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Rheumatology > Other types of arthritis > Flashcards

Other types of arthritis Flashcards

1
Q

Spondyloarthritis - what is it?

A

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

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2
Q

Spondyloarthritis - presentation

A

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)
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3
Q

Sacro-ileitis

A

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

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4
Q

Spondylitis

A

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

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5
Q

Dactylitis

A

Diffuse soft tissue swelling frequently seen leading to sausaging of digits

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6
Q

Physical examination tests to assess spinal disease

A

(1) Occipult-to-wall test
(2) Chest expansion
(3) Schober’s test
(4) Sacro-iliac stress test

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7
Q

Spondyloarthritis - Lab results

A

Anaemia

  • secondary to chronic disease
  • occult IBD
  • treatment SE

Raised inflammatory markers (ESR/CRP)

Negatove RF

HLA-B27 - rarely measured in clinical practice

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8
Q

Difference between axial spondyloarthritis and ankylosing spondylitis:

  • history
  • examination
  • investifations
  • diagnosis
A

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

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9
Q

Ankylosing spondylitis - history

DD

A

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

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10
Q

Ankylosing spondylitis - examination

A

Reduced range of movements

Chest expansion reduced

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11
Q

Ankylosing spondylitis - investigations

A

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)

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12
Q

Ankylosing spondylitis - treatment

A

Treat symptoms with full dose NSAID and/or analgesics pending clinic review

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13
Q

Psoriatic arthritis - history

A

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
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14
Q

Psoriatic arthritis - examination

A

Soft tissue swelling and tenderness of affected joints

Nail pitting and nail dystrophy

Skin rash

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15
Q

Psoriatic arthritis - investigations

A

FBC and ESR (raised in some)

Anti-CCP antibodies (typically negative)

X-ray of hands or feet
- May be normal or show erosions

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16
Q

Psoriatic arthritis - treatment

A

Initial

  • treat symptoms with NSAIDs and/or analgesics pending clinic review
  • avoid giving corticosteroids
17
Q

Enterohepatic arthritis

  • presentation
  • treatment
A
  • 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)
18
Q

Reactive arthritis

A

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

19
Q

Reactive arthritis - presentation

A

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

20
Q

Reactive arthritis - common infectious agents

A

Enterogenic

  • Shigella
  • Campylobacter
  • Yersinia
  • Salmonella

Genito-urinary

  • Chlamydia
  • Gonococcal

Others

  • Ureaplasma
  • Clostridium difficile
21
Q

Reactive arthritis - extra-articular features

A

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

22
Q

Reactive arthritis - investigations

A

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

23
Q

Reactive arthritis - management

A

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

24
Q

What is Reiter’s syndrome?

A

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.
25
Q

Septic arthritis

  • What is it?
  • Risk factors
  • Pathogenesis
A

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
26
Q

Septic arthritis - clinical features

A

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

27
Q

Septic arthritis - most likely organisms

A

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

28
Q

Septic arthritis - management

A

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

29
Q

Viral arthritis

A

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

Rheumatology (7 decks)

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