Other types of arthritis Flashcards
Spondyloarthritis - what is it?
Prevalence 0.1-1.4%
Related disorders with shared genetic predisposition (HLA B27)
- Axial spondyloarthritis
- Ankylosing spondylitis
- Reactive arthritis
- Psoriatic arthritis
- Enterohepatic spondyloarthritis
Share musculoskeletal phenotype
Most common cause of inflammatory back pain in young adults
Age of onset <40 years (average 26 years)
M:F 3:1 More male!!
Predominantly axial, asymmetrical arthritis
Average delay in diagnosis – 9 years
Spondyloarthritis - presentation
Diagnosis rests on history of inflammatory back pain with radiologically confirmed sacro-ileitis
Back pain (insidious onset and duration >3 months)
- Associated with morning stiffness
- Improves with exercises and NSAID
- Decreased spinal movements
Enthesopathies - inflammation at tendon insertion sites
Peripheral arthritis in 30%
Musculoskeletal:
- sacro-ileitis: early changes: subchondral bone resorption leads to pseudo widening of sacroiliac joints / Late changes: obliteration of joint space, crossed by bony trabecular, bones appear osteopenic / alternating buttock pain
- Spondylitis: early squaring of vertebrae / loss of anterior concavity of vertebral bodies and straightening of anterior margin / resorption of enthuses / late calcification of anterior longitudinal ligament
General: fatigue, anorexia, weight loss
Dactylitis - diffuse soft tissue swelling frequently seen leading to sausaging of digits
Extraskeletal features:
- psoriasis
- IBD
- preceding GI/GU infection
- Inflammatory eye disease (conjunctivitis, uveitis)
Sacro-ileitis
Early changes: subchondral bone resorption leads to pseudo widening of sacroiliac joints
Late changes: obliteration of joint space, crossed by bony trabecular, bones appear osteopenic
Alternating buttock pain
Spondylitis
Early squaring of vertebrae
Loss of anterior concavity of vertebral bodies and straightening of anterior margin
Resorption of enthuses
Late calcification of anterior longitudinal ligament
Dactylitis
Diffuse soft tissue swelling frequently seen leading to sausaging of digits
Physical examination tests to assess spinal disease
(1) Occipult-to-wall test
(2) Chest expansion
(3) Schober’s test
(4) Sacro-iliac stress test
Spondyloarthritis - Lab results
Anaemia
- secondary to chronic disease
- occult IBD
- treatment SE
Raised inflammatory markers (ESR/CRP)
Negatove RF
HLA-B27 - rarely measured in clinical practice
Difference between axial spondyloarthritis and ankylosing spondylitis:
- history
- examination
- investifations
- diagnosis
Axial Spondyloarthritis
IMAGING
Sacroilititis on MRI only
HISTORY Back pain >3 months Must have 4 of these characteristics: improved by exercise/ not relieved by rest / insidious onset /night pain/ age at onset <45. Good response of back pain to NSAID FH of spondyloarthritis History of IBD
EXAMINATION
Arthritis / enthesitis / Uveitis / Dactylitis / Psoriasis
INVESTIGATIONS
HLA-B27 +ve
Elevated CRP
DIAGNOSIS
Sacroiliitis on MRI + 1 feature on history, clinical examination or investigation.
May be diagnosed even if sacroiliitis absent if are HLA-B27 +ve and >1 clinical feature
ANKYLOSING SPONDYLITIS
IMAGING
Sacroiliitis on Xray
HISTORY
Low back pain >3 months, improved by exercise, not relieved by rest
EXAMINATION
Limitation of lumbar spine movement in sagittal and frontal planes
Chest expansion reduced
DIAGNOSIS
Xray – evidence of sacroiliitis with one other feature on history/exam
Ankylosing spondylitis - history
DD
Low back pain and stiffness in sacroiliac region sometimes radiating to buttocks
Marked early morning stiffness improving as the day goes on
Onset late teens or early 20’s.
