Seronegative arthritis Flashcards
Define spondylarthropathies
A group of immune mediated inflammatory arthropathies, seronegative (RF-,CCP-), clinically interlinked by certain clinical features and an association with HLA B27 gene
Association in the spine with sacroiliitis and peripherally with enthesopathy
List the spondylarthropathies
Psoriatic arthritis Reactive arthritis Ankylosing spondylitis Enteropathic arthritis -Crohn’s disease -Ulcerative colitis Juvenile ankylosing spondylitis Undifferentiated spondylarthropathies
Non vertebral manifestations of spondylarthropathies
asymmetric peripheral arthritis sausage digits enthesopathy (inflam where tendons insert in bones) -costochondritis -achilles tenosynovitis -plantar fascitis acute anterior uveitis iridocyclitis mucocutaneous lesions nail involvement fatigue,weight loss apical pulmonary fibrosis cardiac involvement
Vertebral changes in ankylosing spondylitis
ankylosing spondilitis occurs in young males and is characterised by inflam back pain (insiduous onset, lasts longer than 3 months, a/w morning stiffness, alleviated w exercise/NSAIDs – onset before age 40)
flattening/ankylosis of lumbar spine (loss of lumbar curvature seen as well) thus impossible for patient to touch toes as cannot flex back- hips do all the flexion.
postural change: forward head, increased dorsal kyphosis : upward gaze w head facing forward, loss of spinal movement ;; reduced chest expansion seen w this
sacroillitis (Seen on Xray) -subchondral bone resorption and irregularity of the sacroiliac joint spaces give rise to the so-called rosary-bead effect and apparent pseudo-widening. Increased sclerosis seen around joint. This describes the early changes.
Advanced sacroiliitis- joint completely destroyed- fusion seen as bony trabeculae cross residual joint - no gross sclerosis
early sydesmophyte formation in cervical spine - fine line (bony growth inside ligament) bridging the articulation of articulating vertebral bodies
sydesmophyte formation can occur in lumbar spine-bamboo shape due to bone fusion
'’squaring’’ of vertebral bodies at lumbar spine (also thoracic sometimes) - loss of anterior concavity of vertebral bodies and straightening of margins –caused by anterior spondylitis with resorption at the enthesis (ligamentous attachment)
Extraarticular features of ankylosing spondylitis
Anterior uveitis of eye: adhesions between iris and lens aka synechiae due to repeat of iritis -> glaucoma/blindness
Apical pulmonary fibrosis
Aortitis with dilation of aortic ring with aortic incompetence
Subclinical inflammatory bowel syndrome
Diagnostic exam for ankylosing spondylitis
Observe : posture, spinal alignment Palpate: sacroiliac, paraspinous muscles Assess range of motion: -finger to floor distance -occiput to wall distance -Schober test for lumbar mobility Assess chest expansion Indirect compression of sacroiliac joint
Explain Schober’s test
Mark 10 cm above superior iliac spines & 5 cm below while standing upright. Get patient to bend
forward as far as possible. At least 5 cm of expansion should be seen.
Tx of ankylosing spondylitis
Intensive Physiotherapy
Home exercise programs to maintain flexibility
NSAIDs (and analgesics if needed)
For progressive disease – Anti-TNF therapy with infliximab, etanercept or adalimumab
Define psoriatic arthritis
Psoriasis and…
An inflammatory arthritis, that is seronegative for rheumatoid factor
Immune mediated & associated with HLA Cw6 and the T8 lymphocyte
Seen in 5% of psoriatic patients – more if severe skin
Prevalance is about 0.1% and M=F overall
What are patterns of psoriatic arthritis
Rheumatoid like pattern of arthritis
Oligoarticular pattern - commonest
Spinal pattern w sacroiliitis or spondylitis
Other patterns include distal DIP arthritis and arthritis mutilans
Musculoskeletal characteristics a/w psoriatic arthritis
Asymmetric (unlike RA)
Oligoarthritis (usually fewer joints than RA)
Dactylitis/Sausage digit (swelling of soft tissue- seen in RA)
Tendonitis
Enthesitis and heel pain
Asymmetric Sacroiliitis and/or Spondylitis
Other manifestations of psoriatic arthritis (cutaneous, heart, eye)
Psoriasis Erythroderma Nail pitting Onycholysis Conjunctivitis/iritis Valvular heart disease
Diagnosis of pt with psoriatic arthritis
Psoriasis and…
Typical pattern of involved joints and/or tendons with inflammatory symptoms
Raised ESR &; CRP & other evidence of inflammation
Negative Rheumatoid factor & negative anti-CCP antibody
Tx for psoriatic arthritis
