Seronegative Arthritis Flashcards by Aimee Love

What are seronegative arthritides (spondyloarthritis)?

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

How well did you know this?

Not at all

Perfectly

What genetic association is common with spondyloarthritis?

HLA-B27

How well did you know this?

Not at all

Perfectly

What sort of arthritis do the spondyloarthritides give rise to?

Usually asymmetric

How well did you know this?

Not at all

Perfectly

What are the cardinal signs of a spondyloarthritis?

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

How well did you know this?

Not at all

Perfectly

What is enthesitis?

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

How well did you know this?

Not at all

Perfectly

What are the types of spondyloarthritis?

Ankylosing spondylitis
Psoriatic arthritis
Bowel related arthritis (IBD)
Reactive arthritis
Others

How well did you know this?

Not at all

Perfectly

Where does ankylosing spondylitis tend to affect?

Axial skeleton and entheses

How well did you know this?

Not at all

Perfectly

What is the epidemiology of AS?

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

How well did you know this?

Not at all

Perfectly

How do you diagnose AS?

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

How well did you know this?

Not at all

Perfectly

What do you want to measure in AS?

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What lab test results would you expect in AS?

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

How well did you know this?

Not at all

Perfectly

What are the clinical features of AS?

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

How well did you know this?

Not at all

Perfectly

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

Acute, unilateral anterior uveitis

How well did you know this?

Not at all

Perfectly

What is the grading for AS?

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

How well did you know this?

Not at all

Perfectly

Define anklyosis

Abnormal fusion of bones

How well did you know this?

Not at all

Perfectly

What are your differentials for AS?

Disc prolapse
Vertebral OM
Diffuse idiopathic skeletal hyperostosis (DISH)

How well did you know this?

Not at all

Perfectly

What is DISH?

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

Define syndesmophyte

Ossification/calcification of annulus fibrosis or spinal ligament

Define spondylophyte

Lipping of vertebral bodies

Where do you get syndesmophytes?

Inflammation spine dx (e.g. AS)

Where do you get spondylophytes?

Degenerative dx (e.g. DISH)

What criteria is used to diagnose AS?

> 3m back pain and age onset <45y

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

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

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

What are the extra-articular features of AS?

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

How do you Mx AS?

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)

What is psoriatic arthritis?

Inflammation of joints (hands, feet, spine) that may occur with psoriasis NB psoriasis and psoriatic arthritis may occur idependently of each other

What are the clinical features of PA?

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

What are the types of PA?

``` Oligoarticular Polyarthritis Predominantly spondylitis Distal IP predominant Arthritis mutilans ```

Severity of joint disease correlates with _____

NOT SKIN DISEASE

What is oligoarticular PA?

Typically v. mild and asymmetric | 2-5 joints

What is polyarthritis PA?

Resembles RA | Involves >5 joints

What is predominantly spondylitis PA?

Assymetric involves spine and SI

What is DIP predominant PA?

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

What is arthritis mutilans PA?

Extremely severe, destructive form | Bone resorption, bone becomes osteoporotic and lytic

What are the radiographic features of PA?

Pencil in cup deformity | In arthritis mutilans - marked bony resorption, collapse of soft tissue can lead to telescoping fingers

What joints tend to be affected by PA?

``` Neck Elbows Shoulders Wrists Hands Ankles Knees Feet Base of spine ```

How do you diagnose PA?

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

How do you Mx PA?

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

What is reactive arthritis?

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

What infections can cause RA?

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

What is the typical presentation of RA?

Symmetric Mono/oligoarthriris Dactylitis/enthesitis Extra-articular symptoms - conjunctivitis, uveitis, iritis, skin lesions of glans (circinate balanitis), urethritis, keratoderma blenorrhagica

What is keratoderma blenorrhagica?

Skin lesions on palms/soles that resemble psoriasis

What is Reiter's syndrome?

Triad of conjunctivitis, arthritis, urethritis

What are prognostic features for chronicity of RA?

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

How do you manage RA?

ACUTE - NSAIDs, joint infection excluded, antibx in chlamdyia CHRONIC - NSAIDs, DMARDs

What is enteropathic arthritis?

Commonly assoc with IBD Rarely seen in infectious enteritis, whipple's dx or coeliac dx Peripheral/axial dx Enthesopathy common

How do you Mx enteropathic arthritis?

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