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4th year Rheumatology > Seronegative arthritis > Flashcards

Seronegative arthritis Flashcards

1
Q

What are the types of seronegative spondylarthropathies?

A
  • Psoriatic arthritis
  • Enteropathic arthritis
  • Ankylosing spondylitis
  • Reactive arthritis
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2
Q

Which allelle are seronegative spondyarthropathies associated with?

A

HLA-B27

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3
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis

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4
Q

Epidemiology of psoriatic arthritis

A
  • 10-20% of patients with psoriasis
  • usually within 10 years of skin changes
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5
Q

What are the patterns of psoriatic arthritis?

A
  1. Symmetrical polyarthritis
  2. Asymmetrical oligoarthritis
  3. Spondyloarthritis
  4. Distal arthritis
  5. Arthritis mutilans
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6
Q

Describe symmetrical polyarthritis

A
  • Presents similarly to rheumatoid
  • ≥ 5 joints affected
  • More common in women
  • Hands, wrists, ankles, distal inter-phalangal joints
  • MCP less commonly affects (unlike rheumatoid)
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7
Q

Describe asymmetrical oligoarthritis

A
  • ≤ 4 joints affected
  • Typically affects the hands and feet
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8
Q

Describe spondyloarthritis

A

Primarily affects the spine and sacroiliac joints

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9
Q

Descibe distal arthritis

A
  • Affects distal interphalangeal joints of hands and/or feet
  • Usually occurs alongside other types
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10
Q

Describe arthritis mutilans

A
  • Most severe and least common form
  • Deforming and destructive subtype
  • Telescoping and flail digits (due to osteolysis of bone around joint)
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11
Q

General symptoms seen in an inflammatory arthropathy

A

Joint pain and stiffness that is worse in the morning and improves on movement.

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12
Q

Signs of psoriatic arthritis

A
  • Psoriasis: psoriatic lesions, scalp and nail symptoms (nail pitting, oncholysis)
  • Joint tenderness, warmth and reduced range of movement
  • Dactylitis: swelling of an entire digit
  • Enthesitis: inflammation of the plantar fascia and Achilles’ tendon
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13
Q

What is oncholysis?

A

Seperation of the nail from the nail bed

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14
Q

What is dactylitis?

A

Swelling of the entire finger or toe

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15
Q

What is enthesitis?

A

Inflammation of the entheses, which are the points of insertion of tendons into bone.

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16
Q

Other associations with psoriatic arthritis

A
  • Eye disease (conjunctivitis and anterior uveitis)
  • Aortitis (inflammation of the aorta)
  • Amyloidosis
17
Q

Which criteria must be fulfilled to diagnose psoriatic arthritis?

A

CASPAR criteria

A diagnosis of psoriatic arthritis can be made if the patient scores > 2 points on the following:

  • History of psoriasis: 2 points
  • Psoriatic nail changes: 1 point
  • Rheumatoid factor negative: 1 point
  • History of dactylitis: 1 point
  • Radiologicl evidence (juxta-articular periostitis): 1 point
18
Q

What X-ray changes are seen for psoriatic arthritis?

A
  • Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone
  • Ankylosis is where bones joining together causing joint stiffening
  • Osteolysis is destruction of bone
  • Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling
  • Pencil-in-cup appearance
19
Q

Management of psoriatic arthritis

A

All patients require referal to a rheumatologist

Mild disease:

  • NSAIDs and physiotherapy: first-line options to reduce inflammation, improve range of motion and strengthen muscles
  • Intra-articular steroids

Progressive disease:

  • Disease-modifying antirheumatic drugs (DMARDs): used in addition to the above for patients with polyarthritis or joint erosions. Methotrexate is first-line, whilst sulfasalazine is used in patients who are intolerant to methotrexate
  • Biologic agents: TNF-α inhibitors, such as etanercept or infliximab, should be considered in patients with oligoarthritis or polyarthritis following the failure of 2 DMARDs
20
Q

Key joints affected in ankylosing spondylits

A
  • Sacroiliac joints
  • Vertebral column
21
Q

How many patients with ankylosing spondylitis have the HLA B27 gene?

How many patients with the HLA B27 gene develop ankylosing spondylitis?

A

90%

2%

22
Q

Typical exam presentation of ankylosing spondylitis

A
  • Young adult male
  • Late teens/twenties
  • Symptoms come on slowly over > 3 months
  • Low back pain and stiffness + Sacroiliac pain
    • Worse with rest
    • Impoves with movement
    • > 30 minutes morning stiffness
23
Q

Describe Schober’s test

A

Find the L5 vertebrae. Mark a point 10cm above L5 vertebrae and 5cm below.

Ask patient to bend forward as far as they can. Measure the distance between the points.

If the distance is <20cm this indicateds a restiction in lumbar movement and supports a diagnosis of ankylosing spondylitis.

24
Q

Investigations for ankylosing spondylitis

A
  • Inflammatory markers: CRP↑ ESR↑
  • Genetic test: HLA B27
  • X-ray: spine and sacrum
  • If X-ray normal: MRI spine may show early changes: bone marrow oedema
25
Q

X-ray changes in ankylosing spondylitis

A
  • Bamboo spine in late disease
  • Squaring of vertebral bodies
  • Subchondral sclerosis
  • Subchondral erosisions
  • Ossification in ligaments, discs and joints
  • Syndesmophytes (bone growth where ligament normally inserts into the bone
26
Q

Medical managment of ankylosing spondylitis

A
  • NSAIDS: ibuprofen or naproxen
  • Steroids: during flares (oral, intramuscular or intra-articular)
  • Anti-TNF (etanercept)
  • Monoclonal antibodies
27
Q

Other managment of ankylosing spondylitis

A
  • Physiotherapy: exercise and mobilise
  • Avoid smoking
  • Bisphosphonates to treat osteoporosis
  • Treat complications
28
Q

1) Typical presentation of reactive arthritis
2) Which joint is most often affected?
3) Main differential
4) Most common infective triggers

A
  1. Acute monoarthritis
  2. Knee
  3. Septic arthritis
  4. Gastroenteritis or STI (chlamydia most common) (gonorrhoea causes septic arthritis)
29
Q

Old name for reactive arthritis

A

Reiter’s syndrome

30
Q

Reactive arthritis associations

A
  • Bilateral conjunctivitis (non-infective)
  • Anterior uveitis
  • Circinate balanitis

Cant see, pee or climb a tree

31
Q

Reactive arthritis acute maagment

A
  • “Hot joint policy”: presume septic arthritis
  • Antibiotics until septic arthritis ruled out
  • Aspirate: gram stain, culture and sensitivity, crystals
32
Q

Managment of reactive arthritis after septic arthritis ruled out

A
  • NSAIDs
  • Intra-articular steroids
  • Systemic steroids

4th year Rheumatology (3 decks)

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