Seronegative arthritis 2

Question 1

What is ankylosing spondylitis?

Answer 1

An inflammatory condition mainly affecting the spine that causes progressive stiffness and pain.

Question 2

Which gene are seronegative spondyloarthropathies linked to?

Answer 2

HLA B27

Around 90% of patients with AS have the HLA B27 gene however around 2% of people with the gene will get AS. This number is higher (around 20%) if they have a first degree relative that is affected.

Question 3

Which joints are most commonly affected in ankylosing spondylitis?

Answer 3

The sacroiliac joints and the joints of the vertebral column.

Question 4

Presentation of ankylosing spondylitis

Answer 4

• Often male in late teens/twenties
• Symptoms develop gradually over more than 3 months
  
  • Lower back pain and stiffness
  • Sacroiliac pain
    
    • Symptoms improve with movement
    • Worse at night
    • >30 minutes of morning stiffness
  • Symptoms can fluctuate with flares

Question 5

Name a complication of ankylosing spondylitis

Answer 5

Vertebral fractures

Question 6

Ankylosing spondylitis associated conditions

Answer 6

• Systemic symptoms such as weight loss and fatigue
• Chest pain related to costovertebral and costosternal joints
• Enthesitis is inflammation of the entheses. This is where tendons or ligaments insert in to bone. This can cause problems such as plantar fasciitis and achilles tendonitis.
• Dactylitis is inflammation in a finger or toe.
• Anaemia
• Anterior uveitis
• Aortitis is inflammation of the aorta
• Heart block can be caused by fibrosis of the heart’s conductive system
• Restrictive lung disease can be caused by restricted chest wall movement
• Pulmonary fibrosis at the upper lobes of the lungs occurs in around 1% of AS patients
• Inflammatory bowel disease is a condition associated with AS

Question 7

Which test is used to assess mobility in the lumbar spine?

Answer 7

Schober’s test

Question 8

Describe Schober’s test

Answer 8

• Mark L5 vertebra and 10cm above and 5 cm below
• Ask the patient to bend forward as far as they can
• Measure the distance between the two points
• <20cm indicates restriction in lumber movement

Question 9

Investigations for ankylosing spondylitis

Answer 9

• Inflammatory markers (CRP and ESR) may rise with disease activity
• HLA B27 genetic test
• X-ray of the spine and sacrum
• MRI of the spine can show bone marrow oedema early in the disease before there are any X-ray changes

Question 10

Pharmacological management of ankylosing spondylitis

Answer 10

• NSAIDs can be used to help with for pain. If the improvement is not adequate after 2-4 weeks of a maximum dose then consider switching to another NSAID.
• Steroids can be use during flares to control symptoms. This could oral, intramuscular slow release injections or joint injections.
• Anti-TNF medications such as etanercept or a monoclonal antibody against TNF such as infliximab, adalimumab or certolizumab pegol are known to be effective in treating the disease activity in AS.
• Secukinumab is a monoclonal antibody against interleukin-17. It is recommended by NICE if the response to NSAIDS and TNF inhibitors is inadequate.

Question 11

Non-pharmacological management of ankylosing spondylitis

Answer 11

• Physiotherapy
• Exercise and mobilisation
• Avoid smoking
• Bisphosphonates to treat osteoporosis
• Treatment of complications
• Surgery is occasionally required for deformities to the spine or other joints

Question 12

How should patients presenting with an acute warm, swollen, painful joint be initially managed?

Answer 12

Need to be treated according to the local hot joint policy.

This will involve giving antibiotics until the possibility of septic arthritis is excluded. Aspirate the joint and send a sample for gram staining, culture and sensitivity testing to exclude septic arthritis.

The aspirated fluid can also be sent for crystal examination to look for gout and pseudogout.

Question 13

Management of reactive arthritis when septic arthritis is excluded?

Answer 13

• NSAIDs
• Steroid injections into the affected joints
• Systemic steroids may be required, particularly where multiple joints are affected
• Most resolve within 6 months and don’t recur. Recurrent cases may require DMARDs or anti-TNF medications

Question 14

What is reactive arthritis?

Answer 14

Reactive arthritis is where synovitis occurs in the joints as a reaction to a recent infective trigger.

Question 15

Reactive arthritis used to be known as:

Answer 15

Reiter Syndrome

Question 16

How does reactive arthritis present?

Answer 16

Typically it causes an acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.

Question 17

What are the most common infective triggers for reactive arthritis?

Answer 17

Gastroenteritis or sexually transmitted infection.

Chlamydia is the most common sexually transmitted cause of reactive arthritis.

Gonorrhoea commonly causes a gonococcal septic arthritis.