Seronegative Arthritis (RF-ve) Flashcards
1
Q
What are the seronegative arthritis
A
Ankylosing spondylitis
Psoriatic
Bowel related
Reactive arthritis
2
Q
What do these conditions have in common
A
-ve RF HLA B27 Axial / sacroiliitis Asymmetrical large joint <5 joints involved or mono
3
Q
What are other SpA features
A
HLA-B27 Inflammatory back pain Worse at night + morning stiffness Enthesitis Dactylitits Uveitits/ iritits Psoriasis IBD Elevated CRP FH Response to NSAID
4
Q
What do SpA’s respond too
A
Good response to NSAIDs
5
Q
What is dactylitis
A
Inflammation of an entire digit due to soft tissue oedema
6
Q
What causes dactylitis
A
SpA - reactive + psoriatic Sickle cell Sarcoidosis Syphillis TB
7
Q
What is enthesitis and examples
A
Inflammation at insertion into bone
Plantar fasciitis
Achilles tendonitis
8
Q
What is ankylosing spondylitis
A
Chronic inflammatory condition of spine and sacroiliac joint
Affects axial skeleton and enthises
9
Q
What is the typical story of Ankylosing Spondylitis
A
Young man Lower back pain and stiffness Insidious onset Worse in the night / early morning Improves with exercise
10
Q
What are diagnostic features of AS
A
>3 months pain in back / hip Worse with rest and improves with movement <45 years BIlateral sacroiliits + 1 SpA feature OR HLAB27 + 2SPA features
11
Q
What are other common features beginning with A
A
Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV block Amyloidosis Arthritis - peripheral Anaemia Axial skeleton involved AND CAUDA EQUINA
12
Q
What else can you get
A
Reduced chest expansion due to loss of spinal movement Restrictive lung Osteoporosis Spinal / vertebral fracture IBD
13
Q
Who is at risk
A
HLA B27 +ve HIV Seborrheic dermaittis Psoriasis M>F
14
Q
What should you always ask about
A
Uveitis
Psoriasis
IBD
15
Q
What is most useful investigation
A
X-ray of pelvic / lumbar spine
16
Q
What other investigations
A
Bloods - raised ESR / CRP, anaemia chronic HLA-B27 test Spirometry = restrictive CXR may show fibrosis Examination
17
Q
What are findings on examination
A
Modified Schober - Mark L5 - Mark 10cm above and 5cm below - Bend forward as far as they can and measure the difference - If distance <20cm suggest reduced lumbar flexion Lateral lumbar flexion Cervical rotation Reduced chest expansion Occipital tuberance to wall Tragus to wall for kyphosis - increased kyphosis Loss of lumbar lordosis Reduced hip rotation
18
Q
What is used to indicate disease activity
A
BASDAI
19
Q
How do you treat and what is important to remember
A
NSAID = 1st line for backpain PHYSIO = mainstay
20
Q
What else can be done
A
Intra-articular steroids Biologics - anti-TNF if persistent DMARD = not really useful unless peripheral joints as well Treat osteoporosis - biphosphonates Refer ortho for replacement
21
Q
Grades of sacroilitis on X-ray
A
0 = normal 1 = suspicious 2 = sclerosis but no alteration in joint width 3 = discussed below 4 = total ankylosis / fusion
22
Q
Grade 3 changes sacroillitis
A
Erosions Sclerosis Widening or narrowing of joint space Osteophytes linking vertebrae (syndesmophwytes) Bamboo spine Square vertebrae Degenerative changes at hip
23
Q
What can disease progress too
A
Kyphosis
- If in neck can lead to fracture and death if immobilise and don’t know Hx
Neck hyperextension
Spino-cranial ankylosis
24
Q
What suggests poor prognosis
A
ESR >30
Onset <16
Early hip involvement
Poor response to NSAID
25
What is Diffuse Idiopathic Skeletal Hyperostosis
```
Similar to AS but older patient a
Less spinal segmented involved
Unilateral
Calcification of anterior spinal ligament
Spondylophytes
```
26
What can you not use
Immunotherapy as doesn't respond
27
What is psoriatic arthritis
Arthritis with DIP + skin involvement
28
Who does it affect
10-40% with psoriasis
| Can have minimal skin disease
29
What are the types of psoriatic and what joints commonly affected
Symmetric polyarthritis - similar to RA (MCP/PIP) but DIP more common
Asymmetric oligoarticular - usually LL e.g. hip / knee
Predominant spondylitis - sacroiliac common
Arthritis mutilans - destructive
30
What are the symptoms
```
Deformed hands
Hot, red, swollen
Nail changes
Dactilitis
Enthesisitis
Can have Hebreden nodes
```
31
What are psoriasis nail changes
Nail pitting
Nail ridging
Onchylosis - separation of nail from nail need
32
How do you Dx
Bloods - FBC, LFT
Immune - ANA / RF
X-ray - pencil and cup deformity
33
How do you treat
```
Treat as RA
NSAID
DMARD
Biologic if 2+ DMARD
Steroids as bridging therapy if struggling
Physio / OT
Refer dermatology for psoriasis
```
34
What DMARD for joint and skin
Methotrexate
| Cyclosporine
35
What DMARD for joint only
Sulfasalazine
| Leflunomide
36
Why is steroid use an issue
Can exacerbate psoriasis when stop
37
What DMARD is not used
Hydroxychloroquine
38
What is reactive arthritis / Reiter's
Sterile synovitis after distant infection
Will no longer be able to culture
Usually 4 weeks after but can be 4-6 months after
39
What must you exclude
Infection as immunosuppression used to treat
40
What are common infection
```
Chlamydia trochomatis / pneumonia
Gonorrhoea
Salmonella
Cambylobacter
Shigela
Neisseria
Strep
```
41
What is classic Reiter's triad
Sterile arthritis
Urethritis / iritis
Conjunctivitis
42
What type of arthritis
Usually mono arthritis but can be oligo
43
What else
Dactylitis
Enthesitis
Systemic Sx
44
What are symptoms of skin and mucous membrane involvement
```
Circinate balantitis (painless vesicles)
Keratoderma blenorrhagica (waxy yellow papule on palms and soles)
```
45
What is important in the Hx
```
Any trauma
Systemic Sx
Any Hx of infection / STI
Any back pain
Eye / skin / GU / GI
FH inflammatory arthritis / IBD / psoriasis / uveitis
Medication
```
46
What investigations
```
Can present like SA so urgent joint aspiration
- No organism cultured
Urinanalysis / culture
Stool culture
Throat swab
STI screen
Serology
Joint aspiration for gram stain, culture, crystals
Bloods - increased CRP
```
47
How do you treat acute reactive
```
Give AX till SA excluded
Analgesia
NSAID
Intra-articular steroid if infection excluded
Ax if STI
```
48
How do you treat chronic
NSAID + DMARD
| May need biologics
49
What does recurrent suggest
Chlamydia
50
What causes enteropathic arthritis
```
IBD
Gastroenteritis
Whipple's
GI bypass
Coeliac
```
51
What are symptoms
Peripheral and axial arthritis
| Enthesitis
52
How do you Rx
```
Rx bowel condition often improves
NSAID
DMARD if resistatn
Biologic - Anti-TNF
Steroid as briding
```
