Seronegative Arthritis Flashcards
What is Ankylosing Spondylitis?
Inflammatory condition affecting the axial skeleton (mainly the spine and sacroiliac joints)
A seronegative spondyloarthropathy
What are the main joints affected by ankylosing spondylitis?
Sacroiliac joints
Vertebral column/spine
How does ankylosing spondylitis affect the sacroiliac and vertebral column joints?
Inflammation leads to pain and stiffness
Spine fusion and sacroiliac fusion can occur
How does a patient with ankylosing spondylitis present?
Slow onset pain and stiffness in the lower back /sacroiliac region > 3months
Morning stiffness > 30mins
Stiffness improves with actiivty worse with rest
What are some additional symtpoms a patient might complain of with ankylosing spondylitis except for lower back pain and stiffness?
Chest pain
Shortness of Breath
Dactylitis
Vertebral fractures (extreme pain)
Enthesitis
Why may a patient with ankylosing spondylitis have chest pain?
Has affected the costovertebral joints or the sternocostal joints
What is enthesitis?
Inflammation of the entheses which is where tendons or r ligaments insert into bone
Why may a patient with ankylosing spondylitis present with shortness of breath?
The disease has restricted the chest wall expansion
What conditions are associated with ankylosing spondylitis?
How can this be remembered?
5 A’s (A for Ankylosing)
Anterior uveitis
Aortic regurgitation
Atrioventricular block
Apical lung fibrosis
Anaemia of chronic disease
What examinations should you do if suspecting ankylosing spondylitis?
Assess chest wall expansion if SOB
Perform Schobers Test
What is the Schobers Test?
Mark an X on the PSIS on the patient
Mark 10cm above the X
Mark 5 cm below the X
Patient bends over/flexes the spine and the distance between the points should be > 20cm. If less than 20cm suggest restricted ROM of the lumbar spine supporting diagnosis of ankylosing spondylitis
What gene is heavily linked with ankylosing spondylitis?
HLA-B27
What diseases are linked to the HLA-B27 gene?
Ankylosing spondylitis
Reactive arthritis/Reiters syndrome
Psoriatic arthritis
Enteropathic arthritis (IBD)
Acute anterior uveitis
IgA nephropathy
Iritis
What investigations would you do if you suspect a patient has ankylosing spondylitis?
Inflammatory markers (CRP + ESR
HLA-B27 testing
Serology screen (ANA)
X-ray spine and sacrum
MRI spine if there’s no x-ray changes
What are the X-ray changes that can be seen with ankylosing spondylitis?
Bamboo spine (late stage, fusion of sacroiliac and spinal joints)
Squared vertebral bodies
Subchondral sclerosis and erosions
Ossification of ligaments
Fusion of facet, sacroiliac and costovertebral joints
Syndesmophytes
What is the medical/surgical management of Ankylosing spondylitis?
NSAIDs are first line (naproxen)
Anti-TNF are second line (infliximab)
Bisphosphonates for osteoporosis
Intra-articular steroid injections
Surgery only for sevre joint disease.
What is the conservative management for ankylosing spondylitis?
Physiotherapy
Exercise
Smoking cessation
What antibodies is ankylosing spondylitis positive for?
None its seronegative
ANA -ve
Anti CCP -ve
Rheumatoid factor -ve
Etc…..
What is the alternate name for reactive arthritis?
Reiters syndrome
What is the pathophysiology of reactive arthritis/reiters syndrome?
Synovitis usually in 1 joint (acute mono arthritis) in response to an infective trigger
How does reactive arthritis typically present?
Usually a single hot swollen painful joint , most often the knee which happens following an infection
What is the main differential that needs to be excluded with a hot swollen painful joint?
Septic arthritis
With reactive arthritis what is happening within the joint?
Inflammation of the synovium
NOT INFECTION IN THE JOINT
What infections commonly trigger reactive arthritis?
Gastroenteritis
STIs
What STI most commonly triggers reactive arthritis?
What STI most commonly causes septic arthritis?
Reactive arthritis likely Chlamydia
Septic arthritis likely gonorrhoea
Who is reactive arthritis more common in, so what do we need to exclude in every patient with reactive arthritis?
HIV infected patients
Since HIV patients more likely to have the HLA-B27 gene
Need to exclude a HIV infection
What gene is linked to reactive arthritis?
HLA-B27
What other issues often present with reactive arthritis?
Bilateral conjunctivitis (non-infective)
Anterior uveitis
Urethritis (non-gonococcal)
Cirinate balanitis (dermatitis of head of penis)
How can you remeber the associations for how reactive arthritis can present?
I cant see, i cant pee or climb a tree
I cant see = bilateral conjunctivitis , anterior uveitis
I cant pee = urethritis, circinate balanitis
I cant climb a tree = arthritic painful swollen joint
How do you manage a patient with reactive arthritis?
Broad spec Abx (meropenem) given until septic arthritis excluded
Join aspiration:
-MCS
-crystal examination
Treat infection
NSAIDs
Steroid injection
Systemic steroids for multiple joints
Why would you examine the joint aspirate (synovial fluid) for crystals with a hot swollen joint?
To investigate for gout or pseudo gout
What medications do you give if the reactive arthritis does not resolve or it recurs after NSAIDs?
DMARDs (methotrexate) or anti-TNF meds (infliximab)
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis
Can lead to mild stiffening and soreness of joints all the way tot complete joint destruction
What can psoriatic arthritis progress to when it leads to joint destruction?
Arthritis mutilans
What are some extra articular manifestations of psoriatic arthritis?
Uveitis
IBD
What joints does psoriatic arthritis most commonly affect?
DIP joints
Spondylitis (stiff back and pain/ AXIAL SKELETON)
How does arthritis mutilans appear?
Shortening of the digit leading to the skin folding so it looks like the digit telescopes
What are the signs of psoriatic arthritis?
Asymmetrical whereas RA is symmetrical
Psoriatic plaques
Nail pitting
Onycholysis
Dactylitis
Enthesitis
What are the x-ray changes seen in psoriatic arthritis?
Pencil in cup appearance (erosion of bones at the joint)
Periostitis
Fusion of bones at joint
Osteolysis
Dactylitis
What is the management for psoriatic arthritis?
Severity depending:
-NSAIDs
-Steroids (Prednisolone)
-DMARDs (methotrexate, leflunomide, sulfasalazine)
-Anti-TNF (infliximab)
-Ustekinumab
What is a side effect when giving NSAIDs to a patent with psoriatic arthritis?
Psoriasis may flare
What is the name of the scoring system for monitoring the success of treatment for psoriatic arthritis?
PSARC
Psoriatic Arthritis Response Criteria
