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Musculoskeletal + Rheumatology > Seronegative Arthritis > Flashcards

Seronegative Arthritis Flashcards

1
Q

What is psoriatic arthritis?

A

Chronic seronegative inflammatory arthritis associated with psoriasis

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2
Q

What percentage of patients with psoriasis develop psoriatic arthritis?

A

10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It ty

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3
Q

What causes psoriatic arthritis?

A

Genetic

  • HLA-B27
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4
Q

What are the recognised patterns of psoriatic arthritis?

A

Symmetrical polyarthritis, presents similarly to RA

Asymmetrical pauciarthritis, affecting mainly the digits and feet

Arthritis mutilans, severe form occuring at phalanxes

Spondylitic pattern, more common in men

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5
Q

What is arthritis mutilans?

A

Most severe form of psoriatic arthritis occurring in the phalanxes.

Destructionof the bones leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a ‘telescopic finger’

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6
Q

How does psoriatic arthritis present?

A

Psoariasis plaques

Pitting of nails

Onycholysis/nail separation from nail bed

Arthritis, particuarly of DIP joints

Brown discolouration of nail

Dactylitis

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7
Q

What xray changes are seen in psoriatic arthritis?

A

Periostitis, thickened and irregular outline of the bone

Ankylosis

Osteolysis/destruction of bone

Dactylitis, inflammation of the whole digit that appears on the xray as soft tissue swelling

Plantar spur

Pencil-in-cup appearance, due to central erosions of the bone beside the joints

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8
Q

How is psoriatic arthritis managed?

A

NSAIDS

DMARDS

Anti-TNF

Ustekinumab is last lin, a monoclonal antibody that targets interleukin 12 and 23

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9
Q

What conditions are associated with psoriatic arthritis?

A

Conjunctivitis and anterior uveitis

Aortitis

Amyloidosis

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10
Q

How are patients with psoriasis screened for psoriatic arthritis?

A

Psoriasis Epidemiological Screening Tool (PEST)

This involves several questions asking about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist.

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11
Q

What is ankylosing spondylitis?

A

Chronic seronegative arthritis in which there is autoimmune inflammation of the spine (most commonly, although other bones can be involved) causing fusion (ankylosis)

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12
Q

What sex is more likely to be affected by ankylosing spondylitis?

A

M>F

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13
Q

What is the most common age of onset of ankylosing spondylitis?

A

20s-30s

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14
Q

What causes ankylosing spondylitis?

A

Genetic

  • Associated with HLA-B27 allele

Connection with HIV

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15
Q

What gene is ankylosing spondylitis associated with?

A

HLA-B27, approx 90% of patients have this gene

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16
Q

How does ankylosing spondylitis present?

A

Symptoms develop gradually, over approx 3 months

Pain

  • Can radiate to buttocks
  • Lower back and sacroiliac joints, usually first to be affected
  • Worsens at night/morning, takes approx 30 minutes to improve in morning
  • Improves with activity

Stiffness

  • Worsens in morning and after periods of rest

Decreased range of movement of lumbar spine

  • Reduced lateral flexion
  • Reduced forward flexion/schobers test
  • Reduced chest expansion

Question mark posture, due to increased kyphosis

Tenderness of sacro-iliac joints

17
Q

What are the systemic signs of ankylosing spondylitis?

A

Uveitis

IBD

Aortic incompetence

Heart block

Enthesitis

Weight loss

Fatigue

Pulmonary Fibrosis

Amyloidosis

18
Q

Describe Schobers test

A

Have the patient stand straight and find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other)

Ask the patient to bend forward as far as they can and measure the distance between the points

If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis

19
Q

What investigations are used in ankylosing spondylitis diagnosis?

A

>CRP and ESR

HLA-B27

Pelvic x ray for diagnosis

MRI of spine, shows bone marrow oedema before xray changes

20
Q

What X-Ray signs are seen in ankylosing spondylitis?

A

Collectively known as bambo spine

X-Ray changes not noticeable until severe disease

Symmetrical blurring and narrowing of sacroiliac joint

Fusion and squaring of vertebral bodies

Ossification of spinal ligament/syndesmophytes

Subchondral sclerosis and erosions of sacroilliac joint

21
Q

How is ankylosing spondylitis managed?

A

Physiotherapy/spinal exercises

Avoid smoking

NSAIDS

  • For pain, if no relief in 2-4 weeks of maximum dose consider switching NSAID

Steroids, used during flares to control symptoms

Anti-TNF medications/monoclonal antibodies, used in failure to respond to NSAIDS

Surgery

  • Joint replacements
  • Spinal surgery
22
Q

What is the first line management of ankylosing spondylitis?

A

Exercise regime and NSAIDS

23
Q

When should anti TNF alpha inhibitors be initiated in ankylosing spondylitis management?

A

Should be used in axial ankylosing spondylitis that has failed on 2 different NSAIDS and meets criteria for active disease on 2 occasions 12 weeks apart

24
Q

Give examples of TNF-alpha blockers

A

Infliximab

Etanercept

25
Q

Give complications of ankylosing spondylitis

A

Those with autoimmune conditions are more prone to infection

26
Q

Give other features of ankylosing spondylitis

A

The A’s

Apical fibrosis

Anterior uveitis

Aortic regurgitation

Achilles tendonitis

AV node block

Amyloidosis

Cauda equina syndrome

Peripheral arthritis

27
Q

Give differential diagnoses of ankylosing spondylitis

A

Disc prolapse

Vertebral osteoarthritis

28
Q

What is reactive arthritis?

A

Defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint

29
Q

What is enteropathic arthritis?

A

Seronegative arthritis commonly associated with IBS and other bowel disorders

30
Q

What sex is more likely to be affected by reactive arthritis?

A

M>F

31
Q

What organisms can cause reactive arthritis?

A

Salmonella

Shigella

Yersinia

Campylobacter

Chlamydia trachomatis

Pneumoniae

Borrelia

Neisseria

Streptococci

32
Q

What are the most common infections that trigger infective arthritis?

A

Gastroenteritis or sexually transmitted infection

Chlamydia is the most common sexually transmitted cause of reactive arthritis

33
Q

What gene is reactive arthritis linked to?

A

HLA-B27, making it part of the seronegative spondyloarthropathy group of conditions

34
Q

How does reactive arthritis present?

A

Symptoms typically occur 4 weeks post initial infection, and last around 4-6 months

Arthritis

  • Acute
  • Lower limb
  • Asymmetrical

Keratoderma blenorrhagica

  • Painless waxy yellow/brown papules on soles and palms

Circinate balanitis

  • Painless superficial ulceration of penis

Conjunctivitis, iritis, anterior uveitis

Urethritis

Dactylitis

35
Q

What is the Reiter’s Syndrome triad?

A

Can’t see, pee or climb a tree

Arthritis

Urethritis

Conjunctivitis

36
Q

How is reactive arthritis managed?

A

Antibiotics until septic arthritis is ruled out

Aspirate joint

NSAIDS

Intraarticular corticosteroid injection

Systemic steroids, particularly if mutliple joints affected

DMARDs or anti TNF, if recurrent

37
Q

Give prognostic signs for chronic reactive arthritis

A

Hip/heel pain

>ESR

FH

HLA-B27

Musculoskeletal + Rheumatology (16 decks)

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