May be associated with iritis and inflammatory bowel disease
DD:
Prolapse intervertebral disc- pain follows nerve root distribution
Mechanical back pain - worse on movement, relieved by rest
Ankylosing spondylitis - examination
Reduced range of movements
Chest expansion reduced
Ankylosing spondylitis - investigations
ESR and CRP (often raised but may be normal)
X-RAYs of pelvis and lumbar spine (sacroileitis and possibly syndesmophwytes but may be normal in early disease)
Ankylosing spondylitis - treatment
Treat symptoms with full dose NSAID and/or analgesics pending clinic review
Psoriatic arthritis - history
Joint pain stiffness and swelling in an asymmetrical distribution affecting the PIP and DIP joints of hands, feet and large joints
Early morning stiffness (typically >30hr)
Inactivity gelling (stiffness after a period of inactivity)
History of psoriasis (precedes arthritis in 70%)
Extra-articular features:
- IBD
- Preceding GI/GU infection
- inflammatory eye disease
Psoriatic arthritis - examination
Soft tissue swelling and tenderness of affected joints
Nail pitting and nail dystrophy
Skin rash
Psoriatic arthritis - investigations
FBC and ESR (raised in some)
Anti-CCP antibodies (typically negative)
X-ray of hands or feet
- May be normal or show erosions
Psoriatic arthritis - treatment
Initial
- treat symptoms with NSAIDs and/or analgesics pending clinic review
- avoid giving corticosteroids
Enterohepatic arthritis
- presentation
- treatment
- typically associated with Crohns or UC
- no gender preference, children=adults
Presentation
- Arthritis: acute onset, migratory, asymmetric, oligo-articular (<5 joints)
- Typically large lower limb joints (knees, ankle, hips)
- Crohns - arthritis usually coincides with exacerbations of underlying bowel disease
- Extra-articular: Uveitis / Erythema nodosum - hypersensitivity reaction; associated with variety of diseases – sarcoidosis, Beta-hemolytic streptococcal infection, TB, coccidiodomycosis, UC / Aphthous stomatitis / Pyoderma gangrenosum - Begin as pustule that breaks down → enlarges to form painful, chronic, deep, undermined ulcers with red raised border
Treatment
- Physio
- NSAID - may need to be avoided as may exacerbate IBD
- Standard DMARDs for persistent peripheral joint involvement (Sulphasalazine, methotrexate)
- Anti-TNF biologic therapy licensed in resistant cases - Certolizumab, etanercept, infliximab)
- IL-23 inhibitor (Ustekinumab)
Reactive arthritis
Inflammatory arthritis which occurs after exposure to certain GI/GU infections.
- Primarily young adults, aged 20-40
- M:F 1:1 for GI / M>F GU
- rare in children
RF: male, HLA-B27 genotype and preceding Chlamydial or GI infection
Reactive arthritis - presentation
Typically acute onset, with inflammatory enthesitis, oligoarthritis, and/or spinal inflammation
Lower limb joints & enthuses predominantly affected
Peripheral arthritis that begins 1-4 weeks after onset of infection
Arthritis
- Mono or oligo-arthritis (<5 joints)
- Sacroileitis
- Spondylitis
- Enthesitis – inflammation at sites where tendons insert into bones (e.g Achilles tendon, plantar fascia at calcaneous – heel pain)
May be systemic disturbance – fever, weight loss
80% resolve within 12 months
- Recurrent/chronic arthritis may occur
Reactive arthritis - common infectious agents
Enterogenic
- Shigella
- Campylobacter
- Yersinia
- Salmonella
Genito-urinary
- Chlamydia
- Gonococcal
Others
- Ureaplasma
- Clostridium difficile
Reactive arthritis - extra-articular features
MUCOCUTANOUS
Circinate balanitis (30%) - Starts as vesicles on coronal margin of prepuce and glans penis -> rupturing to form superficial erosions with minimal surrounding erythema, some coalescing -> circular pattern
Keratoderma blennorhagica (20%) - Begins as discrete waxy, yellow-brown vesico-papules with desquamating margins, occasionally coalescing to form large crusty plaques on palms/soles of feet
Painless oral ulcers (25%)
- Genitourinary – urethritis or cervicitis
- Ocular - Conjunctivitis (60%) / Uveitis (unilateral) (20%)
Common in recurring/chronic arthritis
Reactive arthritis - investigations
Usually diagnosis is made clinically
Joint aspiration may be required to exclude crystal arthritis & articular infection
ESR & CRP raised
Chronic/reccurent disease
Xrays – periarticular osteoporosis, proliferative erosions (esp. at enthuses), periostitis (esp. of metatarsals, phalanges, pelvis), large fluffy calcaneal spurs
Reactive arthritis - management
Acute – rest, NSAID, analgesic
May need intra-articular / systemic gluco-corticoids
DMARDs
2nd line agent – when NSAIDs fail or more aggressive treatment is required to prevent radiographic joint destruction
No evidence for antibiotic use – unless identify triggering infection
What is Reiter’s syndrome?
