Seronegative Arthritis

Question 1

What is seronegative arthritis

Answer 1

Arthritis with a negative rheumatoid factor which may be associated with HLA-B27. There is usually asymmetric arthritis involving the axial skeleton, enthesitis, uveitis and IBD>

Question 2

Different clinical presentations of seronegative arthritis

Answer 2

• Ankylosing spondylitis
• Psoriatic arthritis
• Bowel related arthritis
• Reactive Arthritis
• Others

Question 3

Epidemiology of Ankylosing Spondylitis

Answer 3

Onset is during the second to the third decade of life occuring more in males. Prevelance of 0.5%-1%

Question 4

Clinical history of Ankylosing Spondylitis

Answer 4

Insidious onset lower back pain worse in the morning and after immobility.

If sacroiliac disease they may complain of hip and buttock pain.

Limitation of movements in the antero-posterior as weel as lateral planes at the lateral spine.

Limitation of chest expansion and bilateral sacroilitis on X-rays

Uveitis

Question 5

Examinations that can examine how well the spine moves

Answer 5

Modified Schober - lumbar flexion
Lateral spinal flexion - 20cm is normal. 
Occiput to wall
Tragus to wall (increasing kyphosis)
(10 cm is normal for both)
Cervical Rotation (85 degrees)

Question 6

Radiological investigation of Ankylosing Spondylitis

Answer 6

MRI detects lumbar spine inflammation
CT of the SIJ shows erosive changes
X-ray

Question 7

Grade 0 sacrolitis

Answer 7

normal

Question 8

Grade 1

Answer 8

Suspicious changes

Question 9

Grade 2

Answer 9

Minimal abnormality - small localised areas with erosion or sclerosis, withtout alteration in the joint width

Question 10

Grade 3

Answer 10

Unequivocal abnormality - moderate or advances sacroilits with one or more of erosions, evidence of sclerosis, widening, narrowing or partial ankylosis

Question 11

Grade 4

Answer 11

Total ankylosis

Question 12

Non-radiographic stage of axial spondyloarthritis

Answer 12

Back pain and sacroilitis on MRI

Question 13

Radiographic stage of axial spondyloarthritis

Answer 13

Back pain, radiographic sacroilitis and syndesmophytes

Question 14

Syndesmophytes

Answer 14

A syndesmophyte is a bony growth originating inside a ligament, commonly seen in the ligaments of the spine, specifically the ligaments in the intervertebral joints leading to fusion of vertebrae.

Question 15

Classification criteria for Axial Spndyloarthritis

Answer 15

In patients with more than three months of back pain and age of onset below the age of 45. There should be sacroilitis on imaging plus one or more SpA features OR HLA-B27 plus 2 or more other SpA features:

•	Inflammatory back pain 
•	Arthritis
•	Enthesitis
•	Uveitis
•	Psoriasis
•	Crohns, colitis
•	Good response to 
        NSAIDs
•	Family history
•	HLA-B27
•	Elevate CRP

Question 16

Cardiac features of AS

Answer 16

Aortic incompetence, heart block

Question 17

Neurological features of AS

Answer 17

Cauda Equina Syndrome and atlantoaxial dislocation

Question 18

Renal features of AS

Answer 18

Secondary amyloidosis

Question 19

Management of AS

Answer 19

physiotherapy is the most important and will control the posture, to control pain NSAIDs (etoricoxib), DMARDs (sulfasalazine) however they will not work if the disease is predominately spinal, anti-TNF, Anti-IL-17, treatment of osteoporosis, surgery – joint replacements and spinal surgery especially hip disease requiring hip replacements.

Question 20

Psoriatic Arthritis

Answer 20

Psoriasis alongside arthritis of any joint

Question 21

Different sub-types of psoriatic arthritis

Answer 21

• Arthritis with DIP joint involvement
• Symmetric polyarthritis – similar to RA
• Asymmetric oligoarticular arthritis
• Arthritis mutilans
• Predominant spondylitis

Question 22

Treatment of psoriatic arthritis

Answer 22

• Sulfasalazine
• Methotrexate
• Leflunomide
• Anti-TNF
• Anti-IL-17 and IL-23
• Steroids
• Physiotherapy and occupational therapy
• Axial disease treated similar to AS

Question 23

Reactive Arthritis

Answer 23

This is sterile synovitis after a distant infection (salmonella, shingela, Yersinia enterocolitica, campylobacter, chlamydia, trachomatis, C.Diff etc). It usually results in mono or oligoarthritis. Dactylitis or enthesitis can also be seen.

Question 24

Clinical Features of reactive arthritis

Answer 24

Acute and oligoarticular with a predilection for weight-bearing joints.

May present with inflammatory backache and sacroiliac joint tenderness.

Fever and malaise are also common.

Joint swelling

Question 25

Reiters Syndrome

Answer 25

also known as reactive arthritis, is the classic triad of conjunctivitis, urethritis, and arthritis occurring after an infection, particularly those in the urogenital or gastrointestinal tract

Question 26

Skin and mucous membrane involvement in Reactive Arthritis

Answer 26

• Keratoderma blenorrhagica( skin lesions commonly found on the palms and soles but which may spread to the scrotum, scalp and trunk.)
• Circinate balanitits
• Urethritis
• Conjunctivitis
• Iritis

Question 27

Investigations of Reactive Arthritis

Answer 27

ESR and CRP raised

Autoantibodies present

Question 28

Prognostic signs for chronicity of reactive arthritis

Answer 28

hip and heel pain, high EST and family history and HLA-B27 positive

Question 29

Treatment of reactive arthritis

Answer 29

NSAIDs
DMARDS - methotrexate or sulfasalzine in chronic
Rifampicin with doxycycline or azithromycin in chlamydia related infection

Question 30

Enteropathic Arthritis

Answer 30

This is commonly associated with inflammatory bowel disease. It is rarely seen with infectious enteritis, Whipple’s disease and Coeliac disease. It can present with both peripheral and/or axial disease.

Question 31

Treatment of Enteropathic Arthritis

Answer 31

The treatment includes NSAIDs, sulfasalazine, steroids, methotrexate, anti-TNF, bowel resection may alleviate peripheral disease