Seronegative Arthritis Flashcards
What is it?
- Negative rheumatoid factor
- May be associated with HLA- B27
- Usually an asymmetric arthritis
- Involvement of axial skeleton (spine)
- Enthesitis – inflammation of the area where a tendon or ligament attaches to bone e.g. achiles tendon or around the elbow
- Extra-articular features- uveitis, inflammatory bowel disease
More common in larger joints
what is Enthesitis?
inflammation of the area where a tendon or ligament attaches to bone e.g. achiles tendon or around the elbow
what are some Different clinical presentations?
- Ankylosing Spondylitis – key one, presents with inflammatory back pain
- Psoriatic arthritis
- Bowel related arthritis (Crohn’s, UC) – inflammatory arthritis
- Reactive arthritis – inflammatory arthritis triggered by various pathogens, usually GI infections
- Others
what is Ankylosing Spondylitis?
Ankylosing spondylitis is an inflammatory disease that, over time, can cause some of the small bones in your spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a hunched-forward posture
- Prototype for axial sponyloarthritis
- Chronic inflammatory rheumatic disorder with a predilection for axial skeleton and entheses
whoa nd when does Ankylosing Spondylitis occur in?
- Onset in second to third decade of life
- Males > Females (One of the few rheumatological conditions that effects males more than females)
- Prevalence varies in different parts of the world
is HLA B27 diagnostic and how common is it?
- NOT diagnostic of AS/SpA
- Positive in 80 to 95% of patients with AS (so can still be negative adn have AS)
- In Europe - Approx 10% population are positive and only a Prevelance of AS 1%
- Risk of AS increased in relatives
- Monozygotic twins 63%
- 1st degree relative 8.2%
- Parent – child 7.8%
three different HLA-B27 strucutres
HLA-B27 may be misfolded in some way
spinal mobility - how is modified schober test done?
Measurement of how stiff their spine is
spinal mobility - how is lateral spinal flexion measures?
spinal mobility - how is tragus to wall measured?
Helps to measure the amount of thoracic kyphosis
spinal mobility - how is cervical rotation measured?
Gives a score to indicate how severe someone’s spinal restriction is
what are the clinical features of AS?
- Inflammatory back pain - a lot of stiffness particularly in the morning and gets better with exercise
- Limitation of movements in antero-posterior as well as lateral planes at lumbar spine
- Limitation of chest expansion
- Bilateral sacroiliitis on X-rays (can take many years to develop on normal x-ray but can be picked up earlier on MRI)
what is the grading of radiographic sacroiliitis? (Grading of the x-ray changes) (an inflammation of one or both of your sacroiliac joints — situated where your lower spine and pelvis connect)
Fused spine
On lateral x ray you can see vertebrae are more square in AS
In axial spondyloarhtritis, what are the different stages?
Tend to diagnose more in the non-radiographic stage now due to MRI to pick up sacroiliitis
Radiographic means there is x-ray changes
what is shown here?
Inflammation around on of the sacroiliac joints on the right hand side of the screen, other one looks okay
what is the classification criteria for axial spondyloarthritis?
what are some other features that may be seen?
- Peripheral joints - Hips, shoulders, knees
- 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 (caused by chronic unsuppressed inflammation)
what is the Management of AS?
- Physiotherapy - really important to maintain posture and and as much flexibility of the spine as possible
- NSAIDs - may reduce spinal fusion
- DMARDs- Sulfasalazine
- Anti-TNF
- Anti-IL-17
- Treatment of osteoporosis (are at risk of this even though it is a bone forming disease)
- Surgery- joint replacements & spinal surgery
Benefit of NSAIDs
People who have a higher intake of NSAID have a lower spinal damage score
what is the longterm clinical efficacy of TNF-alpha lbockers in AS?
Percentage improvement
Psoriatic arthritis
what is Psoriatic arthritis?
Psoriatic arthritis is a form of arthritis that affects some people who have psoriasis — a condition that features red patches of skin topped with silvery scales. Most people develop psoriasis first and are later diagnosed with psoriatic arthritis, but the joint problems can sometimes begin before skin patches appear
(nail changes seen in photograph)
what joints are commonly affected by psoriatic arthritis?
Large joints more common than small joints
what are the lcinical subtypes of Psoriatic arthritis?
- Arthritis with DIP joint involvement
- Symmetric polyarthritis- similar to RA
- Asymmetric oligoarticular arthritis
- Arthritis mutilans
- Predominant spondylitis
Also characterized by dactylitis (swelling of digit) & enthesitis (inflammation of ligament or tendons as they attach to bone)
Severity of joint disease does not correlate to extent of skin disease. Nail pitting seen
what is the treatment of psoriatic arhtiritis?
- Sulfasalazine
- Methotrexate
- Leflunomide
- Cyclosporine
- Anti-TNF therapy
- Anti- IL-17 and IL-23
- Steroids
- Physiotherapy and occupational therapy
- Axial disease treated similar to AS
Treatments is with DMARDS
If don’t respond well enough to DMARDS then they can get biologics like anti TF an anti-IL
what causes reactive arhiritis?
- Sterile synovitis after distant infection
- Infections include- Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci
- Infections- throat, urogenital & GI
joint pain and swelling triggered by an infection in another part of your body — most often your intestines, genitals or urinary tract. Reactive arthritis usually targets your knees and the joints of your ankles and feet. Inflammation also can affect your eyes, skin and urethra
what else may also be seen in reactive arthritis?
- Disease may be systemic
- Usually mono or oligoarthritis
- Dactylitis or enthesitis also seen
What Skin and mucous membrane involvement may there be in reactive arthritis?
- Keratoderma blenorrhagica
- Circinate balanitis
- Urethritis
- Conjunctivitis
- Iritis
whata re osme other kinds of reactive arhtritis?
- Recurrent attacks common in chlamydia-induced arthritis
- Reiter’s syndrome – arthritis, urethritis and conjunctivitis
In reactive arthritis, what are some signs for chronicity?
Hip/heel pain
High ESR
Family history and HLA-B27 +ve
what is the acute and chronic treatment of reactive arthritis?
• Acute
- NSAID
- Joint injection (if infection excluded)
- antibiotics in chlamydia infection (contacts as well)
• Chronic
- NSAID
- DMARD (e.g. sulphasalazine, methotrexate)
Initially symptomatic
Continue with anti-inflammatory drugs but then move onto the disease modifying drugs and maybe use biologics if necessary
what is Enteropathic arthritis?
Enteropathic arthritis is an inflammatory condition affecting the spine and other joints that commonly occurs in the inflammatory bowel diseases – Crohn’s disease and ulcerative colitis
- Commonly associated with inflammatory bowel disease (Crohn’s or UC)
- Rarely seen with infectious enteritis, Whipple’s disease and Coeliac disease
how can Enteropathic arthritis present?
- Can present with both peripheral and/or axial disease
- Enthesopathy commonly seen
(a disorder involving the attachment of a tendon or ligament to a bone. This site of attachment is known as the enthesis (pl. entheses). If the condition is known to be inflammatory, it can more precisely be called an enthesitis)
what is the treatment of enteropathic arthritis?
- NSAIDs difficult to use
- Sulfasalazine
- Steroids
- Methotrexate
- Anti-TNF
- Bowel resection may alleviate peripheral disease
Summary:
- HLA B27 is not __________ of AS/SpA
- Inflammatory ____ pain history is the key:
- quality and quantity of early ________ stiffness
- improvement of stiffness with ______
•________ therapy as important as drug therapy
diagnostic
back
morning
activity
Physical
