Seronegative arthritis & spondyloarthropathies Flashcards
What are seronegative arthropathies? (5 types)
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)
Ankylosing spondylitis (4)
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
Epidemiology of AS
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
New York criteria for diagnosis of AS
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
Clinical signs of AS
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
Stages of AS (3,3)
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
How to quantify spinal involvement in AS
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)
Laboratory tests for inflammation in AS
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
Psoriatic arthritis
A seronegative arthritis which usually presents as an inflammatory, peripheral mono- or oligo- arthritis (wrists or knees)
Rarely presents with polyarthritis or spinal disease
Arthritis Mutilans
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
Psoriatic Oligoarthritis
Arthritis effecting up to four joints in the first 6months of the disease classically
Epidemiology of Psoriatic arthritis
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
Radiology of Psoriatic arthritis
classically effects the DIP joints and may cause subchondral bone resorption resulting in ‘pencil in cup’ appearance
Erosive changes seen but without osteopenia
How many ways can Psoriatic arthritis present?
Five – DIP involvement, Arthritis mutilans, Asymmetrical polyarthritis, Oligoarthritis, Ankylosing Spondylitis.
May have palmar/plantar vesicles
Progression of Psoriatic Arthritis
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%)
Poor prognostic factors for Psoriatic arthritis (6)
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
Spinal disease in Psoriatic arthritis
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
Reiter’s syndrome (reactive arthritis)
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
Bacteria most commonly found to trigger Reiter’s syndrome (1,5,4)
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
Progression of Reiter’s syndrome
Simultaneous with infection or 3-4 weeks after
Self limiting but can be relapsing
Lower limb most commonly effected
40% spondylitis
Epidemology of Reiter’s syndrome
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
Keratoderma Blenorrhagicum
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
IBD associated (enteropathic) arthritis
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.
Enthesitis
Inflammation of tendon or ligament insertions – Achilles is particularly common – can also effect the rotator cuff or plantar fasciitis
NSAIDs
Useful analgesia in some cases of mono/oligo arthritis
Also in Enthesitis or spinal disease
Management of psoriatic arthritis
NSAIDs for analgesia
Intra-articular steroid injections
DMARDs (as with RA) to slow disease progression - if synovitis - (Sulfazalazine, methotrexate, leflunomide)
Biologics
Biologics for seronegative spondyloarthropathies
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
Extra-articular features of sponyloarthropathies (AS) (5,3,3)
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
Characteristics of AS back pain
Insidious onset before 40yrs for longer than 3months
Associated with early morning stiffness and improves with exercise
May have nocturnal pain
Degenerative versus ankylosing spinal changes
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
Treatment of AS (6)
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
Clinical features of Psoriatic arthritis (5)
Nail changes -- Pitting or onycholysis Sausage digits Sacroilitis (may also have AS like spinal changes) Enthesopathy Psoriatic skin disease
Treatment of Reiter’s syndrome (5)
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
Presentation of Sacroilitis
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
Peripheral arthritis in AS
Variable and with a better prognosis than RA
Rarely erosive
Occurs in 30% of patients – most commonly lower limb
Association between spondyloarthropathies and IBD
AS may also have clinical or subclinical GI complications or primary IBD – cross over with Enteropathic arthritis
Similar risk factors and genetics
Cardiac complications of AS
Aortitis
Cardiac conduction defects
Pericarditis
Prognosis of Reiter’s/reactive arthritis
30-70% relapse – joint, eye, mucocutanous
40% mild spondylitis and 20% chronic peripheral arthritis
Laboratory tests in psoriatic arthritis
No serological marker - RF negative and 5% ANA positive (same as general population)
ESR/CRP elevated
Prevalence of enteropathic arthritis in IBD
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%)
Extra-articular features of Enteropathic Arthritis (PAIeN)
Pyoderma gangrenosum
Aphthous stomatitis
Inflammatory eye diseases
Erythema nodosum (Crohn’s)
Septic Arthritis
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
Treatment of Enteropathic arthritis
Physiotherapy and NSAIDs Sulfasalazine for peripheral arthritis (poss SI joint) Azathioprine has weak evidence Bowel resection (UC only) Anti-TNF drugs
Enthesopathy
Fibrosis and ossification of ligaments and capsule insertions into bone
Reiter’s syndrome/disease versus reactive arthritis
Very similar and can be used interchangably
Reiter’s is specifically a triad of arthritis, urethritis and conjunctivitis – often linked to STD
Septic polyarthritis
3 joints - 22% of cases of septic arthritis – 30% mortality
50% of cases have a background of RA
Treatment of septic arthritis
Antibiotics for at least 2weeks IV and the 4wks of oral Abx
Presentation of Septic Arthritis
extreme pain with swelling, increased temp and systemic illness. 1/3 of cases present as polyarthritis
Diagnosing septic arthritis
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)
Features of Gonococcal septic arthritis
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.
Relationship between psoriatic skin disease and arthritis
The activity of the two is unrelated and one may flare without the other. Enteropathic arthropathy is more closely related.
Antibiotic treatment of septic arthritis
Normal: flucloxicillin (clindamycin if pen allergic)
MRSA: vancomycin
Gonococcal: cefotaxime
