Sero-negative inflammatory arthritis

Question 1

List the types of sero-negative inflammatory arthritis

Answer 1

Ankylosing spondylitis~
Reactive arthritis~
Psoriatic arthritis~
Enteropathic arthritis~
Behcet's disease
Juvenile idiopathic arthritis

~Spondyloarthritis is associated with HLA-B27

Question 2

Define spondyloarthritis

Answer 2

A group of conditions that affects the spine and peripheral joints with familial clustering and a link with HLA-B27.

Includes:
Axial spondyloarthritis, including ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis (IBD)

Question 3

Name 2 differences between spondyloarthritis and RA

Answer 3

Joint involvement:

• Spondyloarthritis: Spine and asymmetrical peripheral joint involvement
• RA: Symmetrical small joint involvement of the hands and feet, sparring of DIPJs
• Spondyloarthritis is usually more limited
• Spondyloarthritis has different extra-articular features

Spondyloarthritis does not produce RF or anti-CCP
Inflammation of enthesis is commoner
Associated with increased frequency of sacroilitis
Associated with HLA-B27

Question 4

Define ankylosing spondylitis

Answer 4

An inflammatory disorder primarily affecting fibrous and synovial joints of the spine, with involvement of the sacroiliac joints.

Question 5

Differentiate between axial spondyloarthritis and ankylosing spondylitis

Answer 5

Axial spondyloarthritis is an inflammatory disorder primarily affecting fibrous and synovial joints of the spine. Sacroiliac joint changes are seen only on MRI.

Ankylosing spondylitis is a type of axial spondyloarthritis with radiographic changes at the sacroiliac joints.

Question 6

Describe the presentation of ankylosing spondylitis

Answer 6

Lower back pain and stiffness for >3 months
Pain in one or both buttocks
Worse in morning, improves with exercise
Lumbar lordosis during spinal flexion
Reduced lateral flexion of lumbar spine
Reduced lumbar lordosis

May have SIJ tenderness, tenderness at other axial joints, enthesitis, and peripheral synovitis.

Late: restricted range of motion in all planes, paraspinal muscle wasting, kyphosis

Extra-articular features: esp. uveitis or costochondritis

Question 7

Name 3 non-spinal complications of spondyloarthritis

Answer 7

Uveitis (30%) or Costochondritis suggest a diagnosis of spondyloarthritis

Asymmetrical peripheral joint involvement, predominantly affecting few, large joints

Aortic regurgitation
AV block
Achilles tenditis
Anterior uveitis
Arthritis
Amyloidosis
Anaemia
Apical lung fibrosis
Axial osteoporosis (25%) and spinal fracture

Question 8

Outline the diagnostic criteria for axial/ankylosing spondylitis

Answer 8

4 of 5 criteria suggests AS with 80% sensitivity

Age of onset <45
Insidious onset
Improvement of back pain with exercise
No improvement of back pain with rest
Pain at night, with improvement on getting up

Question 9

Describe 2 examinations used to assess the degree of ankylosing spondylitis

Answer 9

Schober test: Mark skin over dimples of Venus and 10cm above. On spinal flexion, an increase <5cm implies spinal stiffness.

Flesche test (occiput to wall): Patient stands erect against a wall and extends neck to touch wall. Distance between occiput and wall is a measure of severity of cervical flexion deformity.

Question 10

Describe the epidemiology of ankylosing spondylitis

Answer 10

Typically affects
<40
Caucasian
Male (3:1)

Question 11

How is ankylosing spondylitis investigated?

Answer 11

ESR and CRP usually raised
HLA-B27 raised (normally present in 8% of Caucasians)

X-ray:

• Erosion and sclerosis of sacroiliac joints
• Syndesmophytes: bony spurs in persistent enthesitis
• Squaring of vertebral bodies
• ‘Bamboo spine’ in advanced AS

Question 12

Outline the management of ankylosing spondylitis

Answer 12

*Early diagnosis is key, so preventative exercises are started before syndesmophytes form.

