Inflammatory Arthropathies Flashcards
Inflammatory arthropathies can be classified into which four main groups?
- Seropositive
- Seronegative
- Infectious
- Crystal deposition
What is the most prevalent seropostive inflammatory arthropathy?
Rheumatoid arthritis
What is rheumatoid arthritis?
An autoimmune inflammtory symmetric polyarthropathy
Which gender is more commonly affected by RA?
Females
An immune response is initiate against what in RA?
The synovium
Which environmental triggers have been associated with RA?
- Smoking
- Infection
- Trauma
What may happen to tendons and soft tissue as RA progresses?
- Tendon rupture
- Soft tissue damage
These can lead to joint instability and subluxation
What are the most common clinical presentations of RA?
- Symmetrical synovitis
- Pain
- Morning stiffness (>30 mins)
Which joints are commonly affected in RA and which joints are not?
- MCPs and PIPs are affected
- DIP joints are NOT affected
Over time, larger joints can become affected in RA. Which is an important joint that may become affected?
Joints in the cervical spine (C1 and C2)
Longstanding disease may cause atlanto-axial subluxation
This can cause spinal cord compression
Rheumatoid nodules occur in around 25% of patients with RA. Where do they commonly occur?
Extensor surfaces or sites of frequent mechanical irritation
Which other body systems are impacted often by RA?
- Lungs
- Heart
- Eyes
Lung involvement in RA involves what?
- Pleural effusions
- Interstitial fibrosis
- Pulmonary nodules
Ocular involvement is common in patients with RA, but what does it include?
- Keratoconjunctivitis sicca
- Episcleritis
- Uveitis
- Nodular scleritis (may lead to scleromalacia)
What is keratoconjunctivitis sicca?
Also called dry eyes syndrome, it is the condition of having dry eyes
What is episcleritis?
A benign, self-limiting inflammatory disease affecting the episclera - a thin layer of tissue that lies between the conjunctiva and the connective tissue layer that forms the sclera.
What is uveitis?
Inflammation of the uvea - the pigmented area of the eye
What is scleritis?
Inflammation of the sclera.
There are three types and the condition has associations with RA and granulmatosis with polyangiitis (Wegener’s).
It can involve very serious and damaging inflammation
Which autoantibodies are tested for in RA and which is the most useful?
- Rheumatoid factor
- Anti-CCP - much more specific
Besides autoantibodies, what else can be tested in the blood?
- Inflammatory markers - CRP, ESR, PV
- FBC
What are the early features of RA which may be picked up on an imaging modality?
- Peri-articular osteopenia (bone thinning)
- Soft tissue swelling
Which imaging modality is useful for detecting synovial inflammation if there is clinical uncertainty?
Ultrasound
Which treatments are used for short term symptom relief in RA?
- Analgesia
- NSAIDs
- IM/IA steroids
What are the drawbacks to DMARDs in general, which are the reason regular blood tests are required?
- The increase risk of infection
- They can cause bone marrow suppression
Hence, regular blood tests are required
What are the most commonly used biologics in RA?
Anti-TNF therapies
The use of biologics increases the risk of infection - especially for which disease?
Tuberculosis
The DAS28 score is a composite score of 4 domains - what are these?
- Tender joint count
- Swollen joint count
- CRP/ESR
- Visual analogue score (patient’s own assessment of their disease activity
What are the cut off values for the DAS28 score?
- < 2.6 = remission
- 2.6-3.2 = low disease activity
- 3.2-5.1 = moderate disease activity
- >5.1 = high disease activity
Besides pharmacological therapy, what are the other options for rheumatoid arthritis?
- Physiotherapists
- Occupational therapists
- Podiatrists
- Othotists
- Surgery - only for resistant disease
Seronegative inflammatory arthropathy is a term encompassing which diseases?
- Ankylosing spondylitis
- Psoriatic arthritis
- Enteropathic arthritis
- Reactive arthritis
How are seronegative inflammatory arthopathies often characterised?
