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MSK > Seronegative Arthritis > Flashcards

Seronegative Arthritis Flashcards

1
Q

What are seronegative arthritides (spondyloarthritis)?

A

Group of chronic inflammatory arthritic dx that are -ve for RF

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2
Q

What genetic association is common with spondyloarthritis?

A

HLA-B27

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3
Q

What sort of arthritis do the spondyloarthritides give rise to?

A

Usually asymmetric

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4
Q

What are the cardinal signs of a spondyloarthritis?

A

Slowly progressive pain in the lower back and SI joints
ESP at night
WITH involvement of the axial skeleton (spine)
Enthesitis
Extra-articular features - uveitis, IBD

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5
Q

What is enthesitis?

A

Inflammation of the entheses (sites where tendons/ligaments attach to bone)

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6
Q

What are the types of spondyloarthritis?

A 
Ankylosing spondylitis
Psoriatic arthritis
Bowel related arthritis (IBD)
Reactive arthritis
Others
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7
Q

Where does ankylosing spondylitis tend to affect?

A

Axial skeleton and entheses

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8
Q

What is the epidemiology of AS?

A

Onset 20-30s
Affects males more
Connection with HIV
90-95% patients are HLA-B27 +ve

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9
Q

How do you diagnose AS?

A

Ex and Hx
Clinical tests to assess reduction in movements and abnormalities of spinal shape
Imaging
Lab tests

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10
Q

What do you want to measure in AS?

A

Spinal mobility - modifier Schober test
Spinal mobility - occiput to wall and tragus to wall
Cervical rotation
Lateral spinal flexion

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11
Q

What imaging can you do in AS and what might you see?

A

XRay - helps confirm diagnosis, may see bamboo spine from squaring off of vertebrae and fusion of the spine, may also see bilateral sacroilitis

MRI - best for early detection of sacroilitis

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12
Q

What lab test results would you expect in AS?

A

High CRP and ESR
Auto-antibody positive (RF, ANA)
HLA-B27 +ve

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13
Q

What are the clinical features of AS?

A

Pain & stiffness in lower back and neck caused by inflammation of the vertebral column & SI joints (improves with activity, worse in morning/at night, gradual onset, dull pain that progresses)

Limited RoM in antero-posterior/lateral planes
Limited chest expansion

Sacroilitis pain in buttocks/lowerpack
Tenderness to percussion/displacement of SI joints
Dactylitis

Fusion of spine leads to inability to flex/extend

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14
Q

What is the most common extra-articular manifestation in AS?

A

Acute, unilateral anterior uveitis

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15
Q

What is the grading for AS?

A

0 - normal
1 - suspicious changes
2 - minimal abnormality - small localized areas, with erosion/sclerosis without alteration in joint width
3 - unequivocal abnormality - mod/advanced sacroilitis with 1 of: erosions, sclerosis, widening, narrowing, partial ankylosis
4 - severe abnormality - total ankylosis

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16
Q

Define anklyosis

A

Abnormal fusion of bones

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17
Q

What are your differentials for AS?

A

Disc prolapse
Vertebral OM
Diffuse idiopathic skeletal hyperostosis (DISH)

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18
Q

What is DISH?

A

Degenerative dx of vertebral column (esp thoracic and lumbar), characterised by severe formation of osteophytes

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19
Q

How does DISH appear on X-Ray compared to AS?

A

Unilateral bulky bridging spondylophytes (lipping of vertebral bodies)
Leads to horizontal growth of spine
Mild/no pain
Develops in older people and tends to not affect SI joints
Extensive calcification of ant. spinal ligament

SqA
Ossification/calcification of annulus fibrosus/spinal ligament (syndesmophytes)
Leads to symmetrical vertical growth directly from vertebral body
Bamboo spine

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20
Q

Define syndesmophyte

A

Ossification/calcification of annulus fibrosis or spinal ligament

21
Q

Define spondylophyte

A

Lipping of vertebral bodies

22
Q

Where do you get syndesmophytes?

A

Inflammation spine dx (e.g. AS)

23
Q

Where do you get spondylophytes?

A

Degenerative dx (e.g. DISH)

24
Q

What criteria is used to diagnose AS?

A

> 3m back pain and age onset <45y

Sacrolitis on imaging and 1+ SpA feature or HLA-B27 and 2+ SpA features

25
Q

What are the SpA features as mentioned in the criteria for diagnosis?

