Inflammatory Arthritis: Spondylopathies / Seronegative arthritis

Question 1

what is Spondylopathies / Seronegative arthritis?

Answer 1

inflammation of the spine

Question 2

What the classifications of Spondyloarthritis

Answer 2

Axial Spondyloarthritis (Axial SpA), Reactive Arthritis, Psoriatic Arthritis, Enteropathic Arthritis, Undifferentiated Spondyloarthritis - all HLA-B27 associated

Question 3

What are the HLA-B27 associated features for Spondylopathies / Seronegative arthritis

Answer 3

• HLA-B27 associated features:
  
  • Sacroiliitis, enthesitis, spondylitis
  • Peripheral joint involvement
  • Inflammatory eye disease, skin disease (psoriasis, keratoderma, balanitis)

Question 4

Link between HLA B27 as inflammatory arthritis

Answer 4

familial disease - very few directly inherited, many associtated with HLA

• HLA DR4 = associated with RA
• HLA B27 = associated with AS, spondyloarthritides
  
  • more likley to have:
    
    • sacroiliitis
    • enthesitis
    • spondylitis (usually ascending)
    • peripheral joint involvement
    • inflammatory eye disease
    • aortitis, valve disease, heart block
    • upper lobe fibrosis
    • skin disease - psoriasis, keratoderma, balanitis
  • 8% of pop. +ve for HLA B27 - inflammation in spine 97% +ve
  • not used in screening but is relevant to people with MSK issue - dont raise in insurance forms

Question 5

What is and what happens with Ankylosing spondylitis?

Answer 5

• sacroiliitis with pain and stiffness and new bone formation
• bending forward and to side is harder - inflammation
• Sacroiliitis at least grade 2 bilaterally or grade 3 or 4 unilaterally
• thoracic spine to take a deep breath in w/ribs moving to out - if inflammed = less chest expansion → less likley to expand lungs

Question 6

how does Axial Spondyloarthritis present?

Answer 6

• present
  
  • 10-20% aged 10-20, vast majority 20-40, less than 5% over 45, more likley in men than women + delay in diagnosis for 8 yrs
  • HLA B27 is associated with inflammatory spine and many other conditiosn

Question 6

how was Axial Spondyloarthritis classified?

Answer 6

MRI showed

• bone marrow oedema
• sacroiliitis with pain and stiffness and new bone formation → before present on plain X-ray
• so broaden - Axial Spondyloarthritis

Question 7

What are the clinical features of Axial Spondyloarthritis?

Answer 7

• gradual onset
• early morning /rest stiffness
• better with movement
• no radicular signs (± symptoms)
• usually at young(er) age
• good response to NSAID
• Fatigue, weight loss, anaemia, increase in ESR
• May develop psoriasis, eye disease, inflammatory bowel
• Lung, heart, renal complications + osteoporosis

Question 8

What is seen in radiology for Axial Spondyloarthritis??

Answer 8

Shiny corners, syndesmophytes, ossification (new bone formation)

Question 9

What are the investigations done for Axial Spondyloarthritis??

Answer 9

• FBC, ESR/CRP
• X-ray - sacroiliac joint, spine - dont wanted as often as amount of radiation near pelvis is high
• MRI

Question 10

What are the treatments for inflammation of the spine?

Answer 10

• Treatment:
  
  • Ankylosing
    
    • Patient + Physiotherapist to treat
    • NSAIDs, biologics (targeted inflammatory response - pain reduced)
    • limited use - DMARDs for peripheral joints only
  • Axial spondyloarthritis
    
    • NSAIDs
    • Exercise
    • Limited DMARD use
    • Anti-TNF – see NICE guidance – covers non-radiographic axial SpA too!
    • Secukinumab AS only – See NICE guidance
    • BASDAI, BASFI, BASMI - measure disease activity

Question 11

What is reactive arthritis?

Answer 11

• Facts:
  
  • More common in young adults
  • More chronic and severe if HLA-B27 positive
  • sysetmic
  • Triggering infections usually in throat, urogenital or GI tracts
  • May be no preceding infection
  • equal to male and female - affects 20-40

Question 12

What is the presentation for reactive arthritis?

Answer 12

• Presentation: ALWAYS BEWARE OF SEPTIC arthritis
  
  • History of infection up to 2 weeks
  • Malaise, fatigue, fever
  • Asymmetric, large joints, knee effusion
  • Conjunctivitis, balanitis, keratoderma

Question 13

What is seen in the examination for reactive arthritis?

Answer 13

• Examination
  
  • Red and Warm
  • Shifting Pattern
  • Dactylitis
  • Low Back Pain in Chronic Disease
• Extra-articular MSK manifestations
  
  • Tenosynovitis, enthesopathy, plantar fasciitis, achilles tendinitis - skin involvvement w/ bladder prostate and mouth

Question 14

investigaitons for reactive arthritis?

Answer 14

• FBC, CRP + ESR
• U&E
• Urinalysis, blood cultures
• Joint aspiration
  
  • Gram staining, polarised light microscop

Question 15

Managment for reactive arthritis?

Answer 15

• Managment:
  
  • Acute
    
    • Analgesia, NSAIDs, steroids
    • Rest, splinting
  • Chronic
    
    • Arthralgia - ?NSAIDs
    • DMARDs
• differential diagnosis of:Septic arthritis, crystal arthritis, psoriatic arthritis

Question 16

Epidemiology for Psoriatic Arthritis?

Answer 16

• Develop the arthritis then the psoriasis
• Nail lesions can predict the arthritis
• Occurs equally in men and women

Question 17

Presentation for Psoriatic Arthritis

Answer 17

• Common - Asymmetrical oligoarthritis, symmetrical polyarthritis
• Uncommon - DIP joint involvement, spondarthritis, mutilans

Question 18

Radiology Findings for Psoriatic Arthritis

Answer 18

Pencil in cup

Question 19

Treatment for Psoriatic Arthritis

Answer 19

• NSAIDs
• DMARDs - methotrexate, sulfasalazine, leflunomide
• Biologics - anti-TNF, usekinumab

Question 20

Epidemiology for Enteropathic Arthritis

Answer 20

• Mainly in ulcerative colitis, Crohns disease
• More likely with HLA-B27

Question 21

Presentation for Enteropathic Arthritis

Answer 21

• Often arthritis and gut symptoms linked
• Associated with extra-intestinal manifestations of IBD e.g uveitis, erythema nodosum