Inflammatory Arthropathies Flashcards
What is Rheumatoid Arthritis
a chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extra-articular features (systemic disease)
RA: seropositive or seronegative
seropositive!!
Anti-CCP antibody
Rheumatoid Factor
joints most commonly affected by RA
small joints of hands and feet - most common
knees
shoulders
elbows
Which serological test is preferred for diagnosis of RA:
Rheumatoid factor or Anti-CCP, and why
Anti-CCP
rheumatoid factor is 70% sensitive, 90% specific
Anti CCP is 70% sensitive, 97% specific
Describe the pathology of RA
an immune response (type IV) is initiated against the synovium which lines synovial joints
the synovium proliferates and becomes invasive
cytokines are released into the synovial space
synovium becomes laden with macrophages
synovial membrane (pannus) expands, actively invades and erodes surrounding bone and cartilage
are women or men more affected by RA
women
2-3x more likely to develop than men
hypersensitivity response in RA
Type IV
causes of RA
genetic factors (account for 50%) triggers -smoking, infection, trauma
is RA usually unilateral or bilateral (in terms of joints)
bilateral - both hands, both feet etc
articular (relating to joint) presentation of RA
pain swelling stiffness - relieved by exercise swelling tenderness reduced ROM
extra-articular presentations of RA
dry eye sclera inflammation pulmonary fibrosis pleural effusions rheumatoid nodules of extensor surfaces anaemia Felty's syndrome osteoporosis
What is Felty’s syndrome
autoimmune triad:
- RA
- splenomegaly
- neutropenia
What are the classic deformities in the hands seen in RA
- Z-shaped thumb - ulnar deviation
- Swan neck deformity - hyperextension of the PIP and flexion of the DIP
- Boutonniere deformity - flexion of the PIP and hyperextension of the DIP
in untreated and aggressive RA, what can happen to the spine
atraumatic cervical instability
there is atlanto-axial subluxation that can result in spinal cord compression
where are rheumatoid nodules most commonly found
extensor surfaces e.g. elbows
lung involvement in RA
pleural effusions
interstitial fibrosis
pulmonary nodules
ocular involvement in RA
keratoconjunctivitis sicca
episcleritis
uveitis
nodular scleritis
What joints of the hands are usually spared in RA
DIP joints (not enough synovium)
Ix for RA
Clinical suspicion
Auto-antibodies (Anti-CCP)
X-ray
Bloods - CRP, ESR and plasma viscosity all raised
Tx of RA
- DMARD combination - methotrexate and one other
+ corticosteroid (prednisolone)
+ NSAIDS for short-term relief
If patient isn’t responding to DMARD, what can they be put on
Biologic therapy - e.g. anti-TNF (Infliximab)
What are the different types of DMARDs
Methotrexate
Sulphasalazine
Hydroxychloroquine
Leflunomide
What are the different classes of biologic drugs
Anti-TNF - infliximab
B cell depletion - rituximab
Disruption of T cell - abatacept
IL6 inhibition - tocilizumab
How do biologic drugs work
They all target a different part of the immune system with a view to reducing the inflammatory process driving the disease
Do all patients with RA get put on biologic therapy?
No - they must have evidence of high disease activity - measured using the DAS 28 score
What are the components of the DAS 28 scoring system
- tender joint count
- swollen joint count
- CRP/ESR
- visual analogue scale (patients own assessment of disease)
What DAS28 score qualifies the patient for biologic therapy?
> 5.1
Below what time limit is the aim to start patients with RA on treatment
within 12 weeks of onset of symptoms
main sign of RA on xray
marginal erosion
what role does surgery have in RA
becoming increasingly less common, but can be used for resistant disease
surgeries that can be done for RA
synovectomy joint replacement joint excision tendon transfers arthrodesis (fusion) cervical spine stabilisation
List the 4 seronegative inflammatory arthropathies
ankylosing spondylitis
psoriatic arthritis
enteropathic arthritis
reactive arthritis
what characterises the seronegative inflammatory arthropathies
they all involve arthritic disease of the spine (spondyloarthropathy) and an asymmetric oligoarthritis (arthritis affecting 1-4 joints)
What individuals are more likely to have a seronegative inflammatory arthropathy
Genetically predisposed individuals - HLA-B27 positive
Shared rheumatological features of the seronegative inflammatory arthropathies
sacroiliac and spinal involvement
enthesitis
dactylitis
What is enthesitis
inflammation at insertion of tendons into bones e.g. achilles tendonitis, plantar fasciitis
What is dactylitis
“sausage digits”
inflammation of the entire digits
Shared extra-articular features of the seronegative inflammatory arthropathies
ocular inflammation (anterior uveitis) mucocutaneous lesions
compare characteristics of mechanical back pain to inflammatory back pain
mechanical:
worse with exercise, relieved by rest
worse at end of day
inflammatory:
worse with rest
early morning stiffness
what is ankylosing spondylitis
a chronic progressive spondyloarthropathy (seronegative) of the spine and sacroiliac joints, which ultimately may lead to spinal fusion.