- Inflammation and/or arthritic disease of the spine (spondyloarthropathy)
- Asymmetric oligoarthritis
- Other features
What are common features of seronegative inflammatory arthropathies?
- Sacroiliitis
- Uveitis
- Dactylitis
- Enthesopathies
Which enthesopathies are most common with seronegative inflammatory arthropathies?
- Achilles insertional tendonitis
- Plantar fasciitis
Patients with seronegative inflammatory arthropathy are often postive for which form of which gene?
HLA-B27
What is ankylosing spondylitis?
Chronic inflammatory disease of the spine and sacro-iliac joints
Left untreated, ankylosing spondylitis may lead to what?
Fusion of the intervertebral joints and SI joints
Which gender and age of people are more susceptible to ankylosing spondylitis?
Males
Aged 20-40
What do patients with ankylosing spondylitis often complain of?
- Spinal pain
- Stiffness (improves with exercise)
- Knee or hip pain (due to associated arthritis)
Over time, with ankylosing spondylitis, there is loss of spinal movement and a development of a ____________ ______ spine with loss of __________ ___________ and increased ___________ _____________
Question mark
lumbar lordosis
thoracic kyphosis
Lumbar spine flexion can be measured via which test?
Schober’s test
Conditions most associated with ankylosing spondylitis include what?
- Anterior uveitis
- Aortitis
- Pulmonary fibrosis
- Amyloidosis
In a patient with ankylosing spondylitis, what features may be present on X-ray?
- Sclerosis
- Fusion of sacroiliac joints
- Syndesmophytes which can bridge the intervertebral disc giving a “bamboo spine appearance”
What features may be detected in early ankylosing spondylitis on MRI?
- Bone marrow oedema
- Enthesitis of the sponal ligaments
90% of ankylosign spondylitis sufferers are __________ positive
HLA-B27
What are the treatment options for ankylosing spindylitis?
- Physiotherapy
- Exercise (more movement, counteracts syndesmophyte formation)
- NSAIDs
- Anti-TNF therapy for severe disease
DMARDs do not impact spinal involvement, but may have a use if there is peripheral joint involvement
What percentage of people with just skin psoriasis also develop psoriatic arthritis?
30%
What is psoriatic arthritis?
An asymmetrical oligoarthritis which may also affect the hands in a similar pattern to RA.
It occurs alongside psoriasis
What are other common features of psoriatic arthritis?
- Spondylitis
- Dactylitis
- Enthesitis
- Nail pitting
- Onycholisis
Which joints can be affected in psoriatic arthritis which are spared in RA?
DIP
What is a very severe form of inflammatory arthritis which can be associated with both psoriatic or rheumatoid arthritis?
Arthritis mutilans
Characterszed by resorption of bones and the consequent collapse of soft tissue. When this affects the hands, it can cause a phenomenon sometimes referred to as ‘telescoping fingers.’
What is the treatment for psoriatic arthritis?
- DMARDs - usually methotrexate
- Anti-TNF therapy in resistant cases
- Joint replacement in larger joints
- DIP joint fusion
What is enteropathic arthritis?
An inflammatory arthritis involving peripheral joints and sometimes the spine. It occurs in patients with inflammatory bowel disease.
It tends to be a large joint asymmetrical oligoarthritis
What is the treatment for enteropathic arthritis?
It usually involves coordination with the GI consultant to find a medication to manage the IBD as well as the arthritis
What is reactive arthritis?
Arthritis which occurs subsequent to an infection that commonyl affects large joints
Which infections commonly lead to reactive arthritis?
- Genitourinary infections (Chlamydia, Neisseria)
- GI infections (Campylobacter, salmonella)
What is Reiter’s syndrome?
This syndrome occurs when patients with reactive arthritis present with a triad of symptoms:
- Urethritis
- Uveitis/conjuctivitis
- Arthritis
Most cases are self-limiting
What is the treatmnent for reactive arthritis?
- Treat underlying cause (infection)
- Symptomatic relief e.g. IA/IM steroids
- DMARDs in chronic cases
