MSPA: Rheumatology- The spondylarthropathies and crystalline arthropathies Flashcards
What are the Major features of spondylarthropathies ?
- Inflammation of the axial joints especially sacroiliitis.
*Asymmetrical oligoarthritis - Dactylitis
- Enthesitis
- HLA-B27
What is Ankylosing Spondylitis?
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.
What is the epidemiology of ankylosing spondylitis ?
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.
What is the clinical presentation of ankylosing spondylitis ?
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.
What are the systemic manifestations of ankylosing spondylitis ?
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.
What are the Lab findings in Ankylosing spondylitis ?
Elevated ESR and CRP. All other markers of autoimmune or inflammatory diseases has to be negative ( seronegative).
What is the Tx of ankylosing spondylitis ?
- PT ,OT interventions and smoking cessation.
- NSAIDs
- steroid injections
- TNF alpha blockers such as Infliximab.
- IL-17 antagonists such as Secukinumab
What is the pathophysiology of reactive arthritis ?
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.
What is the symptomatology of Reactive Arthritis?
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.
What are the laboratory evaluations in reactive arthritis ?
- Culture to rule out infections
- HLA-B27 +
- elevated ESR and CRP.
- RF and ACPA negativity.
What is the management of reactive arthritis ?
*Antibiotics to treat underlying infection.
* NSAIDs for pain control.
What is Psoriatic arthritis clinical presentation?
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.
What is the management of Psoriatic arthritis ?
- NSAIDs
- DMARDs
- TNF antagonists
- IL-17 antagonists
- Surgery for hip and spine may be considered if medical management fails.
What is the pathophysiology of Gout ?
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.
what are the causes of overproduction of uric acid ?
- Diet
- Genetics
- Tumour Lysis Syndrome
- Lymphoproliferative disorders
- Psoriasis
- Drugs: Warfarin, Cytotoxic agents
what are the causes of Underexcretion?
*Age (elderly)
* Male sex
* Post-menopausal female sex
* Impaired renal function
* Metabolic syndrome
* Hypertension
* Drugs:Antihypertensives,Diuretics, Aspirin
What is the epidemiology of Gout ?
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.
What is the presentation of acute gout attack ?
The first gout attack is usually monoarticular for example podagra. The recurrent gouty attacks can be polyartritic. 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.
What are the chronic effects of Gout ?
- Most patients develop Tophis after ~ 10 years from initial attack and it cause Chronic pain, deformity, joint
destruction. - 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.
What should be the laboratory work up in Gout ?
- 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-shaped
crystals.
What is the colour of MUS needles under light microscopy ?
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
What are the radiological findings in gout ?
The plain film will show erosive disease, rat bite lesions, overhanging edges and tophi.
What is the non pharmacological management of gout ? *
- Rest and elevate joint
- Ice packs
- Bed cage
- Reduce intake of purine-rich food
- Weight loss
Indirect treatment - Treat hypertension and hyperlipidaemia
What is the Treatment of Acute gout Attack?
- NSAIDs – generally effective but can’t use if renal insufficiency
- Colchicine – anti-inflammatory, can also be used long-term for
prevention. - Steroids – oral or intra-articular
