Seronegative arthritis & spondyloarthropathies

Question 1

What are seronegative arthropathies? (5 types)

Answer 1

Arthritis in the absence of Rheumatoid factor or other autoantibody/serological abnormalities
Eg: Psoriatic arthritis (PsA), Ankylosing spondylitis (AS), Reactive Arthritis (ReA), Enteropathic Arthritis (IBD) or undifferentiated spondyloparthropathy (SpA)

Question 2

Ankylosing spondylitis (4)

Answer 2

An inflammatory disease of the spine and axial joints – Causes inflammatory back pain with increasing stiffness and kyphosis
Begins in the SI joint progressing upwards
Hips and shoulders can be involved in severe AS and are considered a poor prognostic sign

Question 3

Epidemiology of AS

Answer 3

Typically affects young men (15-30yrs, M:F/3:1)
0.1-1% prevalence
Women may present differently, complaining of neck and breast pain instead of typical inflammatory back pain

Question 4

New York criteria for diagnosis of AS

Answer 4

Limited lumbar movement OR Low back pain improved by exercise not relieved by rest for 3 months OR Reduced chest expansion
AND
Bilateral grade 2-4 sacroilitis on X-ray OR unilateral grade 3-4 sacroilitis on X-ray

Question 5

Clinical signs of AS

Answer 5

Increased thoracic kyphosis and loss of lumbar and cervical lordosis
Progressive ankylosis of the spine leads to immobility (bamboo spine) – ossification of the lateral collateral ligaments and annulus fibrosus (syndesmophytes) – ‘squaring’ of the vertebrae, oestopenia of the bodies

Question 6

Stages of AS (3,3)

Answer 6

Inflammatory –> Can V. painful during flares, hours of morning stiffness, Fatigue (lack of sleep due to pain at night)
Ankylosis –> Increasing stiffness and reduced ROM and increasingly abnormal posture

Question 7

How to quantify spinal involvement in AS

Answer 7

Measure the occiput to wall distance (increases as posture changes)
Chest expansion (reduced as joint fusion increases)  
-- protuberant abdomen from abdominal breathing
Modified Schober test (lumbar spine flexion)

Question 8

Laboratory tests for inflammation in AS

Answer 8

Inflammation –> FBC (normochromic/cytic anemia), raised CRP/ESR, thrombocytosis
Genetic test for HLA B27 – present in 95% of AS patients but only 6% of normal population

Question 9

Psoriatic arthritis

Answer 9

A seronegative arthritis which usually presents as an inflammatory, peripheral mono- or oligo- arthritis (wrists or knees)
Rarely presents with polyarthritis or spinal disease

Question 10

Arthritis Mutilans

Answer 10

A rare destructive arthropathy which can be seen in RA or PsA
Most commonly causes IP and MCP joint destruction with bone resorption and finger shortening (Opera-glass hands) – this eventually leads to paw like hands with subluxation and loss of function

Question 11

Psoriatic Oligoarthritis

Answer 11

Arthritis effecting up to four joints in the first 6months of the disease classically

Question 12

Epidemiology of Psoriatic arthritis

Answer 12

affects 6-42% of people with Psoriasis - precedes skin changes in 1/3 of cases
Onset at 30-50yrs, M=F for peripheral disease but axial disease is more common in men

Question 13

Radiology of Psoriatic arthritis

Answer 13

classically effects the DIP joints and may cause subchondral bone resorption resulting in ‘pencil in cup’ appearance
Erosive changes seen but without osteopenia

Question 14

How many ways can Psoriatic arthritis present?

Answer 14

Five – DIP involvement, Arthritis mutilans, Asymmetrical polyarthritis, Oligoarthritis, Ankylosing Spondylitis.
May have palmar/plantar vesicles

Question 15

Progression of Psoriatic Arthritis

Answer 15

Oligoarticular in 40-50%, Polyarticular in 30-50% (similar to RA)
Spinal disease is predominant in 5% – usually occur after many years of peripheral arthritis
DIP involvement in 5% and Arthritis mutilans in 5% (mildly erosive in 40-50%)

Question 16

Poor prognostic factors for Psoriatic arthritis (6)