are male or females more affected by ank spond?
what is the typical age of onset?
men (3:1)
age onset 20-40 years
characteristic appearance of spine in ank spond
“question mark spine”
loss of lumbar lordosis and increased thoracic kyphosis
presentation of ank spond
inflammatory back pain - early morning stiffness that improves with exercise
improvement with NSAIDs
alternating buttock pain
eye involvement - iritis, anterior uveitis
enthesitis
psoriasis
IBD
normal curvatures of the spine
cervical lordosis
thoracic kyphosis
lumbar lordosis
sacral kyphosis
how is lumbar flexion measured in a patient suspected of having ank spond
Schober’s test -
measure 5cm below the posterior superior iliac crests and 10cm above, then ask them to bend forwards and remeasure the distance.
Normal - should extend beyond 20cm.
Ix for ank spond
No diagnostic test
- Clinical suspicion
- xray pelvis (may be normal, do MRI if so)
- HLA-B27 testing
- inflammatory markers
what does xray of pelvis show in ank spond
N.B. may be normal
sclerosis and fusion of sacroiliac joints
what does xray of spine show in ank spond
syndesmophytes
- bony spurs from vertebral bodies that bridge the IV disc and result in fusion
“BAMBOO SPINE”
Tx ank spond
- NSAIDs (naproxen, ibuprofen, diclofenac)
also
physio
exercise - Anti-TNF inhibitors (infliximab, etanercept)
what treatment is appropriate in ank spond if there is peripheral joint involvement
DMARDs (sulfasalazine)
what % of people with psoriasis also have joint disease (psoriatic arthritis)
30%
joints most commonly affected in psoriatic arthritis
DIP joints of fingers and/or toes
is psoriatic arthritis commonly symmetrical or asymmetrical
asymmetrical!
presentation of psoriatic arthritis
spondylitis
dactylitis
enthesitis
nail changes - pitting, onycholysis
arthritis mutilans
aggressive and destructive form of psoriatic arthritis
Ix for psoriatic arthritis
xrays of hands and feet
inflammatory markers - raised
anti-ccp - negative
classic x-ray sign in psoriatic arthritis
pencil in cup deformity at DIP joints
Tx psoriatic arthritis
- DMARDs - methotrexate
also NSAIDs - Biologic therapy - anti-TNF (infliximab)
what is enteropathic arthritis
inflammatory arthritis involving the peripheral joints and sometimes spine, associated with IBD (Crohn’s, UC)
presentation of enteropathic arthritis
loose watery stools weight loss eye involvement (iritis, anterior uveitis) enthesitis aphthous ulcers
What Tx cannot be given for enteropathic arthritis
NSAIDs - exacerbates IBD
what is reactive arthritis
inflammatory seronegative arthritis that occurs in response to infection in another part of the body. The infection triggers an autoimmune arthropathy
most common infections that result in reactive arthritis
genitourinary infections (Chlamydia, Neisseria) GI infections (salmonella, campylobacter)
what is Reiter’s syndrome
triad of symptoms of reactive arthritis
urethritis
uveitis/conjunctivitis
arthritis
presentation of reactive arthritis
large joints e.g. knee, hip, wrist become inflamed 1-3 weeks following infection.
Tx of reactive arthritis
treat underlying cause
most cases are self limiting
symptomatic: analgesia, NSAIDs, intra-articular steroids
persistent disease: sulphasalazine, methotrexate
Biologic drugs are associated with what infection
TB
saying to remember the symptoms of reactive arthritis
“cant see, cant pee, cant climb a tree”
“A’s” of ank spond
Atypical Fibrosis Anterior Uveitis Aortic Regurgitation Achilles Tendonitis AV node block Amyloidosis
respiratory problems seen in RA
pulmonary fibrosis pleural effusion pulmonary nodules bronchiolitis obliterans pleurisy Caplan's syndrome
imaging that should be performed pre-operatively in patients with RA
anteroposterior and lateral Cervical spine radiographs - check for atlanto-axial subluxation so head can be placed in collar during op if necessary
what are the skin abnormalities that can be seen in Reactive Arthritis
- Circinate Balanitis
(painless lesions on the coronal margins of the prepuce) - Keratoderma Blennorhagica
(waxy brown/yellow pap§ules on the soles of the feet/palms)
Extra-articular complications of RA
respiratory complications ocular complications ischaemic heart disease osteoporosis increased risk of infections depression
