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MSK > Seronegative Arthritis (RF-ve) > Flashcards

Seronegative Arthritis (RF-ve) Flashcards

1
Q

What are the seronegative arthritis

A

Ankylosing spondylitis
Psoriatic
Bowel related
Reactive arthritis

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2
Q

What do these conditions have in common

A 
-ve RF
HLA B27 
Axial / sacroiliitis 
Asymmetrical large joint 
<5 joints involved or mono
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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
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4
Q

What do SpA’s respond too

A

Good response to NSAIDs

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5
Q

What is dactylitis

A

Inflammation of an entire digit due to soft tissue oedema

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6
Q

What causes dactylitis

A 
SpA - reactive + psoriatic
Sickle cell
Sarcoidosis
Syphillis
TB
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7
Q

What is enthesitis and examples

A

Inflammation at insertion into bone
Plantar fasciitis
Achilles tendonitis

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8
Q

What is ankylosing spondylitis

A

Chronic inflammatory condition of spine and sacroiliac joint
Affects axial skeleton and enthises

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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
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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
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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
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12
Q

What else can you get

A 
Reduced chest expansion due to loss of spinal movement 
Restrictive lung
Osteoporosis
Spinal / vertebral fracture
IBD
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13
Q

Who is at risk

A 
HLA B27 +ve
HIV
Seborrheic dermaittis
Psoriasis 
M>F
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14
Q

What should you always ask about

A

Uveitis
Psoriasis
IBD

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15
Q

What is most useful investigation

A

X-ray of pelvic / lumbar spine

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16
Q

What other investigations

A 
Bloods - raised ESR / CRP, anaemia chronic
HLA-B27 test 
Spirometry = restrictive
CXR may show fibrosis 
Examination
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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
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18
Q

What is used to indicate disease activity

A

BASDAI

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19
Q

How do you treat and what is important to remember

A 
NSAID = 1st line for backpain
PHYSIO = mainstay
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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
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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
Q

What is Diffuse Idiopathic Skeletal Hyperostosis

A 
Similar to AS but older patient a
Less spinal segmented involved
Unilateral
Calcification of anterior spinal ligament
Spondylophytes
26
Q

What can you not use

A

Immunotherapy as doesn’t respond

27
Q

What is psoriatic arthritis

A

Arthritis with DIP + skin involvement

28
Q

Who does it affect

A

10-40% with psoriasis

Can have minimal skin disease

29
Q

What are the types of psoriatic and what joints commonly affected

A

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
Q

What are the symptoms

A 
Deformed hands
Hot, red, swollen
Nail changes
Dactilitis
Enthesisitis
Can have Hebreden nodes
31
Q

What are psoriasis nail changes

A

Nail pitting
Nail ridging
Onchylosis - separation of nail from nail need

32
Q

How do you Dx

A

Bloods - FBC, LFT
Immune - ANA / RF
X-ray - pencil and cup deformity

33
Q

How do you treat

A 
Treat as RA
NSAID
DMARD
Biologic if 2+ DMARD 
Steroids as bridging therapy if struggling
Physio / OT
Refer dermatology for psoriasis
34
Q

What DMARD for joint and skin

A

Methotrexate

Cyclosporine

35
Q

What DMARD for joint only

A

Sulfasalazine

Leflunomide

36
Q

Why is steroid use an issue

A

Can exacerbate psoriasis when stop

37
Q

What DMARD is not used

A

Hydroxychloroquine

38
Q

What is reactive arthritis / Reiter’s

A

Sterile synovitis after distant infection
Will no longer be able to culture
Usually 4 weeks after but can be 4-6 months after

39
Q

What must you exclude

A

Infection as immunosuppression used to treat

40
Q

What are common infection

A 
Chlamydia trochomatis / pneumonia
Gonorrhoea 
Salmonella
Cambylobacter
Shigela 
Neisseria
Strep
41
Q

What is classic Reiter’s triad

A

Sterile arthritis
Urethritis / iritis
Conjunctivitis

42
Q

What type of arthritis

A

Usually mono arthritis but can be oligo

43
Q

What else

A

Dactylitis
Enthesitis
Systemic Sx

44
Q

What are symptoms of skin and mucous membrane involvement

A 
Circinate balantitis (painless vesicles) 
Keratoderma blenorrhagica (waxy yellow papule on palms and soles)
45
Q

What is important in the Hx

A 
Any trauma
Systemic Sx
Any Hx of infection / STI
Any back pain
Eye / skin / GU / GI
FH inflammatory arthritis / IBD / psoriasis / uveitis
Medication
46
Q

What investigations

A 
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
Q

How do you treat acute reactive

A 
Give AX till SA excluded 
Analgesia
NSAID
Intra-articular steroid if infection excluded
Ax if STI
48
Q

How do you treat chronic

A

NSAID + DMARD

May need biologics

49
Q

What does recurrent suggest

A

Chlamydia

50
Q

What causes enteropathic arthritis

A 
IBD
Gastroenteritis
Whipple's
GI bypass
Coeliac
51
Q

What are symptoms

A

Peripheral and axial arthritis

Enthesitis

52
Q

How do you Rx

A 
Rx bowel condition often improves
NSAID
DMARD if resistatn
Biologic - Anti-TNF
Steroid as briding

MSK (21 decks)

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