Answer 16

Younger age of onset
HLA B27 correlates to spondylitic involvement, HLA DR3/4 correlates with erosive disease
Extensive skin involvement or polyarticular involvement
Lack of response to NSAIDs or HIV co-infection

Question 17

Spinal disease in Psoriatic arthritis

Answer 17

Sacroiliac involvement – sacroilitis in 1/3 patients, Usually unilateral and may be asymptomatic
Spinal involvement – Can affect any part of the spine in a random fashion, unlike AS

Question 18

Reiter’s syndrome (reactive arthritis)

Answer 18

A seronegative asymmetrical post-infective arthropathy where there is at least one: Urethritis/cervicitis, Diarrhoea, Uveitis/conjunctivitis, circinate balanitis, oral ulceration (can also occur with HIV infection)
Rheumatic diseases excluded – usually last 3-6months

Question 19

Bacteria most commonly found to trigger Reiter’s syndrome (1,5,4)

Answer 19

Definate:chlamydia trachomatis, salmonella species, shigella flexneri, yersinia enterocolitica/pseudotuberculosis, campylobacter jejuni,
Probable: Neisseria gonorrhoeae, streptococcus pyogenes, Ureaplasma, C Diff
Often can grow organism from synovium

Question 20

Progression of Reiter’s syndrome

Answer 20

Simultaneous with infection or 3-4 weeks after
Self limiting but can be relapsing
Lower limb most commonly effected
40% spondylitis

Question 21

Epidemology of Reiter’s syndrome

Answer 21

M:F/4:1 – 90% of patients are HLA-B27
No.1 cause of inflammatory arthritis in young (20-40)
White>black, M=F if GI related but M>F if urogenital

Question 22

Keratoderma Blenorrhagicum

Answer 22

A feature seen in 15% of male patients with reactive arthritis
vesico-pustular waxy, hyperkeratotic lesions with a yellow brown colour commonly on palms and soles but may spread

Question 23

IBD associated (enteropathic) arthritis

Answer 23

UC or Crohn’s disease (whipple’s or microscopic colitis). peripheral arthritis which usually self limits in 4-6wks. May effect the SI joints or Enthesitis No relationship between axial disease and IBD activity but peripheral arthritis tends to be related to gut disease activity.

Question 24

Enthesitis

Answer 24

Inflammation of tendon or ligament insertions – Achilles is particularly common – can also effect the rotator cuff or plantar fasciitis

Question 25

NSAIDs

Answer 25

Useful analgesia in some cases of mono/oligo arthritis | Also in Enthesitis or spinal disease

Question 26

Management of psoriatic arthritis

Answer 26

NSAIDs for analgesia Intra-articular steroid injections DMARDs (as with RA) to slow disease progression - if synovitis - (Sulfazalazine, methotrexate, leflunomide) Biologics

Question 27

Biologics for seronegative spondyloarthropathies

Answer 27

Biggest advance in years -- licensed to treat Psoriatic arthritis and ankylosing spondylitis Significantly improve both peripheral/axial arthritis, other clinical parameters and slows joint damage

Question 28

Extra-articular features of sponyloarthropathies (AS) (5,3,3)

Answer 28

Asymmetric peripheral arthritis Sausage digits Achilles tenosynovitis Costochondritis Plantar fasciitis/Mucocutaneous lesions Iritis/anterior uveitis Cauda equina/atlantoaxial sublux Aortitis/reguritation Apical pulmonary fibrosis Amyloidosis Constitutional symptoms AV block

Question 29

Characteristics of AS back pain

Answer 29

Insidious onset before 40yrs for longer than 3months Associated with early morning stiffness and improves with exercise May have nocturnal pain

Question 30

Degenerative versus ankylosing spinal changes

Answer 30

Degenerative will have joint space narrowing with transverse osteophytes growing away from the vertebra AS starts with Romanus lesion which grows into a early vertebral syndesmophyte --> eventually grows into a Bridging syndesmophyte

Question 31

Treatment of AS (6)

Answer 31

Patient education and Exercise --> physiotherapy or OT Pain relief with NSAIDs Intra-articular steroid injections --> Surgical intervention if hip disease Anti-TNF therapy -- DMARDs can be used if there is peripheral arthritis (sulfasalazine mainly) but others are not useful

Question 32

Clinical features of Psoriatic arthritis (5)

