Seronegative Arthritis (Spondyloarthritis) Flashcards
What is seronegative arthritis?
What will be raised? Whats the pattern? What are its other features?
Negative rheumatoid factor
May be associated with HLA-B27
Usually an asymmetric arthritis
Involvement of axial skeleton (spine)
Enthesitis
Extra-articular features- uveitis, inflammatory bowel disease
What is enthesitis?
Enthesitis is inflammation of the entheses, the sites where tendons or ligaments insert into the bone.
One of the primary entheses involved in inflammatory autoimmune disease is at the heel, particularly the Achilles tendon.
It is associated with HLA B27 arthropathies like ankylosing spondylitis, psoriatic arthritis, and reactive arthritis.
Name 4 different clinical presentations of seronegative arthritis?
PAIR
-Psoriatic arthritis
-Ankylosing Spondylitis
- Intestinal Arthropathy
- —Bowel related arthritis
- –(Crohn’s, UC)
-Reactive arthritis
others
What is reactive arthritis also known as?
Reiter Syndrome
What is the epidaemiology of ankylosing spondylitis?
Onset in second to third decade of life
Males > females
Prevalence varies in different parts of the world
What are the 4 different tests for spinal mobility?
Modified Schober
Lateral Spinal Flexion
Occiput to Wall and Tragus to Wall
Cervical Rotation
-Uses Goniometer
What are the clinical features of ankylosing spondylitis?
Inflammatory back pain
Limitation of movements in antero-posterior as well as lateral planes at lumber spine
Limitation of chest expansion
Bilateral sacroiliitis on X-rays
How do you grade radiographic sacroiliitis?
5 grades
Grade 0 = Normal
Grade 1 = Suspicious changes
Grade 2 = Minimal abnormality
-Small localised areas with erosion or sclerosis, without in the joint width
Grade 3 = unequivocal abnormality
-Moderate or advanced + 1 or more of: erosions, evidence of sclerosis, widening, narrowing or partial ankylosis
Grade 4 = Severe abnormality
-Total ankylosis
What is Diffuse Idiopathic Skeletal Hyperostosis?
Non-inflammatory spondyloarthropathy of the spine.
Characterised by ulilateral bridging spondylophytes mimicking mixed syndesmophytes and extensive calcification of anterior spinal ligament
What is the ASAS classification criteria for axial spondyloarthritis?
(dont need to go into SpA features, just what qualifys as axial spondyloarthritis)
3 or more months back pain at age
What are the SpA features used to classify axial spondyloarthritis?
Inflammatory back pain Arthritis Enthesitis (heel) Uveitis Dactylitis Psoriasis Crohn's/colitis Good response to NSAIDs FH for SpA HLA-B27 Elevated CRP
What is the management of ankylosing spondylitis?
Physiotherapy
NSAIDs
DMARDs -> sulphasalazine
Anti-TNF
Treatment of osteoporosis
Surgery- joint replacements and spinal surgery
What joints are commonly affected by psoriatic arthritis?
- Neck
- Shoulders
- Elbows
- Base of spine
- Wrist
- All joints of knuckles, fingers and thumbs
- Knees
- All joints of toes
- Ankles
Name some clinical subtypes of psoriatic arthritis?
Arthritis with DIP joint involvement
Symmetric polyarthritis- similar to RA
Asymmetric oligoarticular arthritis
Arthritis mutilans
Predominant spondylitis
What is the treatment of psoriatic arthritis?
Sulphasalazine Methotrexate Leflunomide Cyclosporin Anti-TNF therapy Steroids Physiotherapy + Occupational therapy Axial disease treated similar to Ankylosing Spondylitis
What is Reactive arthritis?
Autoimmune condition that develops in response to an infection in another part of the body (cross-reactivity).
Sterile synovitis after distant infection
By the time the patient presents with symptoms, often the “trigger” infection has been cured or is in remission in chronic cases, thus making determination of the initial cause difficult.
What is Reiter’s syndrome?
Reactive arthritis + other characteristic symptoms like urethritis and conjunctivitis
What infections cause reactive arthritis?
- Salmonella
- Shigella
- Yersinia
- Campylobacter
- Chlamydia trachomatis or pneumoniae
- Borrelia
- Neisseria
- Streptococci
How can skin and mucous membrane be involved in reactive arthritis?
(Name symptoms/ signs)
Keratoderma blenorrhagica Circinate balanitis Urethritis Conjunctivitis Iritis
What is Keratoderma blennorrhagicum?
Skin lesions commonly found on the palms and soles but which may spread to the scrotum, scalp and trunk. The lesions may resemble psoriasis
Commonly seen as an additional feature of reactive arthritis in almost 15% of male patients.
The appearance is usually of a vesico-pustular waxy lesion with a yellow brown colour. These lesions may join together to form larger crusty plaques with desquamating edges.
What is circinate balanitis?
Dermatologic manifestation of reactive arthritis comprising a serpiginous annular dermatitis of the glans penis.
Circinate balanitis is the most common cutaneous manifestation of reactive arthritis. However, circinate balanitis can also occur independently.
What treatments are used for circinate balanitis?
Topical corticosteroid therapy is the most commonly used treatment, and topical calcineurin inhibitors have also been used successfully
Recurrent attacks are common in reactive arthritis caused by what organism?
Chlamydia
What prognostic signs indicate chronic reactive arthritis?
Hip/heel pain
High ESR
FH and HLA-B27 +ve
What is the acute treatment of reactive arthritis?
NSAID
Joint injection (if infection excluded)
Antibiotics in chlamydia infection (contacts as well)
What is the treatment of chronic reactive arthritis?
NSAID
DMARD (e.g. sulphasalazine, methotrexate)
Enteropathic arthritis is commonly associated with which diseases?
It is rarely seen with which diseases?
Commonly associated with IBD (Crohn’s and UC)
Rarely seen with infectious enteritis, whipple’s disease and coeliac disease
What is the distribution of joints in enteropathic arthritis?
What can also be affected?
Can present with both peripheral and/or axial disease
Enthesopathy commonly seen
What is the treatment of enteropathic arthritis?
- NSAIDs difficult to use
- Sulfasalazine
- Steroids
- Methotrexate
- Anti-TNF
- Bowel resection may alleviate peripheral disease
