Seronegative Arthritis Flashcards
What is seronegative arthritis?
- A group of arthritic conditions which are negative for rheumatoid factor
- May be associated with HLA-B27
- Usually asymmetric and spinal involvement
- Enthesitis and extra-articular features
What extra-articular features can occur in seronegative arthritis?
- Uveitis
- IBD
- Psoriasis
What are the different clinical presentations of seronegative arthritis?
- Ankylosing Spondylitis
- Psoriatic arthritis
- Bowel related arthritis (Crohn’s, UC)
- Reactive arthritis
- Others
What is ankylosing spondylitis?
-A chronic inflammatory rheumatic disorder with a predilection for axial skeleton and enthuses
Who is affected by ankylosing spondylitis?
- M>F
- 2nd to 3rd decade
- Prevalence varies worldwide
How can spinal mobility be tested/measured?
- Modified Schober test
- Lateral spinal flexion
- Occiput to wall and tragus to wall
- Cervical rotation
What surface antigen is associated with ankylosing spondylitis?
HLA-B27
What are the clinical features of ankylosing spondylitis?
- Inflammatory back pain (worse in the morning, better after activity and insidious onset)
- Limitation of movements in antero-posterior as well as lateral planes at lumbar spine
- Limitation of chest expansion
- Bilateral sacroiliitis on X-rays
How is radiographic sacroiliitis graded?
Grade 0
-Normal
Grade1
-Suspicious changes
Grade 2
-Minimal abnormality
Grade 3
-Unequivocal abnormality
Grade 4
-Severe abnormality
How does axial spondyloarthritis progress?
Non-radiographic stage
-Back pain and sacroiliitis on MRI
Radiographic stage
- Back pain and radiographic sacroiliitis
- Back pain and syndesmophytes
- Modified New York Criteria used
What is the ASAS classification criteria for axial spondyloarthritis?
In patients with 3 months or more history of back pain and age of onset <45
- Sacroillitis on imapging pulse 1 or mor SpA features OR
- HLA-B27 plus 2 or more SpA features
What are the SpA features?
- Inflammatory back pain
- Arthritis
- Enthesitis (heel)
- Uveitis
- Dactylitis
- Psoriasis
- Crohn’s/colitis
- Good response to NSAIDs
- Family history
- HLA-B27
- Elevated CRP
What are the systemic features of SpA?
- Achilles tendonitis, dactylitis
- Uveitis
- Cardiac- Aortic incompetence, heart block
- Pulmonary- restrictive disease, apical fibrosis
- GI- IBD
- Osteoporosis and spinal fractures
- Neurological- AAD & cauda equina syndrome
- Renal- secondary amyloidosis
How is ankylosing spondylitis managed?
- Physiotherapy (mainstay)
- NSAIDs
- DMARDs- Sulfasalazine
- Anti-TNF
- Anti-IL-17
- Treatment of osteoporosis
- Surgery- joint replacements & spinal surgery
What joints are commonly affected by psoriatic arthritis?
- Neck
- Shoulders
- Elbows
- Wrists
- All joints of the digits
- Ankles
- Knees
- Spine
What are the clinical subtypes of psoriatic arthritis?
- Arthritis with DIP joint involvement
- Symmetric polyarthritis- similar to RA
- Asymmetric oligoarticular arthritis
- Arthritis mutilans
- Predominant spondylitis
How is psoriatic arthritis treated?
- Sulfasalazine
- Methotrexate
- Leflunomide
- Cyclosporine
- Anti-TNF therapy
- Anti- IL-17 and IL-23
- Steroids (oral, IM, IA etc.)
- Physiotherapy and occupational therapy
- Axial disease treated similar to AS
What is reactive arthritis?
A painful form of arthritis which occurs after a distant infection
What organisms have been implicated in reactive arthritis?
- Salmonella
- Shigella
- Yersinia
- Campylobacter
- Chlamydia trachomatis/penumoniae
- Borrelia
- Neisseria
- Streptococci
What are the features of reactive arthritis?
- Disease may be systemic
- Usually mono or oligiarthritis
- Dactylitis or enthesitis may be seen
- Associated with throat, urogenital and GI infections
What skin and mucosal involvement can occur in reactive arthritis?
- Keratoderma blenorrhagica
- Circinate balanitis
- Urethritis
- Conjunctivitis
- Iritis
What is the triad of Reiter’s syndrome (reactive arthritis)?
- Arthritis
- Urethritis
- Conjunctivitis
What are the prognostic signs for chronicity of reactive arthritis?
- Hip/heel pain
- High ESR
- Family history and HLA-B27 positive
When are recurrent reactive arthritis attacks common?
In chlamydia induced arthritis
How is reactive arthritis treated?
Acute
- NSAID
- Joint injection (if infection excluded)
- Antibiotics in chlamydia infection (contacts as well)
Chronic
- NSAID
- DMARD (e.g. sulphasalazine, methotrexate)
What is enteropathic arthritis commonly associated with?
IBD (Crohn’s or colitis)
When can enteropathic arthritis rarely be seep?
- Enteritis
- Whipple’s disease
- Coeliac disease
How does enteropathic arthritis present?
- Can present with both peripheral and/or axial disease
- Enthesopathy commonly seen
What is the treatment for enteropathic arthritis?
- NSAIDs difficult to use
- Sulfasalazine
- Steroids
- Methotrexate
- Anti-TNF
- Bowel resection may alleviate peripheral disease