NSAIDs and analgesics initially
Local steroid injections (not systemic steroids)
Disease modifying therapy with Methotrexate, Sulphasalazine and other DMARDs
Anti-TNF therapy very effective
Anti-IL23 therapy with ustekinumab
Physiotherapy and Occupational therapy
Describe reactive arthritis
a/ features
Seronegative asymmetric arthritis following:
Urethritis or cervicitis often secondary to chlamydiae
Infectious diarrhea due to gram negative bacteria: e.g. shigella, salmonella or campylobacter
Often associated with:
-Conjunctivitis(The erythema and exudate on the bulbar and palpebral conjunctivae) or Anterior Uveitis
-Enthesopathy;; tendinitis (swelling, erythema, tenderness eg on Achilles tendon)
-Circinate balanitis (lesions on penis), urethritis, oral ulceration or keratoderma blenorrhagica(skin thickening of hands/feet soles)
-sausage fingers
-sacroiilitis
Define conjunctivitis symptoms
burning, excessive lacrimination, intense hypereamia
Describe keratoderma blenorrhagica
Numerous pustules are present on the feet of a patient with reactive arthritis. They begin as vesicles on erythematous bases and become sterile pustules -> keratotic scales aka keratoderma blenorrhagica
Triad a/w Reiter’s syndrome
conjunctivitis/anterior uveitis
urethritis/cervicitis
arthritis
Differential for Reiter’s syndrome
gonococcal infection w septic arthritis
Management of reactive arthritis
Need to rule out septic arthritis or gonococcal arthritis – joint aspiration & culture & gram stain
Urethral, cervical, stool and oral cultures including specific cultures for chlamydia and gonococcus and other STDs
Treat any infections found,
Rx w NSAIDs and if not settling w DMARDs
Most cases settle over time
Define enteropathic arthritis
Inflammatory bowel arthritis Seen with both Crohn’s and UC in 10% Pts
50% HLA B27+ve – spinal arthritis w sacroilitis and spondylitis
Define gout
A group of diseases resulting from deposition of monosodium urate crystals in tissues or supersaturation of MSU in extracellular fluids
- tophi (uric acid deposition in tissues eg DIP )
- acute/chronic
Define acute gouty arthritis
Abrupt onset of severe joint inflammation, often with onset in the night
75% of initial attacks in first MTP joint
Usually monarticular, may be polyarticular
Attack subsides in 3-10 days
Urate crystals present in synovial fluid
Hyperuricemia usually present but not always
-podagra - base of big toe and ankle swollen(Eg) and extremely painful
What does acute gout mimic?
cellulitis
What does gout of DIP resemble?
Osteoarthritis
Tophi/gout diagnosis
mass of bright birefringent needle-shaped urate crystals from material aspirated from this joint is seen under compensated polarizing microscopy.
Epidemiology of gout
disease of men peak 40-50
genetic componentic -20% (primary cause)
a/w prologed hyperurucaemia
a/w underexcretion/overproduction of urate(secondary cause)
Outline causes of hyperuricaemia as it relates to over production
Overproduction (10%) Ethanol HGPRT or G6PD deficiency PRPP synthetase overactivity Myeloproliferative disorders Cytotoxic chemotherapy Sickle-cell anemia
Outline causes of hyperuricaemia as it relates to underexcretion
Underexcretion(90%) Renal insufficiency Drugs and toxins Diuretics Ethanol Cyclosporine A Pyrazinamide Lead nephropathy Low-dose aspirin
Pathogenesis of inflammation in gout
MSU crystals are the cause of inflammation
Induce phagocytes and synovial cells to generate multiple inflammatory enzymes, COX, lipoxygenases, proteases, TNF-a, IL-1, IL-6, bradykinins etc
May activate via Toll like receptor and NALP-3 inflammasome, IL-1 a major cytokine
Activation of neutrophils most important event
Tx of gout
Non-steroidal anti-inflammatory drugs at full dose are very effective if tolerated (care in renal impairment or peptic ulcer)
NSAIDS inhibit Cyclo-oxygenase 1& 2
Colchicine inhibits microtubule polymerisation and prevents neutrophil mediated release of inflammatory agents
Corticosteroids are very effective for inflammation
Prevention of gout
drugs used to prevent also
Alter correctable causes – reduce alcohol, loose weight, avoid large protein meals, stop diuretics and other drugs aggravating hyperuricaemia
Allopurinol blocks xanthine oxidase and is most used preventative Rx working by lowering urate levels- has no effect on ACUTE gout
Probenecid promotes excretion of urate in kidneys lowering urate if renal function is adequate
Febuxistat is a new agent xanthine oxidase inhibitor in clinical trials