Morning exercise/physio: maintain spinal mobility, posture, and chest expansion

Regular NSAIDs
Evening dose of slow-release NSAIDs improves sleep
Sulfasalazine, MTX, leflunomide for peripheral arthritis
Anti-TNF if NSAIDs fail

Question 13

Define reactive arthritis

Answer 13

Sterile inflammatory arthritis following infection. It can occur up to an hour post-infection, and is reversible once the infection has resolved.

Question 14

Name 2 common causative agents of reactive arthritis

Answer 14

STIs: Chlamydia trachomatis, Ureaplasma urealyticum

Post-dysentery: Salmonella, Shigella spp.

Question 15

Describe the clinical features of reactive arthritis

Answer 15

Acute, asymmetrical, lower-limb arthritis*
Enthesitis (common): plantar fasciitis, Achilles tendon enthesitis, and dactylitis may occur

Conjunctivitis* (30%)
GU: urethritis*
GI: precipitating colitis
Skin: Keratoderma blenorrhagicum, circinate balanitis

(Can’t see, can’t pee, can’t jump a tree)

Question 16

How is reactive arthritis managed?

Answer 16

Treat persistent infections with antibiotics
Cultures
Screening of sexual partners*

NSAIDs, injected or oral corticosteroids
Anti-TNF if severe and persistent disease

Question 17

Define psoriatic arthritis

Answer 17

Inflammatory arthritis associated with psoriasis, which precedes the skin condition in 15% of cases.

Question 18

What is the prevalence of psoriasis, and how many have psoriatic arthritis?

Answer 18

2-3% prevalence

10% of this population develops psoriatic arthritis

Question 19

Describe the clinical patterns of psoriatic arthritis

Answer 19

• Symmetrical rheumatoid-like polyarthritis (30-40%)
• Mono- or oligoarthritis (20-30%): typically hands and feet
• DIPJ involvement (10%), with onychosis, and characteristic dactylitis*
• Spondylitis: only 50% are HLA-B27 positive
• Arthritis mutilans (5%)*: periarticular osteolysis and bone shortening

Question 20

Describe the radiological features seen in psoriatic arthritis

Answer 20

Asymmetrical joint involvement
DIPJs typically
Central erosion - ‘pencil in cup’

Question 21

Outline the management of psoriatic arthritis

Answer 21

Referral to dermatology
Physiotherapy and OT

NSAIDs and/or analgesia
Intra-articular steroid injections
Sulfasalazine, MTX, leflunomide if persistent peripheral joint involvement
Anti-TNF for severe skin and joint disease, used when MTX fails

Question 22

Define enteropathic arthritis

Answer 22

Inflammatory arthritis occurring in 10-15% of patients with inflammatory bowel disease. May predate development of bowel disease.

Question 23

Describe the presentation of enteropathic arthritis

Answer 23

Asymmetrical arthritis mainly affecting lower-limbs

May predate development of IBD

Question 24

What is the management of enteropathic arthritis?

Answer 24

Treatment of IBD
NSAIDs relieve arthritis symptoms
Intra-articular steroids for mono-arthritis
Sulfasalazine: helps mild-moderate IBD and enteropathic arthritis
Anti-TNF: helps severe IBD and enteropathic arthritis

Remission of UC or total colectomy usually leads to remission of joint disease.

Question 25

What is Behcet’s disease?

Answer 25

Systemic inflammatory disorder of unknown cause. Presents with wide-ranging generalised symptoms, and is most commonly seen in Mediterranean to China. Linked to HLA-B5.

Question 26

Outline the international criteria for diagnosis of Behcet’s disease

Answer 26

Oral ulceration, plus any two of the following:

• Genital ulcers*
• Defined eye lesions: uveitis* or retinal vascular lesions
• Defined skin lesions: erythema nodosum, pseudofolliculitis, and papulopustular lesions
• Positive skin pathergy test
• Oral ulcers - aphthous or herpetiform

Question 27

What test is highly specific to Behcet’s disease?

Answer 27

Pathergy test:
Skin injury (e.g. needle prick) causes papule or pustule formation within 24-48 hours

Question 28

How is Behcet’s disease managed?

Answer 28

Colchicine for erythema nodosum and joint pain

Corticosteroids and immunosuppressive agents for chronic uveitis and neurological complications
Anti-TNF for severe uveitis and serious manifestations e.g. neurological or GI Behcet’s