Rheumatology - Seronegative

Question 1

Discuss the pathophysiology, presentation and management of ankylosing spondylitis

Answer 1

Pathophysiology
- chronic inflammatory arthritis involving SI joint and vertebra
- inflammation leads to osteopenia and erosion which causes ossification and osteoproliferation (syndesmophytes)
- HLA-B27
Presentation
- mid and lower back stiffness >1h in morning, night pain
- Positive FABER
- spinal restriction with decreased Schober, descreased chest wall expansion and increased occiput to wall distance
- asymetrical large joint arthritis
- enthesitis: tibial tuberosity, Achilles, plantar fascia
- dactilytis
- anterior uveitis
- IBD
Investigation
- pseudowidening of SI joint to bony fusion
- bridgeging syndesmophytes leading to bamboo spine
- T2 stir on MRI
MAnagement
- NSAIDS
- Glucocorticoids
- DMARDS for peripheral arthritis
- anti-TNF for axial (infliximab)

Question 2

List the extra-articular manifestation of ankylosing spondylolitis

Answer 2

6 As

• Atlanto-axial subluxation
• Anterior uveitis
• Apical lung fibrosis
• Aortic incompentence
• Amyloidosis (kidneys)
• Autoimmune bowel (UC)

Question 3

Discuss the pathophysiology, presentation and management of psoriatic arthritis

Answer 3

Pathophysiology
- arthritis associated with psoriasis
Presentation
- erythematous plaques with silvery scales
- nail involvement: pitting, transverse longitudinal ridging
- asymmetric oligoarthritis
- arthritis of DIP
- sacroilitis
- dactylitis
Investigation
- floating syndesmophytes
- pencil-in-cup of IP joints
Management
- NSAID or IA
- DMARDS
- anti-TNF

Question 4

Discuss the pathophysiology, presentation and management of reactive arthritis

Answer 4

- peripheral arthritis (>=1mon) accompoanied by one or more extra-articular manifestations that appear shortly after GI or GU infection
Pathophysiology
- GI: Shigella, salmonella, Campylobacter, C difficile
- GU: chlamydia
- 1-4 weeks following infection
- spinal involvement persists
Presentation
- peripheral arthritis, spondylitis, plantar fasciitis
- iritis
- hyperkeratotic skin lesions on palms and soles
- balantis circinate (small, shallow, ulcers on glans penis and urethral meatus
- oral ulcers
- urethritis/cervicitis/sterile pyuria
Investigations
- sterile cultures
- HLA-B27
Management
- antibiotics
- NSAIDs
- TNF-alpha for spinal inflammation