Sero-Negative arthritis Flashcards
What are the Seronegative spondyloarthropathies
Seronegative spondyloarthropathies are a family of joint disorders that classically include ankylosing spondylitis (AS), psoriatic arthritis (PsA), inflammatory bowel disease (IBD) associated arthritis, reactive arthritis (formerly Reiter syndrome; ReA), and undifferentiated SpA.
What are classic features of the Seronegative spondyloarthropathies
Negative rheumatoid factor
May be associated with HLA- B27
Usually an asymmetric arthritis
Involvement of axial skeleton (spine) – sacroiliitus
Enthesitis
Extra-articular features- uveitis, inflammatory bowel disease, Psoriasis
What is Enthesitis
Enthesitis is inflammation of the entheses, the sites where tendons or ligaments insert into the bone.
What is common in all the Seronegative spondyloarthropathies
Sacroiliitus
What at the common seronegative arthritis’
Ankylosing spondylitis (AS),
Psoriatic arthritis (PsA),
Inflammatory bowel disease (IBD) associated arthritis,
Reactive arthritis (formerly Reiter syndrome; ReA),
Undifferentiated SpA.
What is Ankylosing Spondylitis
Chronic inflammatory rheumatic disorder with a predilection for axial skeleton and entheses
What is Epidemiology
of Ankylosing Spondylitis
Onset in second to third decade of life
Males 3X more likely that Females
Prevalence varies in different parts of the world
What are the genetics of Ankylosing Spondylitis
HLA B27 is positive in 80-95% of patients with AS
BUT
It is not diagnostic of AS/Spa
Risk of AS increases in relatives
What are the common presenting symptoms of Ankylosing Spondylitis
Inflammatory back pain
- Stiffness in morning that gets better during day
Sacroiliac pain (buttock region)
Limitation of movements in antero-posterior as well as lateral planes at lumbar spine
Limitation of chest expansion
What examinations can be done to test for Ankylosing Spondylitis
Schober’s Test
What is the Schober’s Test
Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points.
If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.
What investigations can be used for Ankylosing Spondylitis
MRI
Xray
What radiographic investigation would you do first for Ankylosing Spondylitis
MRI is used to pick up sacroiliitis initially. (picks up bone marrow oedema)
Changes take a while to be seen on an X-ray
What are the changes seen on an MRI of Ankylosing Spondylitis called
Non-radiographic stage changes
What are the changes seen on an X-ray of Ankylosing Spondylitis called
Radiographic stage changes
What Radiographic stage changes could be seen in Ankylosing Spondylitis
Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Ossification of the ligaments, discs and joints.
Fusion of the facet, sacroiliac and costovertebral joints
What is the typical description of the xray appearance of the spine in later stage ankylosing spondylitis.
Bamboo spine
What is the diagnostic criteria for ankylosing spondylitis
Sacroiliitis on imaging and one SpA feature
OR
HLA-B27 and >2 SpA feature
What are diagnostic SpA features
Inflammatory back pain arthritis enthesitis Uveitis dactylritis Psoriaisas Crohns Good response to NSAIDS Family Hx Elevated CRP
What is first line treatment of ankylosing spondylitis
Physiotherapy
What are the treatment options for ankylosing spondylitis
Physiotherapy NSAIDS DMARDs- Sulfasalazine Anti-TNF Anti-IL-17 Treatment of osteoporosis Surgery
What is Psoriatic Arthritis
Psoriatic arthritis is a type of arthritis that affects some people with the skin condition psoriasis. It typically causes affected joints to become swollen, stiff and painful.
What is the prognosis of Psoriatic Arthritis
Can be bad but if its treated early, it’s progression can be slowed down and permanent joint damage can be prevented or minimised
What are the important sub-groups of Psoriatic Arthritis
Symmetric polyarthritis
Asymmetric oligoarticular arthritis
Spondylitic pattern
Arthritis mutilans
What is the epidemiology of Psoriatic Arthritis
It occurs in 10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age.
Describe Symmetric polyarthritis
presents similarly to rheumatoid arthritis and is more common in women. The hands, wrists, ankles and DIP joints are affected. The MCP joints are less commonly affected (unlike rheumatoid).
Describe ASymmetric oligoarticular polyarthritis
Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints.
Describe Spondylitic pattern
Spondylitic pattern is more common in men. It presents with:
Back stiffness
Sacroiliitis
Atlanto-axial joint involvement
What are signs of Psoriatic arthritis
Plaques of psoriasis on the skin Pitting of the nails Onycholysis Dactylitis Enthesitis
What is Onycholysis
Separation of the nail from the nail bed
What is Dactylitis
Inflammation of the full finger
What is Enthesitis
Inflammation of the entheses, which are the points of insertion of tendons into bone
What is management for Psoriatic arthritis
DMADS Anti-TNF therapy Anti- IL-17 and IL-23 Steroids Physiotherapy and occupational therapy
Name some DMADS that can be used for Psoriatic arthritis
methotrexate
leflunomide
sulfasalazine
Name some Anti-TNFs that can be used for Psoriatic arthritis
Etanercept
Infliximab
Adalimumab
What is Reactive arthritis
Reactive arthritis is where synovitis occurs in the joints as a reaction to a recent infective trigger
What did Reactive arthritis used to be known as
Reiter Syndrome
What is a typical presentation of Reactive arthritis
Acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.
What infections typically causes Reactive arthritis
Gastroenteritis
STI
What STI most commonly causes Reactive arthritis
Chylamydia
Whats the prognosis of Reactive arthritis
Usually resolve within 6 months but sometimes need medications
What are common associated symptoms of Reactive arthritis
Bilateral conjunctivitis (non-infective)
Anterior uveitis
Circinate balanitis dermatitis of the head of the penis
What is Circinate balanitis
Circinate balanitis is dermatitis of the head of the penis
What is treatment for acute Reactive arthritis
NSAID
Joint injection (if infection excluded)
Antibiotics in chlamydia infection (contacts as well)
What is treatment for chronic Reactive arthritis
NSAID
DMARD (e.g. sulphasalazine, methotrexate)
