Seronegative Arthritis

Question 1

What is seronegative arthritis?

Answer 1

• 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

Question 2

What extra-articular features can occur in seronegative arthritis?

Answer 2

• Uveitis
• IBD
• Psoriasis

Question 3

What are the different clinical presentations of seronegative arthritis?

Answer 3

• Ankylosing Spondylitis
• Psoriatic arthritis
• Bowel related arthritis (Crohn’s, UC)
• Reactive arthritis
• Others

Question 4

What is ankylosing spondylitis?

Answer 4

-A chronic inflammatory rheumatic disorder with a predilection for axial skeleton and enthuses

Question 5

Who is affected by ankylosing spondylitis?

Answer 5

• M>F
• 2nd to 3rd decade
• Prevalence varies worldwide

Question 6

How can spinal mobility be tested/measured?

Answer 6

• Modified Schober test
• Lateral spinal flexion
• Occiput to wall and tragus to wall
• Cervical rotation

Question 7

What surface antigen is associated with ankylosing spondylitis?

Answer 7

HLA-B27

Question 8

What are the clinical features of ankylosing spondylitis?

Answer 8

• 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

Question 9

How is radiographic sacroiliitis graded?

Answer 9

Grade 0
-Normal

Grade1
-Suspicious changes

Grade 2
-Minimal abnormality

Grade 3
-Unequivocal abnormality

Grade 4
-Severe abnormality

Question 10

How does axial spondyloarthritis progress?

Answer 10

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

Question 11

What is the ASAS classification criteria for axial spondyloarthritis?

Answer 11

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

Question 12

What are the SpA features?

Answer 12

• Inflammatory back pain
• Arthritis
• Enthesitis (heel)
• Uveitis
• Dactylitis
• Psoriasis
• Crohn’s/colitis
• Good response to NSAIDs
• Family history
• HLA-B27
• Elevated CRP

Question 13

What are the systemic features of SpA?

Answer 13

• 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

Question 14

How is ankylosing spondylitis managed?

Answer 14

• Physiotherapy (mainstay)
• NSAIDs
• DMARDs- Sulfasalazine
• Anti-TNF
• Anti-IL-17
• Treatment of osteoporosis
• Surgery- joint replacements & spinal surgery

Question 15

What joints are commonly affected by psoriatic arthritis?

Answer 15

• Neck
• Shoulders
• Elbows
• Wrists
• All joints of the digits
• Ankles
• Knees
• Spine

Question 16

What are the clinical subtypes of psoriatic arthritis?

Answer 16

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

Question 17

How is psoriatic arthritis treated?

Answer 17

• 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

Question 18

What is reactive arthritis?

Answer 18

A painful form of arthritis which occurs after a distant infection

Question 19

What organisms have been implicated in reactive arthritis?

Answer 19

• Salmonella
• Shigella
• Yersinia
• Campylobacter
• Chlamydia trachomatis/penumoniae
• Borrelia
• Neisseria
• Streptococci

Question 20

What are the features of reactive arthritis?

Answer 20

• Disease may be systemic
• Usually mono or oligiarthritis
• Dactylitis or enthesitis may be seen
• Associated with throat, urogenital and GI infections

Question 21

What skin and mucosal involvement can occur in reactive arthritis?

Answer 21

• Keratoderma blenorrhagica
• Circinate balanitis
• Urethritis
• Conjunctivitis
• Iritis

Question 22

What is the triad of Reiter’s syndrome (reactive arthritis)?

Answer 22

• Arthritis
• Urethritis
• Conjunctivitis

Question 23

What are the prognostic signs for chronicity of reactive arthritis?

Answer 23

• Hip/heel pain
• High ESR
• Family history and HLA-B27 positive

Question 24

When are recurrent reactive arthritis attacks common?

Answer 24

In chlamydia induced arthritis

Question 25

How is reactive arthritis treated?

Answer 25

Acute

• NSAID
• Joint injection (if infection excluded)
• Antibiotics in chlamydia infection (contacts as well)

Chronic

• NSAID
• DMARD (e.g. sulphasalazine, methotrexate)

Question 26

What is enteropathic arthritis commonly associated with?

Answer 26

IBD (Crohn’s or colitis)

Question 27

When can enteropathic arthritis rarely be seep?

Answer 27

• Enteritis
• Whipple’s disease
• Coeliac disease

Question 28

How does enteropathic arthritis present?

Answer 28

• Can present with both peripheral and/or axial disease

- Enthesopathy commonly seen

Question 29

What is the treatment for enteropathic arthritis?

Answer 29

• NSAIDs difficult to use
• Sulfasalazine
• Steroids
• Methotrexate
• Anti-TNF
• Bowel resection may alleviate peripheral disease