A 
Inflammatory back pain 
Arthritis
Enthesitis (heel) 
Uveitis
Dactylitis
Psoriasis
Crohn's/colitis
Good response to NSAIDs
FH for SqA
HLA-B27
Raised CRP
26
Q

What are the extra-articular features of AS?

A

Peripheral joints - hips, shoulder, knees
Achilles tendonitis
Dactylitis
Uveitis
Cardiac - aortic incompetence, heart block
Pulmonary - restrictive dx, apical fibrosis
GI - IBD
Osteoporosis and spinal fractures
Alantoaxial dislocation & cauda equina syndrome
Renal - secondary amyloidosis

27
Q

How do you Mx AS?

A

Physio - keep mobility/muscle strength
First choice - NSAIDs (pain)
DMARDs (e.g. sulfasazaline - for peripheral arthritis)
Anti-TNF (can put patients into remission)
Rx osteoporosis
Surgery for severe joint dx - joint replacement, spinal surgery (e.g. decompression for cauda equina syndrome)

28
Q

What is psoriatic arthritis?

A

Inflammation of joints (hands, feet, spine) that may occur with psoriasis

NB psoriasis and psoriatic arthritis may occur idependently of each other

29
Q

What are the clinical features of PA?

A

Red, swollen, painful joints
Nail changes - thickened, dystrophic, pitted, discoloured
Dactylitis, enthesitis

30
Q

What are the types of PA?

A 
Oligoarticular 
Polyarthritis
Predominantly spondylitis
Distal IP predominant
Arthritis mutilans
31
Q

Severity of joint disease correlates with _____

A

NOT SKIN DISEASE

32
Q

What is oligoarticular PA?

A

Typically v. mild and asymmetric

2-5 joints

33
Q

What is polyarthritis PA?

A

Resembles RA

Involves >5 joints

34
Q

What is predominantly spondylitis PA?

A

Assymetric involves spine and SI

35
Q

What is DIP predominant PA?

A

Affects DIP and fingers/toes –> dactylitis/nail abnormalities

36
Q

What is arthritis mutilans PA?

A

Extremely severe, destructive form

Bone resorption, bone becomes osteoporotic and lytic

37
Q

What are the radiographic features of PA?

A

Pencil in cup deformity

In arthritis mutilans - marked bony resorption, collapse of soft tissue can lead to telescoping fingers

38
Q

What joints tend to be affected by PA?

A 
Neck 
Elbows
Shoulders
Wrists
Hands
Ankles
Knees
Feet
Base of spine
39
Q

How do you diagnose PA?

A

XRay
Negative RF
Looking for evidence of psorasis, nail dystrophy and dactylitis

40
Q

How do you Mx PA?

A 
DMARDs (sulfasalazine, methotrexate, lefulonamide, cyclosporine)
Anti-TNF therapy 
Anti-IL17, IL23
Steroids
Physio and OT
Axial dx treated similar to AS
41
Q

What is reactive arthritis?

A

Autoimmune condition that occurs after a bacterial infection of throat, GI, urinary tract and results in sterile synovitis

42
Q

What infections can cause RA?

A

Salmonella, shigella, yersinia, campylobacter, chlamydia trachomatis, pneumonia, borrelia, neisseria, strep

43
Q

What is the typical presentation of RA?

A

Symmetric
Mono/oligoarthriris
Dactylitis/enthesitis

Extra-articular symptoms - conjunctivitis, uveitis, iritis, skin lesions of glans (circinate balanitis), urethritis, keratoderma blenorrhagica

44
Q

What is keratoderma blenorrhagica?

A

Skin lesions on palms/soles that resemble psoriasis

45
Q

What is Reiter’s syndrome?

A

Triad of conjunctivitis, arthritis, urethritis

46
Q

What are prognostic features for chronicity of RA?

A

HLA-B27 +ve or FH
High ESR
Hip/heel pain

47
Q

How do you manage RA?

A

ACUTE - NSAIDs, joint infection excluded, antibx in chlamdyia

CHRONIC - NSAIDs, DMARDs

48
Q

What is enteropathic arthritis?

A

Commonly assoc with IBD
Rarely seen in infectious enteritis, whipple’s dx or coeliac dx

Peripheral/axial dx
Enthesopathy common

49
Q

How do you Mx enteropathic arthritis?

A 
NSAIDs difficult to use
Sulfasalazine 
Steroids
MTX
Anti-TNF if severe
Bowel resection may alleviate peripheral disease

MSK (27 decks)

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