Inflammatory Arthritis Flashcards
Soft tissue rheumatism, Spondyloarthropathy, Psoriatic Arthritis, Enteropathic Arthritis, Reactive arthritis.
What is the definition of soft tissue rheumatism?
Inflammation/damage to ligaments, tendons, muscles or nerves near a joint rather than either the bone or cartilage
What is the most common area for pain for those who suffer with Soft tissue rheumatism
Shoulder
What conditions are associated with the elbow?
(To do with Soft tissue rheumatism)
- Medial and lateral epicondylitis
- Cubital tunnel syndrome
What are the conditions associated with the wrist?
( To do with Soft tissue rheumatism )
- De-Quervains tenosynovitis
- Carpal tunnel syndrome
What condition is associated with the foot?
(To do with Soft tissue rheumatism)
Plantar fascitis
What are the two main clinical presentations of Soft tissue rheumatism
- Pain confined to a specific site
- Localised soft tissue pain (fibromyalgia)
Treatment for soft tissue rheumatism
(1) Pain control
(2) Rest and ice compressions
(3) Physical Therapy (PT)
If fails, then steroids or surgery
What is spondyloarthropathy?
Family of inflammatory arthritides characterised by involvement of both the spine and joints, primarily affecting genetically predisposed individuals
What does the mnemonic PAIR stand for in relation to diseases associated with HLA B27?
PAIR
- Psoriatic arthritis
- Ankylosing spondylitis
- IBS
- Reactive arthritis
What type of MHC is HLA B27?
Class 1 MHC type
What is the difference between mechanical and inflammatory back pain?
(1) Mechanical back pain worsens with activity and improves with rest
(2) Inflammatory back pain improves with activity and worsens with rest
What are the non-pharmacological management strategies for spondyloarthropathies?
(1) Exercise, especially swimming
(2) Physiotherapy
(3) Occupational Therapy
What is the first line pharmacological treatment for spondyloarthropathies?
(1) NSAIDs like ibuprofen → not for IBS
(2) Corticosteroids → for joint injections
(3) Topical steroid eye drops → managing ocular inflammation
What is the second treatment for spondyloarthropathies?
DMARDS
What is the third-line treatment for spondyloarthropathies?
Biologics such as Anti-TNF
What is Psoriatic Arthritis?
An inflammatory arthritis associated with psoriasis
What are common extra-articular symptoms of Psoriatic Arthritis?
Nail involvement - pitting
Eye disease - Uveitis
What blood test findings are common in Psoriatic Arthritis?
(1) ↑ inflammatory markers
(2) Negative RF and Anti-CCP to rule out RA
What is the first-line pharmacological treatment for Psoriatic Arthritis?
NSAIDs are the first-line treatment.
What is the next step if NSAIDs do not control Psoriatic Arthritis symptoms?
DMARDs (e.g., methotrexate, sulfasalazine)
+
Consider anti-TNF therapy in severe cases
What is Enthesitis, and how does it relate to Psoriatic Arthritis?
(1) Inflammation of the site where ligaments or tendons attach to bones
(2) It is a common feature in Psoriatic Arthritis, often affecting areas like the Achilles tendon or plantar fascia
What conditions are associated with psoriatic arthritis?
Psoriasis
Cardiovascular disease
Gout
Psychological issues
Which infections typically lead to reactive arthritis?
(1) STI’s
(2) Gastroenteritis
= Salmonella, Shigella,
and Campylobacter
Which cancer are patients with Sjogren’s syndrome at risk of?
B-cell (marginal zone) lymphoma
How does the pattern of joint involvement differ between rheumatoid and psoriatic arthritis?
Both have variable and overlapping joint involvement, but distal interphalangeal joint involvement is much more common in psoriatic than rheumatoid arthritis
What demographic of patients are typically affected by pseudogout?
Elderly women
What is Ankylosing Spondylitis (AS)?
A chronic inflammatory disease of the axial skeleton (vertebral joints) that can lead to partial or complete fusion and rigidity of the spine
What is the genetic predisposition for Ankylosing Spondylitis?
HLA-B27
Who is most affected by Ankylosing Spondylitis?
- It is more common in males (~4:1 ratio)
- Typically presents between the ages of 20-40
- Onset often during late adolescence
What are the hallmark articular symptoms of Ankylosing Spondylitis?
- Gradual onset of dull pain, especially in the spine and neck
- Morning stiffness lasting >30 minutes, improving with activity
- Late AS: loss of lumbar kyphosis with pronounced cervical lordosis
What is Schober’s Test used for in AS?
Schober’s test measures lumbar spine flexion.
= A normal result should show an increase of more than 5 cm in the measured distance when the patient bends forward
What is the hallmark X-ray finding in Ankylosing Spondylitis?
Bamboo spine
What is the first-line pharmacological treatment for Ankylosing Spondylitis?
NSAIDS
What are the ASAS classification criteria for diagnosing axial spondyloarthritis?
Criteria require ≥3 months of back pain and onset before age 45
+ either sacroiliitis on imaging and
(1) ≥1 SpA feature
(2) HLA-B27 positivity and ≥2 SpA features
What are the surgical options in Ankylosing Spondylitis?
Mainly for hip and knee arthritis and is reserved for severe cases.
Kyphoplasty for spinal issues is controversial and carries significant risk.
What is Enteropathic Arthritis?
IBD associated arthritis
= Inflammatory arthritis, involving the (1) Peripheral joints
(2) Sometimes the spine
(3) Occurs in patients with inflammatory bowel disease
What gastrointestinal symptoms are common in IBD-associated arthritis?
(1) Loose watery stool
(2) with mucus and blood
(3) weight loss
What is the diagnostic finding in joint aspiration for IBD-associated arthritis?
