Seronegative Arthritis

Question 1

Definition of seronegative arthritis

Answer 1

• -VE RHEUMATOID FACTOR
  
  • May be ass. w/ HLA-B27 (this is NOT a causative gene)
  • Usually ASYMMETRIC ARTHRITIS (rheumatoid arthritis is usually SYMMETRIC)
  • AXIAL SKELTON (SPINE) INVOLVED = SACROILIITIS, LOSS of NORMAL SPINE CURVATURES + OTHER JOINT DEFORMITIES AS A RESULT (e.g. fixed flexion of hip & knees)
  • ENTHESITIS = can result in SECONDARY SYNOVITIS
  • EXTRA-ARTICULAR FEATURES = UVEITIS, INFLAMMATORY BOWEL DISEASE, SKIN

Question 2

Ankylosing Spondylitis: definition

Answer 2

• CHRONIC INFLAMMATORY RHEUMATIC DISORDER w/ a PREDILECTION for AXIAL SKELTON & ENTHESES

	○ PROTOTYPE for AXIAL SPONDYLOARTHRITIS

Question 3

Ankylosing Spondylitis: presentation

Answer 3

MSK:

• INFLAMMATORY BACK PAIN = PAIN ALLEVIATED BY MOVING/EXERCISE (MECHANICAL PAIN WORSENS W/ MOVING/EXERCISE)
• LIMITED MOVEMENT in ANTERO-POSTERIOR + LATERAL PLANES at LUMBAR SPINE
• LIMITED CHEST EXPANSION - if CHOSTOCHONDRAL JOINTS involved (may not be able to see this on X-ray)
• BILATERAL SACROILIITIS on X-RAYS

Other:

* PERIPHERAL JOINTS = HIPS, SHOULDERS, KNEES
* ACHILLES TENDONITIS, DACTYLITIS - can be any joint

* EYES = UVEITIS
* CARDIAC = AORTIC INCOMPETENCE, HEART BLOCK
* PULMONARY = RESTRICTIVE DISEASE, APICAL FIBROSIS
* GI = IBD
* BONE = OSTEOPOROSIS & SPINAL FRACTURES
* NEUROLOGICAL = ATLANTO-AXIAL DISLOCATION (AAD) & CAUDA EQUINA SYNDROME
* RENAL = SECONDARY AMYLOIDOSIS

Question 4

Ankylosing Spondylitis: investigations/diagnosis

Answer 4

• Hx & EXAMINATION = SPINAL MOBILITY (modified Schober, lateral flexion, occiput to wall + tragus to wall, cervical rotation)
  
  • BLOODS = CRP (low CRP shouldn’t deter from making diagnosis)
  • X-RAY = BILATERAL SACROILIITIS, will only show ESTABLISHED CHANGES, not active inflammatory process
  • DEXA = do if HIGH CRP - LOTS of FRACTURES + LOW BONE DENSITY
  • MRI = shows ACTIVE INFLAMMATION, allows for pt. to be diagnosed sooner

Question 5

Ankylosing Spondylitis: management

Answer 5

• PHYSIOTHERAPY

• NSAIDs = pt. who take them long-term may have less issues w/ spinal fusion, but at increased risk of ulcers & bleeding esp. if they have IBD
	○ Pt. who have the WORST DISEASE (e.g. HIGH CRP, SYNDESMOCYTES) BENEFIT MOST from TREATMENT

* DMARDs = SULFASALAZINE - for peripheral arthritis
* BIOLOGICS = ANTI-TNF (INFLIXIMAB, ETANERCEPT), ANTI-IL-17 - unknown if they prevent spinal fusion damage
* TREATMENT of OSTEOPOROSIS = consider doing DEXA scan as well
* SURGERY = JOINT REPLACEMENTS & SPINAL SURGERY

Question 6

Ankylosing Spondylitis: ASAS classification

Answer 6

3/more months back pain + <45yrs age of onset

sacroiliitis on imaging + 1 extra feature/HLA-B27 + 2 extra features:

inflammatory back pain
arthritis
enthesitis
uveitis
dactylitis
psoriasis
crohn's/colitis
good response to NSAIDs
FHx for AS
HLA-B27
elevated CRP