Answer 32

``` Nail changes -- Pitting or onycholysis Sausage digits Sacroilitis (may also have AS like spinal changes) Enthesopathy Psoriatic skin disease ```

Question 33

Treatment of Reiter's syndrome (5)

Answer 33

screen for STDs --> refer to GUM clinic NSAIDs or antibiotics Intra-articular steroids for mono- or oligo arthritis In severe, intractable disease --> use methotrexate, azathioprine or sulfazalazine

Question 34

Presentation of Sacroilitis

Answer 34

Low back pain or bilateral buttock pain -- may radiate down one or both legs - worse after prolonged immobility Will show juxta-articular osteoporosis and sclerosis Eventually the joint is obliterated Test for with Pelvic compression or Patrick's test

Question 35

Peripheral arthritis in AS

Answer 35

Variable and with a better prognosis than RA Rarely erosive Occurs in 30% of patients -- most commonly lower limb

Question 36

Association between spondyloarthropathies and IBD

Answer 36

AS may also have clinical or subclinical GI complications or primary IBD -- cross over with Enteropathic arthritis Similar risk factors and genetics

Question 37

Cardiac complications of AS

Answer 37

Aortitis Cardiac conduction defects Pericarditis

Question 38

Prognosis of Reiter's/reactive arthritis

Answer 38

30-70% relapse -- joint, eye, mucocutanous | 40% mild spondylitis and 20% chronic peripheral arthritis

Question 39

Laboratory tests in psoriatic arthritis

Answer 39

No serological marker - RF negative and 5% ANA positive (same as general population) ESR/CRP elevated

Question 40

Prevalence of enteropathic arthritis in IBD

Answer 40

occurs in 7-21% of cases -- 3:1/M:F Peripheral arthritis - UC (10%), Crohn's (20%) Sacroilitis - UC (15%), Crohn's (15%) Spondylitis - UC (5%), Crohn's (5%)

Question 41

Extra-articular features of Enteropathic Arthritis (PAIeN)

Answer 41

Pyoderma gangrenosum Aphthous stomatitis Inflammatory eye diseases Erythema nodosum (Crohn's)

Question 42

Septic Arthritis

Answer 42

Occurs due to acute primary infection. Risk factors- pre existing joint disease, DM, Immunosuppresion, renal compromise, trauma/surgery, IVDU. 10% mortality (medical emergency) Usually caused by staph or strep

Question 43

Treatment of Enteropathic arthritis

Answer 43

``` Physiotherapy and NSAIDs Sulfasalazine for peripheral arthritis (poss SI joint) Azathioprine has weak evidence Bowel resection (UC only) Anti-TNF drugs ```

Question 44

Enthesopathy

Answer 44

Fibrosis and ossification of ligaments and capsule insertions into bone

Question 45

Reiter's syndrome/disease versus reactive arthritis

Answer 45

Very similar and can be used interchangably | Reiter's is specifically a triad of arthritis, urethritis and conjunctivitis -- often linked to STD

Question 46

Septic polyarthritis

Answer 46

3 joints - 22% of cases of septic arthritis -- 30% mortality | 50% of cases have a background of RA

Question 47

Treatment of septic arthritis

Answer 47

Antibiotics for at least 2weeks IV and the 4wks of oral Abx

Question 48

Presentation of Septic Arthritis

Answer 48

extreme pain with swelling, increased temp and systemic illness. 1/3 of cases present as polyarthritis

Question 49

Diagnosing septic arthritis

Answer 49

joint aspiration is the central feature but cultures are negative in 75% of gonococcal arthritis (20% - mainly younger, fitter people) and blood cultures are less sensitive (50% for non-gonococcal and ~0% for gonococcal)

Question 50

Features of Gonococcal septic arthritis

Answer 50

Occurs in younger, healther people and it tends to present with a migratory pattern of arthritis. tenosynovitis and skin lesions are a frequent feature. The initial infection can often be asymptomatic.

Question 51

Relationship between psoriatic skin disease and arthritis

Answer 51

The activity of the two is unrelated and one may flare without the other. Enteropathic arthropathy is more closely related.

Question 52

Antibiotic treatment of septic arthritis

Answer 52

Normal: flucloxicillin (clindamycin if pen allergic) MRSA: vancomycin Gonococcal: cefotaxime