Triad:
(1) post-infectious arthritis
(2) non-gonococcal urethritis
(3) conjunctivitis
Feet, pustules and keratoderma blennorhagica
- Pustules begin as vesicles on erythematous bases and become sterile pustules
Palate erosion – ulcers
Conjunctivitis
- Erythema & exudate on bulbar and palpebral conjunctivae are characteristic of acute transient conjunctivitis of Reiter’s syndrome.
- Reaction is often mild and easily overlooked, but photophobia, excessive lacrimation, burning, and intense hyperemia may occur.
- Iritis and episcleritis usually do not involve the palpebral conjunctivae.
Septic arthritis
- What is it?
- Risk factors
- Pathogenesis
Most rapid & destructive joint disease
RF: increasing age, pre-existing joint disease (RA), Diabetes, immunosuppression (drugs/ disease) and IV drug misuse
RA – skin = frequent portal of entry because of marceration of skin between toes due to joint deformity & difficulties with foot hygiene caused by hand deformity
Pathogenesis:
- Haematogenous spread from infections of skin or upper resp. tract
- Infection from direct puncture wounds or secondary to joint aspiration is uncommon
Septic arthritis - clinical features
Acute/sub-acute mono-arthritis and fever
Joint – usually swollen, hot, red with pain at rest and movement
Any joint may be affected –lower limb joints (knee & hip) – most common
Septic arthritis - most likely organisms
Most likely organism: Staph aureus, (esp. if RA, diabetes)
Young sexually active – gonococcus – migratory arthralgia, low-grade fever, tenosynovitis
Elderly/ IV drug users – Gram-negative bacilli, group C, C and G streptococci
Septic arthritis - management
Admit patient to hospital
Perform urgent investigations:
- Aspirate joint - Gram stain & culture / Synovial fluid – usually turbid, blood stained, may appear normal
Prosthetic joints – only aspirated in theatre
- Send blood for culture, routine biochemistry and haematology including ESR, CRP
- Consider other samples (sputum, urine, wound swab): for culture depending on history, to determine primary source of infection
Commence IV antibiotics - Flucloxacillin (2g 4x daily) - If penicillin allergic: Clindamycin (450-600mg 4x daily in younger patients) IV vancomycin (1g 2x daily if >65 years)
If high-risk of gram –ve sepsis (recurrent UTI)
- IV gentamicin (5mg/kg once daily) or vancomycin (750-1000mg 2x daily)
Relieve pain
- Oral and/or IV analgesics
- Consider local ice packs
Aspirate joint
- Perform serial needle aspiration to dryness (1-3 times daily/ as required)
- Consider arthroscopic drainage if needle aspiration difficult
Arrange physio
- Early regular passive movement, progressing to active movements once pain controlled and effusion not re-accumulating
Viral arthritis
Acute polyarthritis following febrile illness
May have a rash
Most self limiting and settle down within 4-6 weeks
Human parvovirus (B19) most common in Europe
- Adults may not have classic slap cheek rash seen in children
- Diagnosis confirmed by rise in specific IgM
Rarely can be Hep B & C, rubella (including vaccination), HIV infection
Variety of mosquito-borne viruses may cause epidemics of acute polyarthritis – Ross River (Australia, Pacific), Chikunguna and O’nyong-nyong (Asia, Africa), Mayaroa viruses (South America)
Management: symptomatic
