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Rheumatology > Seronegative arthritis > Flashcards

Seronegative arthritis Flashcards

1
Q

Seronegative arthritis - definition

A

Group of chronic diseases which are negative for rheumatoid factor - no autoantibody linked to the disease
but positive for the HLA-B27 gene which runs in families.

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2
Q

HLA-B27 gene : Pathophysiology

A
  1. MHC Class 1 molecule : Cell surface protein which presents molecules within it, to the immune system
  2. CD8+ T cell binds to the antigen presented by the MHC Class 1 molecule.
  3. HLA -B27 gene : Codes for a specific type of MHC Class 1 molecule
  4. T cell recognises the MHC Class 1 molecule as foreign
  5. Resulting in : Inflammation and Cytokine release
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3
Q

Seronegative arthritis : Inflammation causes -

A
  • Destroys the joints : fibroblasts replace the destroyed joint with fibrous tissue which limits range of movement.
  • Syndesmophytes : Osteoblasts get activated and process of ossification resulting in small bony outgrowths at joint edges
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4
Q

Seronegative arthritis : Conditions

A
  1. Ankylosing spondylitis,
  2. Psoriatic arthritis
  3. Reactive arthritis
  4. Enteropathic arthritis
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5
Q

Seronegative arthritis : Clinical features

A

Affects bone, spine and nearby joints
1. Peripheral arthritis
2. Enthesitis - inflammation where tendons/ligaments insert to the bone
3. Extra-articular sx :
* Eyes : anterior uveitis
* Skin : psoriasis
* CVS : Aortic regurgitation / Pericarditis
* GI : Crohns disease or Ulcerative colitis.

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6
Q

Ankylosing Spondylitis : Definition

A
  • Chronic inflammatory disease that affects the vertebral joints and increases stiffness of the joints
  • Also associated with blood vessel inflammation
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7
Q

Ankylosing Spondylitis : Pathophysiology

A
  1. Intervertebral disc between the vertebra which is made up of type 1 and type 2 collagen
  2. Autoimmune inflammation of Collagen (T1 +T2)
  3. Collagen gets destroyed and is replaced by fibrin and ultimately ossification.
  4. Resulting in inflammation and reduction in ROM
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8
Q

Ankylosing Spondylitis : Associated conditions

A
  • A – Anterior uveitis
  • A – Aortic regurgitation
  • A – Atrioventricular block (heart block)
  • A – Apical lung fibrosis (fibrosis of the upper lobes of the lungs)
  • A – Anaemia of chronic disease
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9
Q

Ankylosing Spondylitis : Incidence

A

Presents in males between 20-30 years of age

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10
Q

Ankylosing Spondylitis : Clinical features

A

‘Young man presents with lower back pain’
* Onset : Insidious, slow onset of stiffness
* Main affected joints :
the sacroiliac joints + the vertebral column joints

1 . Stiffness in Lower back
* Worse in the morning
* improved with exercise / pain at night which improves on getting up.

2 . Area of inflammation
* sacroiliac joint : Pain in buttocks } most common
* cervical region : neck pain
* Ribs and vertebra effects : shortness of breath

  1. Systemic inflammatory disease - weightless, fevers, fatigue
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11
Q

Ankylosing Spondylitis : Clinical examination

A
  1. Schober’s test :
    line is drawn 10cm above and 5cm below
    The distance between the line must increase more > 5cm when patient bends as far forward as possible
  • Reduced Forward Flexion
  • Reduced Lateral Flexion
  • Reduced Chest expansion
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12
Q

Ankylosing Spondylitis : Investigations

A
  1. Bloods -
    * Raised inflammatory makers ESR, CRP a
  2. X-ray :
    Most commonly effects sacroiliac joint, therefore X-ray of sacroiliac joint is the most useful investigation in diagnosis.
  • Squaring of lumbar vertebrae
  • Bamboo spine : fusion of joints
  • Syndesmophytes : areas of bone growth where ligaments insert into bone
  • Ossification : ligament, discs and joints start to turn to bone

MRI - if XR is negative but high suspicion, consider MRI as it shows early inflammation of the joints.

  • **CXR **- apical fibrosis
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13
Q

Ankylosing Spondylitis : Management

A
  1. Life style advice : Regular exercise
  2. First line : NSAIDs
  3. Second line (severe disease) : Anti-TNF disease e.g. Infliximab
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14
Q

Psoriatic arthritis : Definition

A

inflammatory arthritis associated with psoriasis.

It can vary in severity from mild stiffening and soreness in the joints to complete joint destruction in arthritis mutilans

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15
Q

Psoriatic arthritis : Patterns of disease

A

Psoriatic arthritis : Patterns of disease
1 . Symmetric polyarthritis } most common
* > 4 joints are affected - such as the hands, wrists and ankles.
* presents similarly to rheumatoid arthritis.

2 . Asymmetrical oligoarthritis} 2nd most common
* 1-4 joints on one side of the body

3 . Distal interphalangeal predominant pattern*
* DIP joints } mostly affected

4 . Spondylitis
* Back stiffness and pain

5 . Arthritis Mutilans
* Phalanges of the fingers and toes
* Severe destruction of bone - causing digit shortening

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16
Q

Psoriatic arthritis : Clinical features

A

* most likely cause of asymmetrical polyarthritis in an afebrile patient*

1 . Arthritis :
* Distal interphalangeal joints and axial skeleton

2 . Skin changes
* Plaques of psoriasis on the skin

3 . Nail changes
* Nail pitting - indents in nails
* Onycholysis -separation of the nail from the nail bed
* Dactylitis - inflammation of the entire finger

3 . Enthesitis
* inflammation at the points of insertion of tendons into bone
* Dactylitis inflammation of the entire finger
* Achilies Tendonitis

17
Q

Psoriatic arthritis : Ix

A

unusual combination of coexistence of erosive changes and new bone formation
1. X-ray : Pencil in cup’ appearance
* Assoc with : arthritis mutilans
* Cup-like appearance.: central erosion on one side of the joint
* ‘Pencil’ : The other bone becomes pointed and looks like a pencil in the cup.

18
Q

Psoriatic arthritis : Mx

A

Smilar to RA management
1. Mild peripheral / Axial disease : NSAID
2. Moderate/Severe : Methotrexate

19
Q

Reactive arthritis : Definition

A
  • Reactive arthritis involves synovitis in joints in response to an infective trigger.
  • Typically it causes acute monoarthritis- affecting a single joint - most often the knee
  • Presenting with a warm, swollen and painful joint.
20
Q

Reactive arthritis : Cause

A

Autoimmune response to an infectious trigger such as;
1. Gastroenteritis or Sexually transmitted infections
* Chlamydia may cause reactive arthritis
* Associated in patients with HIV

21
Q

Reactive arthritis : Clinical features

A

“can’t see, pee or climb a tree”.
* Arthritis : single, hot swollen and painful joint
* Bilateral conjunctivitis -non-infective
* Anterior uveitis
* Urethritis
* Circinate balanitis (dermatitis of the head of the penis)

keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

22
Q

Reactive arthritis : Management

A
  1. Joint aspiration of synovial fluid
    * R/o septic arthritis
  2. Tx underlying triggering infection
  3. NSAID therapy

Most cases resolve within 6 months and do not recur

Rheumatology (11 decks)

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