No organisms or crystals
What imaging modalities are used to diagnose sacroiliitis in IBD-associated arthritis?
X-ray or MRI
What treatment leads to improvement in enteropathic arthritis?
Treating the underlying inflammatory bowel disease (IBD)
A 21-year-old female presents to the rheumatology clinic with a 6-week history of joint pain, swelling and early morning stiffness affecting her left ankle and right knee. The pain is improved with movement. On further questioning, over the past few years, she has also been experiencing recurrent episodes of crampy central abdominal pain and diarrhoea, sometimes with blood in the stool and this has been especially bad during the last few weeks too.
What is the most likely cause of her joint pain?
Enteropathic arthritis
Signs and symptoms of Enteropathic arthritis are what?
(1) Lower back pain
(2) Stiffness
(3) Localised pain in specific tendon insertion areas
(4) Transient joint inflammation
Seronegative spondyloarthropathies should all be what?
RF and ANA negative
p-ANCA is seen in 55–70% of patients with ulcerative colitis
When should coxibs be considered in place of NSAIDs?
When NSAIDs are needed, but there is a high risk of GI ulceration
Enteropathic arthritis is a feature of which GI diseases?
Inflammatory bowel disease
(either Crohn’s or UC)
What are the differences between the clinical features of inflammatory and mechanical joint pain?
Inflammatory:
- Improves movement.
- Prolonged (>30 min) early morning stiffness.
Mechanical:
- Exacerbated by movement.
- Short early morning stiffness (<30 min).
Which features would you expect to see on lumbar XR in a patient with ankylosing spondylitis?
- Squaring of the vertebrae
- Syndesmophytes
- A bamboo sign (late)
What is reactive arthritis?
An infection-induced systemic illness characterised by inflammatory synovitis, where microorganisms cannot be cultured.
What are the most common preceding infections for reactive arthritis?
Urogenital infections (e.g., chlamydia, Neisseria)
Entheogenic infections (e.g., salmonella, campylobacter)
What gene is associated with reactive arthritis?
HLA B27
What age group is most commonly affected by reactive arthritis?
Young adults, aged 20-40
What are the main triggers of reactive arthritis?
Sexually transmitted infections (STI) or gastroenteritis
When do symptoms of reactive arthritis typically appear?
1-4 weeks after the initial infection
What type of arthritis is most common in reactive arthritis?
Asymmetrical monoarthritis or oligoarthritis
= often affecting a single large joint, like the knee
What is Reiter’s syndrome?
A triad of urethritis, conjunctivitis/uveitis/iritis, and arthritis
What is the typical outcome of reactive arthritis?
Most cases are self-limiting, with 90% resolving spontaneously within 6 months
What is the management for reactive arthritis?
Symptomatic relief → (IA/IM steroid injections)
Chronic cases → DMARDs may be needed
What is the sex ratio for reactive arthritis?
M: F 9:1
(Compared to 3:1 for ankylosing spondylitis and 1:9 for SLE)
What is the most common route of infection in Septic Arthritis?
Haematological which means that the source of infection is coming from somewhere else in the body
What is the management of patients with ankylosing spondylitis who have ongoing back pain despite using NSAIDs and following a regular exercise routine?
TNF-a inhibitors such as Infliximab
Why is a joint aspiration done in a suspected diagnosis of Septic Arthritis?
Joint aspiration is done for two reasons;
(1) to remove all the infected fluid and to send the fluid for urgent Gram stain
(2) culture to determine the sensitivities and confirm the diagnosis
What is the main differential diagnosis of diarrhoea in combination with arthritis?
Enteropathic arthritis (during arthritis)
Reactive arthritis (preceding arthritis)
In Septic Arthritis, what is the recommended length of the oral antibiotic regimen?
At least 4 – 6 weeks (after at least 2 weeks of intravenous antibiotics)
In Septic Arthritis, what is the recommended length of the intravenous antibiotic regimen?
At least 2 weeks
What is the NHS Tayside empirical treatment for acute septic arthritis?
IV Flucloxacillin
A 27-year-old man presents to his GP with back pain. This is worse in the mornings and improves with exercise. On further questioning, he reveals 10kg unintentional weight loss in the last 3 months. He reports a change in bowel habits towards looser stool. He has been stressed at work recently and has had a painful rash on his shins.
What is the most likely diagnosis?
Enteropathic arthropathy
What triggers reactive arthritis?
(1) Infection, particularly gastrointestinal infections (like Shigella, Salmonella, and Campylobacter) or
(2) Urogenital infections (like Chlamydia)
What triggers enteropathic arthritis?
Associated with inflammatory bowel disease (IBD), such as Crohn’s disease or ulcerative colitis
A 28-year-old man presents to general practice with a 3-day history of swelling of the right knee and right ring finger. He has also developed “grittiness”, redness and pain in the left eye over the last 24 hours.
On examination he is systemically well and afebrile. There is tender swelling and pain around the right knee joint, and the right ring is diffusely swollen. His visual acuity is normal, but the eye appears red. There is no hypopyon or abnormalities on direct fundoscopy.
He denies recent chest, urinary or enteric infection. But underwent treatment for an undisclosed infection 2 weeks ago.
What is the single most appropriate management? and what does this patient have/ had?
Oral NSAIDs
= reactive arthritis likely due to a sexually transmitted infection
A 25-year-old woman presents to the GP with ankle pain. She does not recall a history of trauma. On further questioning, she reveals that she has had a red, gritty eye for the last few days and generalised joint pains. She was treated for Chlamydia two weeks ago when she presented with dysuria.
On examination, she has swelling of the Achilles tendon and tenderness on palpation. What is the likely cause of her ankle pain?
Reactive arthritis
