17 antagonists such as Secukinumab

Question 8

What is the pathophysiology of reactive arthritis ?

Answer 8

It is a seronegative arthritis triggered often in HLA B-27 positive people by infectious antigens from GI pathogens such as Shigella, Salmonella etc. STIs due to C.trachomatis, and GAS.

Question 9

What is the symptomatology of Reactive Arthritis?

Answer 9

In most cases the symptom onset is 2 to 3 weeks post infection and often presents as Reiter’s syndrome which consist of conjunctivitis, urethritis and joint inflammation. The patients may also present with cervicitis and pericarditis. The joint involvement may manifest as a single large joint involvement, ankle, hip and small joints or polyarticular.

Question 10

What are the laboratory evaluations in reactive arthritis ?

Answer 10

• Culture to rule out infections * HLA-B27 + * elevated ESR and CRP. * RF and ACPA negativity.

Question 11

What is the management of reactive arthritis ?

Answer 11

Antibiotics to treat underlying infection. NSAIDs for pain control.

Question 12

What is Psoriatic arthritis clinical presentation?

Answer 12

The dermal psoriatic lesions + asymmetric oligoarticular (<5 joints) involvement is the most common presentation in PA. Th rheumatoid pattern of polyarticular ( >5 joint) presentation and axial arthritis presentation may also be seen. However, the lab works will be negative for RA.

Question 13

What is the management of Psoriatic arthritis ?

Answer 13

• NSAIDs* DMARDs* Antti-TNF drugs * IL-17 antagonists * Surgery for hip and spine may be considered if medical management fails.

Question 14

What is the pathophysiology of Gout ?

Answer 14

The under execration or over-production of uric acid causes the formation of MSU crystals, which gets deposited in and around the joints triggering humoral and cellular inflammatory process leading to acute gouty attacks.In chronic stage the disease causes MSU renal stone formation, interstitial nephritis, and most commonly tophi.

Question 15

what are the causes of overproduction of uric acid ?

Answer 15

• Diet* Genetics* Tumour Lysis Syndrome* Lymphoproliferative disorders* Psoriasis* Drugs: Warfarin, Cytotoxic agents

Question 16

what are the causes of Underexcretion?

Answer 16

Age (elderly) Male sex* Post-menopausal female sex* Impaired renal function* Metabolic syndrome* Hypertension* Drugs:Antihypertensives,Diuretics, Aspirin

Question 17

What is the epidemiology of Gout ?

Answer 17

The uric acid levels tends to be more in men than in woman. But the risk of gout is equal in both gender. It is rarely seen before the age of 30 in men and woman rarely get it before menopause.

Question 18

What is the presentation of acute gout attack ?

Answer 18

The first gout attack is usually monoarticular for example podagra. The recurrent gouty attacks can be polyarticular The attack itself presents with cardinal signs of inflammation and progressive intense pain. It usually peaks within 1 to 2 days and prolongs approximately 7-10 days.

Question 19

What are the chronic effects of Gout ?

Answer 19

• Most patients develop Tophis after ~ 10 years from initial attack and it cause Chronic pain, deformity, jointdestruction.* Chronic gout also cause Nephrolithiasis due to MSU stones or it can act as a nidus for calcium oxalate stones. * It can also cause urate nephropathy marked by uric acid crystals in renal parenchyma reducing kidney’s ability to concentrate urine.

Question 20

What should be the laboratory work up in Gout ?

Answer 20

• FBC to rule out lymphoproliferative or myeloproliferative disorders. * Blood culture to rule out infectious causes.* BUN and creatinine to rule out renal under excretion causes.* Serum uric acid- which may not be elevated. * Joint aspirate will show synovial fluid, which is often turbid with low viscosity. * The light microscopy of joint aspirate will show negatively birefringent needle-shapedcrystals.

Question 21

What is the colour of MSUneedles under light microscopy ?

Answer 21

Under polarizing light microscopy, urate crystals are yellow when aligned parallel to the axis of the red compensator and blue when aligned across the direction of polarization

Question 22

What are the radiological findings in gout ?

Answer 22

The plain film will show erosive disease, rat bite lesions, overhanging edges and tophi.

Question 23

What is the non pharmacological management of gout ? *

Answer 23

• Rest and elevate joint* Ice packs* Bed cage* Reduce intake of purine-rich food* Weight loss
  *Indirect treatment for hypertension and hyperlipidaemia

Question 24

What is the Treatment of Acute gout Attack?

Answer 24

• NSAIDs – generally effective but can’t use if renal insufficiency* Colchicine – anti-inflammatory, can also be used long-term forprevention.* Steroids – oral or intra-articular

Question 25

What is the Tx approach to chronic gout and gout attack prevention?

Answer 25

If > 1 acute attack per year, tophior renal stones, treat it pharmacologically with Xanthine oxidase inhibitors and Low dose colchicine.

Question 26

What are the factors to consider while treating chronic gout with xanthine oxidase inhibitors ?

Answer 26

The goal is to reduce uric acid production. The Tx should only be started at least after 3 weeks form the acute gout symptoms resolution. Continue NSAIDs for the first several weeks. Start low and increase dose over time. Titrate to serum uric acid < 0.3 mmol/L. Low dose colchicine can be continued for up to 6 months.

Question 27

What is the epidemiology of CPPD ?

Answer 27

It is commonly seen in people over the age of 50. Vast majority of the cases are in people over the age of 85.

Question 28

What are the risk factors for CPPD ?

Answer 28

• Trauma to joint* Hyperparathyroidism* Hypomagnesemia* Hypothyroidism* Hypophosphatemia* Hemochromatosis

Question 29

What is the pathophysiology of CPPD?

Answer 29

Idiopathic excessive pyrophosphate production causes calcium pyrophosphate dihydrate crystal deposition on joints and soft tissues which stimulate inflammatory responses.

Question 30

What is the clinical presentation of CPPD?

Answer 30

It has a similar presentation as gout. The most common joints affected are the knee followed by elbow, shoulder and wrist. The patients typically presents with Red, tender, swollen joint with limited mobility. It can co-occur with RA and OA.

Question 31

What are the findings in the synovial fluid analysis in CPPD?

Answer 31

It will show Weakly positive birefringent rhomboidal crystals in polarizing filter.

Question 32

What are the radiological findings in CPPD ?

Answer 32

It is not necessary unless there is diagnostic uncertainty. The hallmark finding in X-ray will be chondrocalcinosis.

Question 33

What is the treatment of CPPD ?

Answer 33

• NSAIDS – first-line therapy in those with intact renal function* Colchicine – may be useful for long-term therapy at low doses* Steroids* No agents for decreasing pyrophosphate exist.