Seronegative Arthritis

Question 1

What is seronegative arthritis also called?

Answer 1

Spondyloarthritis

Question 2

What is seronegative arthritis?

Answer 2

Collection of inflammatory conditions:

• Negative rheumatic factor
• May be associated with HLA-B27
• Clinical features usually
  
  • Asymmetric arthritis
  • Involvement of axial skeleton (spine)
  • Enthesitis
  • Extra-articular features such as uveitis and IBD

Question 3

What is enthesitis?

Answer 3

Inflammation of the entheses, the sites where tendons or ligaments insert into the bone

Question 4

What are the different kinds of clinical presentations of serongetive arthritis?

Answer 4

• Ankylosing spondylitis
• Psoriatic arthritis
• Bowel related arthritis (Crohn’s, UC)
• Reactive arthritis

Question 5

What is ankylosing spondylitis?

Answer 5

Chronic inflammatory rheumatic disorder with predilection for axial skeleton and enthuses

Question 6

Describe the epidemiology of ankylosing spondylitis in terms of sex and age?

Answer 6

• M > F
• Onset 2^nd and 3^rd decade
• Prevalence varies around world due to genetic link

Question 7

What is the aetiology of ankylosing spondylitis?

Answer 7

• Genetics
  
  • HLA B27
    
    • This is not diagnostic of the disease as the gene doesn’t always mean the condition

Question 8

Describe the pathogenesis of ankylosing spondylitis?

Answer 8

• Unsure, but main theory is peptides from antigens get processed in genes and presented to immune cells that trigger inflammatory process

Question 9

What are examples of spinal mobility tests?

Answer 9

• Modified Schober
  
  • Patient stands erect and two points 10cm apart drawn on spine, bends maximally forward and points measured again, >15cm is normal
• Lateral spinal flexion
• Occiput to wall
• Cervical rotation

Question 10

Describe the modified schober test?

Answer 10

• Patient stands erect and two points 10cm apart drawn on spine, bends maximally forward and points measured again, >15cm is normal

Question 11

What are some ankylosing spondylitis clinical features?

Answer 11

• Inflammatory back pain
• Limitations of movement in antero-posterior as well as lateral planes at lumbar spine
• Limitation of chest expansion
• Bilateral sacroiliitis on x-rays
• Other
  
  • Peripheral joints – hips, shoulders, knees
  • Uveitis
  • Cardiac – aortic incompetence, heart block
  • Pulmonary – restrictive disease, apical fibrosis
  • GI – IBD
  • Osteoporosis and spinal fractures
  • Neurological – cauda equina syndrome

Question 12

What are the different stages of ankylosing spondylitis?

Answer 12

Question 13

Describe the classification for diagnosing axial spondyloarthritis?

Answer 13

Question 14

What is the management of ankylosing spondylitis?

Answer 14

• Physiotherapy
• NSAIDs
• DMARDs
  
  • Sulfasalazine
• Anti-TNF
• Anti-IL-17
• Treatment of osteoporosis
• Surgery
  
  • Joint replacement and spinal surgery

Question 15

What joints does psoriatic arthritis commonly affect?

Answer 15

Usually affects large joints

Question 16

What are the clinical subtypes of psoriatic arthritis?

Answer 16

• Arthritis with DIP joint involvement
• Symmetric polyarthritis (similar to RA)
• Asymmetric oligoarticular arthritis
• Arthritis mutilans
• Predominant spondylitis

Question 17

What is the treatment of psoriatic arthritis?

Answer 17

• Sulfasalazine
• Methotrexate
• Leflunomide
• Cyclosporin
• Anti-TNF
• Anti IL-17 and IL-23
• Steroids
• Physiotherapy
• Axial disease treated similar to AS

Question 18

What is reactive arthritis?

Answer 18

Is joint inflammation triggered by an infection in another part of your body

Question 19

What are some infections that can cause reactive arthritis?

Answer 19

• Salmonella
• Shigella
• Yersinia
• Campylobacter
• Chlamydia

Question 20

What are some clinical features of reactive arthritis?

Answer 20

• May be systemic
• Usually mono or oligoarthritis
• Dactylitis or enthesitis also seen
• Skin and mucous membrane involvement
  
  • Keratoderma blenorrhagica
  • Circinate balanitis
  • Urethritis
  • Conjunctivitis
  • Iritis

Question 21

What is dactylitis?

Answer 21

Severe inflammation of the finger and toe joint

Question 22

What is reactive arthritis also called?

Answer 22

Reiter’s syndrome

Question 23

What is the classic triad of reactive arthritis?

Answer 23

Classic triad of conjunctivitis, urethritis and arthritis occurring after an infection

Question 24

What is the treatment of reactive arthritis?

Answer 24

• Acute
  
  • NSAID
  • Joint injection (if infection excluded)
  • Antibiotics in chlamydia infection
• Chronic
  
  • NSAID
  • DMARD
    
    • Such as sulphasalazine, methotrexate

Question 25

What is enteropathic arthritis commonly associated with?

Answer 25

Commonly associated with IBD (Crohn’s or UC):

• Rare causes includes infectious enteritis, Whipple’s disease and coeliac disease

Question 26

What are clinical features of enteropathic arthritis?

Answer 26

• Both peripheral and/or axial disease
• Enthesopathy common

Question 27

What is the treatment of enteropathic arthritis?

Answer 27

• NSAIDs
  
  • Difficult to use in people with bowel disease though
• Sulfasalazine
• Steroids
• Methotrexate
• Anti-TNF
• Bowel resection may alleviate peripheral disease