Seronegative Arthritis: Psoriatic, Ankylosing Spondylitis, IBD, Reactive, Stills

Question 1

How would you differentiate between inflammatory and non inflammatory causes of joint pain?

Answer 1

Inflammatory

• systemic symptoms, v prominent fatigue
• insidious onset (seropositive, seronegative)
• sudden onset (infection, gout)
• morning stiffness, 1hr+
• worst pain on waking and when resting
• pain decreases with activity but increases with overuse

Non inflammatory

• unusual to have systemic symptoms
• gradual onset (mono/oligoarthritis)
• morning stiffness, U1hour
• pain increases as day progresses, worsens with activity
• pain improves with rest

Question 2

Psoriatic arthritis

• presentation
• diagnosis, investigations
• management

Answer 2

Symmetrical/asymmetrical - hands, feet, DIP/PIP
Sacroilitis
Dactylitis, enthesitis, tenosynovitis
Psoriatic skin lesions - ext itchy silver plaques
Nail pitting, onycholysis

Xray - erosion and bone formation

• periostitis, pencil in cup
• sacroilitis, enthesistis, dactylitis

Initial - NSAIDs + physiotherapy

• add DMARD
• add biologic (TNF a, monoclonal)

Question 3

Ankylosing spondylitis

• epidemiology
• presentation
• diagnosis, investigations
• management

Answer 3

Male dominated, 20s

Lower back pain, insidious onset
Reduced spine mv - kyphoscoliosis

Xray - sacroilitis
-bamboo spine - late sign
MRI if no Xray signs present - early inflammation

Initial - NSAIDs + physiotherapy
-add DMARD if peripheral involvement

Question 4

Enteropathic arthritis

• presentation
• diagnosis, investigations
• management

Answer 4

IBD presentation with
Spondylitis, sacroilitis in joints

Xray - assess severity

Initial - NSAIDs + treat underlying GI problem

Question 5

Reactive arthritis

• presentation
• diagnosis investigations
• management

Answer 5

Sterile arthritis within 1 month of STI, food poisoning => symptomatic up to 6 months
Can’t see, pee, climb a tree
-urethritis, conjunctivitis, enthesitis, dactylitis, feet rash

Xray - sacroilitis, enthesitis

Initial - NSAID + ABx for causative organisms
-CS if needed
Chronic - sulfasalazine

Question 6

Characterististics of seronegative spondyloarthropathies

Answer 6

Seronegative = negative for rheumatoid factor

Greater male prevalence
Asymmetrical, large lower extremities
Enthesitis, tendinitis, costochondritis
Sacroiliac, axial disease
-AS, non radiographic SpA

Can have multiple seronegative SpA

HLA B27

Question 7

Stills Disease/Adult Onset Still Disease

• presentation
• diagnosis investigations
• management

Answer 7

Fever, arthritis, salmon rash, sore throat

Xray - assess severity
Diagnosis of exclusion

Initial - NSAIDs

• CS if needed
• biologics if needed or severe