Seronegative arthritis (spondyloarthirtis) Flashcards
What is it?
what can it be associated with?
involvement of?
more common in?
- Negative rheumatoid factor
- HLA- B27
- axial skeleton (spine)
- larger joints
what is Enthesitis
inflation of area where tendon r ligament attaches to bone - around elbow, Achilles
Extra-articular features- ? (3)
uveitis, inflammatory bowel disease, psoriasis
Clinical presentations
- Ankylosing Spondylitis - back pain
- Psoriatic arthritis
- Bowel related arthritis (Crohn’s, UC)
- Reactive arthritis
Others
Age where sacroiliitis occurs?
late teens
Diagnosis of ankylosing spondylitis?
evidence of bilateral sacroiliitis
Ankylosing Spondylitis - prototype of?
Predilection for?
who is it more common in?
axial sponyloarthritis
axial skeleton and entheses
MALES
HLA b27 is not diagnostic of?
where is it positive in?
AS/SpA
80-95% of patients with AS
theories of HLA-B27 that may induce AS (3)
- peptides from foreign antigens presented and trigger inflammatory process
- mis folded - triggering of certain parts of the immune system
- inability to fold into homodimers
Clinical aspects of AS - what do we look at (mobility)
spinal mobility - modified schober’s test
10cm mark - patient bends forward - anything less is abnormal
Clinical aspects of AS - what do we look at (laterally)
lateral spinal flexion
- best of 2 tries on left and right are recorded
- score is an average of both
Clinical aspects of AS - what do we look at (occiput)
- occiput to wall and trigs to wall
- ## measures the amount of thoracic kyphosis
Clinical aspects of AS - what do we look at (cervical rotation)
- goniometer on top of the head
- rotate head and records angle between sagital plane and new plane
- average calculated
AS- Clinical features (NY criteria) (4)
- Inflammatory back pain
- Limitation of movements in antero-posterior as well as lateral planes at lumbar spine
- Limitation of chest expansion
- Bilateral sacroiliitis on X-rays
Grading of sacroiliitis goes from?
0-4
a fused spine also known as?
what is it?
in advanced AS the vertebrae are more?
bamboo spine
inflammation nat corner of vertebrae - shiny corners - calcification and ossification
- squaring of the vertebrae
Diffuse idiopathic skeletal hyperostosis (foresters disease) (3)
bony projections from vertebra
- unilateral bridging spodylophytes
- extensive calcification of the anterior spinal ligament
radiographic means there are?
non radiographic means?
x ray changes
- picked up on MRI
classification criteria for SpA
Sacroiliitis on imaging plus >1 SpA feature
or HLA-B27 plus >2 SpA features
Name some SpA features
- inflammatory back pain
- arthritis
- Enthesitis
(heel) - uveitis
- psoriasis
- crohn’s
Other features: systemic
Cardiac- Aortic incompetence, heart block, regurgitation
Pulmonary- restrictive disease, apical fibrosis
Osteoporosis and spinal fractures
Neurological- AAD & cauda equina syndrome
Renal- secondary amyloidosis
management of AS (6/7)
- Physiotherapy - posture and spine flexibility
- NSAIDs- anti inflammatory, GI problems
DMARDs- Sulfasalazine
Anti-TNF
Anti-IL-17
- Treatment of osteoporosis
- Surgery- joint replacements and spinal surgery
Patients with risk factors for radiographic spinal
progression eg…..?
what do these patients benefit most from?
syndesmophytes (bony changes) , elevated CRP
- NSAID therapy
hand features of psoriatic arthritis
distal inter-phalangeal involvement
-lifting of the nail bed, pitting
most destructive type of psoriatic arthritis
arthritis mutilans
- pencil cup deformity
some joints involved in psoriatic arthritis
large joints more common
- knees
- toes
- base of spine
- hands
- neck
Psoriatic arthritis- clinical subtypes (6)
- Arthritis with DIP joint involvement
- Symmetric polyarthritis- similar to RA
- Asymmetric oligoarticular arthritis (effect less than 5 joints)
- Arthritis mutilans
- Predominant spondylitis
Also characterized by dactylitis (sausage finger) & enthesitis (where tendon joints to bone)
Severity of joint disease does not correlate to extent of skin disease. Nail pitting seen
Treatment of PA? (lots of examples)
Sulfasalazine Methotrexate Leflunomide Cyclosporine Anti-TNF therapy Anti- IL-17 and IL-23 Steroids Physiotherapy and occupational therapy Axial disease treated similar to AS
Reactive arthritis triggers
- Sterile synovitis after distant infection
- Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci
- GI infections, throat infections
Skin and mucous membrane involvement of reactive arthritis (psoriasis)
- Keratoderma blenorrhagica
- Circinate balanitis - chlamydia
- Urethritis - chlamydia
- Conjunctivitis
- Iritis
Reiter’s syndrome ? (3)
arthritis, urethritis and conjunctivitis
Prognostic signs for chronicity?
Prognostic signs for chronicity
Hip/heel pain
High ESR
Family history and HLA-B27 +ve
Treatment of reactive arthritis - acute
NSAID
Joint injection (if infection excluded)
antibiotics in chlamydia infection (contacts as well)
Treatment of reactive arthritis - chronic
NSAID
DMARD (e.g. sulphasalazine, methotrexate)
Enteropathic arthritis is commonly associated with?
it can be both?
what is commonly seen in this patient group?
Crohn’s or UC
peripheral and/or axial disease
Enthesopathy commonly seen
Treatment of reactive arthritis?
what may alleviate peripheral disease?
- NSAIDs difficult to use
- Sulfasalazine
- Steroids
- Methotrexate
- Anti-TNF
- Bowel resection may alleviate peripheral disease
what in the history is key to pick up on?
inflammatory back pain
- quality and quantity of early morning stiffness - tends to be more severe in inflammatory not mechanical
- improvement of stiffness with activity
- physical therapy is just as important as the drug therapy
