Sero-negative inflammatory arthritis Flashcards
List the types of sero-negative inflammatory arthritis
Ankylosing spondylitis~ Reactive arthritis~ Psoriatic arthritis~ Enteropathic arthritis~ Behcet's disease Juvenile idiopathic arthritis
~Spondyloarthritis is associated with HLA-B27
Define spondyloarthritis
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)
Name 2 differences between spondyloarthritis and RA
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
Define ankylosing spondylitis
An inflammatory disorder primarily affecting fibrous and synovial joints of the spine, with involvement of the sacroiliac joints.
Differentiate between axial spondyloarthritis and ankylosing spondylitis
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.
Describe the presentation of ankylosing spondylitis
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
Name 3 non-spinal complications of spondyloarthritis
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
Outline the diagnostic criteria for axial/ankylosing spondylitis
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
Describe 2 examinations used to assess the degree of ankylosing spondylitis
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.
Describe the epidemiology of ankylosing spondylitis
Typically affects
<40
Caucasian
Male (3:1)
How is ankylosing spondylitis investigated?
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
Outline the management of ankylosing spondylitis
*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
Define reactive arthritis
Sterile inflammatory arthritis following infection. It can occur up to an hour post-infection, and is reversible once the infection has resolved.
Name 2 common causative agents of reactive arthritis
STIs: Chlamydia trachomatis, Ureaplasma urealyticum
Post-dysentery: Salmonella, Shigella spp.
Describe the clinical features of reactive arthritis
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)
How is reactive arthritis managed?
Treat persistent infections with antibiotics
Cultures
Screening of sexual partners*
NSAIDs, injected or oral corticosteroids
Anti-TNF if severe and persistent disease
Define psoriatic arthritis
Inflammatory arthritis associated with psoriasis, which precedes the skin condition in 15% of cases.
What is the prevalence of psoriasis, and how many have psoriatic arthritis?
2-3% prevalence
10% of this population develops psoriatic arthritis
Describe the clinical patterns of psoriatic arthritis
- 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
Describe the radiological features seen in psoriatic arthritis
Asymmetrical joint involvement
DIPJs typically
Central erosion - ‘pencil in cup’
Outline the management of psoriatic arthritis
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
Define enteropathic arthritis
Inflammatory arthritis occurring in 10-15% of patients with inflammatory bowel disease. May predate development of bowel disease.
Describe the presentation of enteropathic arthritis
Asymmetrical arthritis mainly affecting lower-limbs
May predate development of IBD
What is the management of enteropathic arthritis?
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.
What is Behcet’s disease?
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.
Outline the international criteria for diagnosis of Behcet’s disease
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
What test is highly specific to Behcet’s disease?
Pathergy test: Skin injury (e.g. needle prick) causes papule or pustule formation within 24-48 hours
How is Behcet’s disease managed?
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
