Seronegative Arthritis (Spondyloarthrosis) Flashcards
Another name for seronegative arthritis
Spondyloarthrosis
Features of seronegative arthritis
Negative rheumatoid factor may be associated with HLA-B27 usually asymmetric arthritis involvement of axial skeleton enthesis extraarticular features - uveitis - IBD
What does seronegative arthritis mean?
The absence of the antibody called rheumatoid factor
Different clinical presentations of seronegative arthritis (the spondyloarthropathies)
ankylosing spondylitis
psoriatic arthritis
bowel related arthritis (crohns, UC)
Reactive arthritis
What is ankylosing spondylitis?
Chronic inflammatory rheumatoid disorder with a predilection for axial skeleton and entheses
Who gets ankylosing spondylitis?
M > F
2-3rd decade
What antigens are present and related to ankylosing spondylitis?
HLA-B27
What examination techniques are used to look at the mobility of the spine?
Bending over
Lateral spine flexion
Occiput to wall and tragus to wall
Cervical rotation
Criteria for ankylosing spondylitis
Inflammatory back pain
Limitation of movements in antero-posterior as well as lateral plates at lumbar spine
limitation of chest expansion
bilateral sacroiliitis on x ray (pelvis)
Grading of radiographic sacroilitis
Grade 0 - normal
Grade 1 - suspicious changes
Grade 2 - MINIMAL abnormality - small localised areas of erosion or sclerosis, without alteration or joint width
Grade 3 - UNEQUIVOCAL abnormality - moderate or advanced sacroiliitis with 1 or more of erosions, sclerosis, widening, narrowing, or partial ankylosis
Grade 4 - SEVERE abnormality - total ankylosis
Stages of axial spondylosis
- non radiographic stage
- back pain
- sacroiliitis on MRI - Radiographic stage
- back pain
- radiographic sacrolitis
- syndesmophytes
Classification criteria for axial spondyoarthritis
in patients with >_ 3 months back pain and age at onset of <45 years
sacroiliitis on imaging plus >_ 1 SpA feature OR HLA-B27 plus >_2 SpA features
SpA features
inflammatory back pain arthritis enthesitis (heel) uveitis dactylitis psoriasis chrons/colitis good response to NSAIDs FH for SpA HLA-B27 Elevated CRP
On MRI imaging, what is highly suggestive of sacroiliitis associated with SpA?
Active (acute) inflammation
Features (as well as SpA criteria features) of ankylosing spondylitis
peripheral joints (hip, shoulders, knees) achilles tendonitis, dactylitis uveitis aortic incompetence heart block restrictive pulmonary disease pulmonary apical fibrosis IBD Osteoporosis and spinal fractures AAD Cauda equina syndrome renal; secondary amyloidosis
Management of ankylosing spondylitis
Physio
Encourage regular exercise such as swimming
NSAIDs - 1st line
DMARDs - sulfasalazine (useful when peripheral joint involvement)
Anti-TNF, Anti-IL-17 (if persistent high disease activity despite other treatments)
treatment of osteoporosis
surgical
- spinal
- joint replacements
Joints commonly affected in psoriatic arthritis
neck shoulders elbows base of spine wrists all joints of knees, fingers and thumbs knees ankles all joints of the toes
Clinical subtypes of psoriatic arthritis
Arthritis with DIP joint involvement Symmetric polyarthritis (similar to RA) asymmetric oligoarticular arthritis Arthritis mutilans Predominant spondylitis
Relation of joint disease and skin disease in psoriatic arthritis
Severity of joint disease does not correlate to the extent of skin disease
Presentation of psoriatric arthritis
Arthritis
Psoriasis
Nail pitting skin
Treatment of psoriatric arthritis
Sulfasalazine Methotrexate Leflunomide Cyclosporin Anti-TNF therapy Anti-LF-17 and IL-23 steroids physio and OT Axial disease treated similar to AS
What is reactive arthritis?
sterile synovitis after distant infection
Infections included in reactive arthritis
salmonella shigella campylobacter chlamydia pneumoniae Neisseria streptococci throat infections urogenital infections GI infections
Presentation of reactive arthritis
Systemic disease Mono or oligoarthritis skin and mucous membrane involvement - keratoderma blenhorrhagica - circinate balantis - urethritis - conjunctivitis - iritis Reiters syndrome
Features of Reiter’s Syndrome
Arthritis
Urethritis
Conjunctivis
Prognostic factors for chronicity of reactive arthritis
Hip/heel pain
High ESR
FH
HLA-B27
Treatment of reactive arthritis
acute - NSAID - joint injection (if infection excluded) - Antibiotics in chlamydia infection Chronic - NSAID - DMARD e.g. sulphasalazine, methotrexate
What is enteropathic arthritis seen in?
IBC (CRONHS OR UC) !!! rarely - infectious entereritis - whippels disease - coeliac disease
Presentation of enteropathic arthritis
Both peripheral and/or axial disease
Enthesopathy
Treatment of enteropathic arthritis
sulfasaline steroids methotrexate Anti-TNF Bowel resection may alleviate peripheral disease NSAIDs difficult to use
Extra-articular features of spondyloarthrosis
Uveitis
IBD
What does a bamboo spine indicate?
Ankylosing spondylitis
Investigation of ankylosing spondylitis
ESR and CRP raised
HLA-B27
XRAY
What can be seen on Xray in ankylosing spondylitis?
Sacroiliitis; subchondral erosions, sclerosis Squaring of lumbar vertebrae Bamboo spine (late and uncommon) Syndesmosphytes Atypical fibrosis on CXR
HLA allele of reiters syndrome
HLA-B27
What is one of the earliest signs of ankylosing spondylitis?
Reduced lateral flexion of the lumbar spine
1st line management for AS
Exercise regimes + NSAIDs
What chest sign may be seen in late AS?
Apical fibrosis
What are typical Xray deformities found in psoriatic arthritis?
Plantur spur
Pencil and cup
What value of schobers test suggests ankylosing spondylitis and what does it indicate?
< 5cm
Reduced lumbar flexion