Question 7

Ankylosing Spondylitis: epidemiology + aetiology

Answer 7

• AGE = 2ND - 3RD DECADE of LIFE - could be in TEENAGE YEARS (due to prevalence of HLA B27)
  
  • MALES > FEMALES
  • PREVALENCE VARIES THROUGHOUT THE WORLD
  • GENETIC = HLA B27 - NOT DIAGNOSTIC of ANKYLOSING SPONDYLITIS/SPONDYLOARTHRITIS
  • AS risk increases in relative

Question 8

Psoriatic Arthritis: presentation

Answer 8

various (mono/oligo/polyarthritis - joints of hand + wrist, elbows, shoulder, neck, base of spine, knee, ankle, all joints of feet)

clinical subtypes:

* ARTHRITIS w/ DIP INVOLVEMENT
* SYMMETRIC POLYARTHRITIS - similar to RA
* ASYMMETRIC OLIGOARTICULAR ARTHRITIS
* ARTHRITIS MUTILANS
* PREDOMINANT SPONDYLITIS

* Also characterised by DACTYLITIS & ENTHESITIS
* NAIL PITTING, ONYCHOLYSIS may be seen
* SEVERITY of JOINT DISEASE doesn’t correlate to EXTENT of SKIN DISEASE

Question 9

Reactive Arthritis: management

Answer 9

Acute - NSAID, joint injection (if infection excluded), antibiotics (in chlamydia infection - also for contacts)

Chronic - NSAID, DMARD (sulfasalazine, methotrexate)

Question 10

Reactive Arthritis: presentation

Answer 10

ARTHRITIS (monoarthritis/oligoarthritis), URETHRITIS, CONJUNCTIVITIS

also see dactylitis, enthesitis

may be systemic

Skin + mucous involvement:
	• KERATODERMA BLENORRHAGICA
	• CIRCINATE BALANITIS
	• URETHRITIS
	• CONJUNCTIVITIS
	• IRITIS

Question 11

Reactive Arthritis: management

Answer 11

Acute - NSAID, joint injection (if infection excluded), antibiotics (in chlamydia infection - also for contacts)

Chronic - NSAID, DMARD (sulfasalazine, methotrexate)

Question 12

Reactive Arthritis: prognostic signs for chronicity

Answer 12

• HIP/HEEL PAIN
• HIGH ESR
• FHx + HLA-B27 +VE

Question 13

Reactive Arthritis: micro-organisms + infections

Answer 13

• SALMONELLA
• SHIGELLA
• YERSINIA
• CAMPYLOBACTER
• CHLAMYDIA TRACHOMITIS/PNEUMONIAE
• BORRELIA
• NEISSERIA
• STREPTOCOCCI

throat, urogenital, GI

Question 14

Reactive Arthritis: pathology

Answer 14

• INFECTION TRIGGERS IMMUNE SYSTEM to produce INFLAMMATION in JOINTS - depends on HOST FACTORS (their GENERAL SUSCEPTIBILITY)

Question 15

Enteropathic Arthritis: aetiology

Answer 15

• COMMONLY IBD = CROHN’S/UC

* RARELY seen w/ INFECTION ENTERITIS, WHIPPLE’S DISEASE, COELIAC DISEASE

Question 16

Enteropathic Arthritis: presentation

Answer 16

• Can present w/ BOTH PERIPHERAL ± AXIAL DISEASE

* ENTHESOPATHY COMMONLY SEEN

Question 17

Enteropathic Arthritis: management

Answer 17

• NSAIDs = DIFFICULT TO USE DUE TO IBD
  
  • DMARDs = SULFASALZINE, METHOTREXATE
  • STEROIDS
  • BIOLOGICS = ANTI-TNF
  • BOWEL RESECTION may ALLEVIATE PERIPHERAL DISEASE (leaky bowels = bowels leak antigens, so in severe disease a bowel resection may be req.)

Question 18

Reactive Arthritis: definition

Answer 18

sterile synovitis after distant infection (arthritis 2 - 3 weeks after infection)