Seronegative Arthritis Flashcards
What are the features of seronegative arthritis?
- Negative rheumatoid factor
- May be associated with HLA-B27
- Usually asymmetric
- Involvement of axial skeleton (spine)
- Enthesitis (inflamm of where the tendon or ligament inserts into the bone)
- Extra articular features: uveitis and IBD
What are the different types of seronegative arthritis?
- Ankylosing Spondylitis
- Psoriatic arthritis
- Bowel related arthritis (IBD)
- Reactive arthritis
What is ankylosing spondylitis?
Chronic inflammatory rheumatic disorder with a predilection for axial skeleton and entheses
Which groups of patients are most likely to be affected by ankylosing spondylitis?
- Onset 20-30s
- Males > females
Is HLA B27 diagnostic of ankylosing spondylitis?
No - whilst it is positive in most patients with AS it is also present in approx. 10% of the general population of which only 1% have AS
Which tests can be used to assess a patient’s spinal mobility?
- Modified Schober
- Lateral Spine Flexion
- Occiput to wall and tragus to wall
- Cervical rotation
What are the clinical features of AS (NY criteria)?
- Inflammatory back pain
- Limitation of movements in antero-posterior as well as lateral planes at the lumbar spine
- Limitation of chest expansion
- Bilateral sacroiliitis on X-rays
How is radiographic sacroiliitis graded?
Grade 0: normal Grade 1: suspicious changes Grade 2: minimal abnormality Grade 3: Unequivocal abnormality -Grade 4: Severe abnormality (total ankylosis)
What are the features of axial spondlyoarthritis (SpA)?
- Inflammatory back pain
- Arthritis
- Enthesitis (heel)
- Uveitis
- Dactylitis
- Psoriasis
- Crohn’s/colitis
- Good response to NSAIDs
- FH
- HLA-B27
- Elevated CRP
What are the ASAS classification criteria for SpA?
- Patients with > 3 months back pain
- Age of onset < 45yrs
- Sacroiliitis on imaging + 1 or more SpA features OR
- HLA-B27 + 2 other SpA features
Name some of the other features of SpA
- Peripheral joint involvement (hips/shoulders/knees)
- Achilles tendonitis, dactylitis
- Aortic incompetence, heart block
- Restrictive lung disease, apical fibrosis
- Neuro: AAD and cauda equina syndrome
- Renal: secondary amyloidosis
What are the management options for AS?
- Physio
- NSAIDs
- DMARDs - sulfasalazine
- Anti-TNF
- Anti-IL-17
- Treatment of osteoporosis
- Surgery: joint replacements and spinal surgery
Which joints are commonly affected by psoriatic arthritis?
Neck, shoulder, elbows, wrists, all joints of knuckles/thumbs/fingers, base of spine, knees, ankles and all joints of the toes
What are the clinical subtypes of psoriatic arthritis?
- Arthritis with DIP joint involvement
- Symmetric polyarthritis
- Asymmetric oligoarticular arthritis
- Arthritis mutilans
- Predominant spondylitis
What are the treatment options for psoriatic arthritis?
- Sulfasalazine
- Methotrexate
- Leflunomide
- Cyclosporine
- Anti-TNF therapy
- Anti-IL-17 and IL-23
- Steroids
- Physio and OT
- Axial disease is treated similar to AS
What is reactive arthritis?
Sterile synovitis after distant infection
Which organisms are most likely the cause of reactive arthritis?
Salmonella, shigella, yersinia, campylobacter, chlamydia trachomatis or pneumoniae, borellia, neisseria and strep
Which skin and mucous membrane features may be seen in reactive arthrits?
- Keratoderma blenorrhagica (skin lesions on the palm and soles)
- Circinate balanitis (ring shaped dermatitis on the glans penis)
- Conjunctivitis
- Iritis
What are the features of Reiter’s syndrome?
Arthritis, urethritis and conjunctivitis
What are the prognostic signs for the chronicity of reactive arthritis?
- Hip/heel pain
- High ESR
- FH history and positive HLA-B27
What are the treatment options for acute reactive arthritis?
- NSAIDs
- Joint injection (if infection excluded)
- Antibiotics in chlamydia infection
What are the treatment options for chronic reactive arthritis?
- NSAIDs
- DMARD (e.g. sulphasalazine, methotrexate)
Which conditions are associated with enteropathic arthritis?
- Commonly: IBD
- Rarely: infectious enteritis, Whipple’s disease and coeliac disease
How does enteropathic arthritis present?
- Peripheral and/or axial disease
- Enthesopathy
What are the treatment options for enteropathic arthritis?
- Sulfasalazine
- Steroids
- Methotrexate
- Anti-TNF
- Bowel resection may alleviate peripheral disease
- NSAIDs difficult to use
