SARA Flashcards
What is SARA
Sexual acquired reactive arthritis.
One of the seronegative spondyloarthropathies (seronegative for rheumatoid factor but has an association with HLAB27).
An autoimmune inflammatory disorder which develops soon after an infection.
Sterile inflammation of the synovial membranes, fascia and tendons triggered by an infection at a distal site.
Linked STIs and % cases of SARA
CT (60%)
GC (16%)
MGen
Ureaplasma urealyticum
Sexual transmission of enteric pathogens (eg Shigella)
More common in men or women?
M:F - 10:1
Risk factors
- Male
- HLA B27 (increased susceptibility and severity)
- sub-Saharan HIV + (almost all HLAB27 negative)
-
What is seronegative spondyloarthritis?
Heterogeneous group of related polygenic diseases that affect the axial skeleton.
The most representative is axial spondyloarthritis (eg AS)
Other related diseases = psoriatic arthritis, IBD- associated arthritis and synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO)
Seronegative = Rheumatoid factor is absent
History
- Genital Sx
- Urinary Sx
- FH / PMH: spondyloarthritis, iritis, psoriasis, IBD, SAPHO
- full sexual hx (usually history of SI with new partner within 3/12 of onset of arthritis Sx)
- on average genital Sx occur 14/7 before arthritis
There is usually a history of a new partner x months prior to onset of arthritis
3/12
How long on average of genital symptoms precede arthritis
14/7
Men or women most likely to be asymptomatic ?
Women
Arthritis features
Inflammatory therefore:
- at night
- swelling
- early morning stiffness
Asymmetrical
Oligoarthritis
Primarily lower limbs - knees, ankles, feet
Other MSK features
20-40%
Achilles enthesitis and / or Plantar fasciitis
(difficulty walking)
30%
Tenosynovitis
(Painful movements)
16%
Dactiylitis
(Fusiform swelling of finger / toe)
10%
Sacroiliitis
(Lower back pain and stiffness)
Eye Sx/signs
Irritable and red eyes with photophobia May be due to:
20-50%
Conjunctivitis
2-11%
Iritis
Less commonly
Disturbance of visual acuity and ocular pain with uveitis
Genital manifestations
STI Sx plus:
M: circinate balanitis
F: vulvitis
(14-40% of patients)
Extra genital mucocutaneous features
Psoriasisiform eruptions (12%)
Keratoderma blenorrhagica (5-33%)
Nail dystrophy (6-12%)
Oral ulceration / geographical tongue (minority)
Other rare extra-articular features which may have few or no Sx/signs
CVS: tachycardia, LV dilatation, aortic valve disease, cardiac conduction delays
Renal: proteinuria, microscopic haematuria, aseptic pyuria, GN
Others: CN palsies, meningoencephalitis, thrombophlebitis of LL, subcutaneous nodules.
Diagnosis
Clinical based on typical features of spondyloarthritis with an STI
Initial investigations
NAAT CT/GC
Urethral smear / GC culture if uretral discharge
Endocervical GC culture if indicated
BBV screen
Consider MGen
Plus:
CRP or ESR
FBC
Further investigations in some situations
May be useful in some situations:
Biochem:
UE, LFT
Micro
blood cultures
Stool culture
Synovial fluid aspirate (cell count, gram stain, crystals, culture [excl SA])
Radiology
XR affected joints
USS affected joints or entheses
MRI SI joints and spine
Others
- HLAB27
- ECG
- Echo
- Synovial biopsy
- exclusion tests for other rheum diseases
- ACCP (RA)
- autoantibodies (SLE)
- plasma urate (gout)
- CXR and serum ACE (sarcoidosis)
Referrals
Eye Sx = Urgent referral ophthalmologist
Significant peripheral joint or spinal joint Sx = rheum
Antimicrobial management
Standard courses for STI identified
Management in addition to ABx
Physical therapy - rest, physio, cold pads, orthotics
NSAIDs
Corticosteroids
- intrarticular CS injections for single troublesome joints (no RCT evidence in SARA)
- local injections for enthesitis
- topical - cutaneous/ mucosal lesions
- systemic - where multiple joints involved / severe constitutional Sx
(No RCT data in SARA, although evidence in RA)
DMARDs
- disabling joint Sx >3/12
- sulfasalazine or methotrexate
- can help with peripheral joints and enthesis
- no RCT data in SARA
Biologics
- TNF alpha blockers
- no large RCT data in SARA but known to be highly effective in RA, AS, PA
Radiotherapy
- severe, disabling heel pain from enthesitis
Management principles
Self limiting in most.
4-6 months is mean duration
50% May experience recurrent episodes at variable time intervals (particularly HLAB27)
17% develop chronic symptoms making over 12/12
15% experience persistent locomotor disability
Antibiotics as for STI identified (standard course)
- physical therapy
- NDAIDs
- corticosteroids
- DMARDs
- Biologics
Follow up as per STI and with relevant specialists
Enteric organisms that could cause SARA
Shigella (in particular consider this is history or oro-anal contact)
Yersinia
Salmonella
Campylobacter
Clostridium
Mycobacterium species
Prevalence of SARA
Unclear as under diagnosed
Incidence falling despite rising CT
M>F
