Seronegative Arthritis Flashcards by Callum Donoher

What is Ankylosing Spondylitis?

Inflammatory condition affecting the axial skeleton (mainly the spine and sacroiliac joints)

A seronegative spondyloarthropathy

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What are the main joints affected by ankylosing spondylitis?

Sacroiliac joints
Vertebral column/spine

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How does ankylosing spondylitis affect the sacroiliac and vertebral column joints?

Inflammation leads to pain and stiffness

Spine fusion and sacroiliac fusion can occur

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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

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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

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Why may a patient with ankylosing spondylitis have chest pain?

Has affected the costovertebral joints or the sternocostal joints

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What is enthesitis?

Inflammation of the entheses which is where tendons or r ligaments insert into bone

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Why may a patient with ankylosing spondylitis present with shortness of breath?

The disease has restricted the chest wall expansion

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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

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What examinations should you do if suspecting ankylosing spondylitis?

Assess chest wall expansion if SOB

Perform Schobers Test

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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

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What gene is heavily linked with ankylosing spondylitis?

HLA-B27

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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

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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

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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

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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.

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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