Seronegative Arthropathies Flashcards
What are Seronegative Spondyloarthropathies?
This refers to any joint disease of the axial skeleton with a negative serostatus (RF negative). Depending on the type of disease, there may be an associaton with HLA-B27.
The shared features between spondyloarthropathies include:
- Seronegativity
- HLA-B27 association
- Axial Arthritis - spine and SI joints
- Asymmetrical lare-joint oligoarthropathies or monoarthritis
- Enthesitis
- Dactylitis - inflammation of entire single digit
- Extra-articular manifestations
What are the subclassifications of Spondyloarthropathies?
- Ankylosing Spondylitis
- Psoriatic arthritis
- Bowel related arthritis (Crohn’s, UC)
- Reactive arthritis
- Others
What is Ankylosing Spondylitis?
Ankylosing spondylitis (AS), which has a prevalence of between 0.5% and 1%, is the principal inflammatory disease of the axial skeleton, with variable inolvement of peripheral joints and nonarticular structures.
What is the cause of AS?
Aetiology is unkown, although 90% of patients are HLA-B27 positive
What groups does AS most commmonly affect?
- Males>Females - men present earlier
- Onset in 2/3rd decade
- 90% are HLA-B27 positive
What are the clinical features of AS?
Men <30 yrs old
- Gradual onset lower back pain - radiates from SI joint to hip/buttocks, improves towards the end of the day
- Spinal Stiffness - worse in the morning, releived with exercise, worse at night
- Decreased thoracic expansion - due to loss of spinal movement
- Thoracic kyphosis + cervical hyperextension
- Decreased ROM - antero-posterior and lateral planes of lumbar spine
- Enthisitis - Achilles tendonitis, Plantar fasciitis, Tibial and ischial tuberosities and Iliac crests
- Acute Iritis - 1/3rd patients
- Chostochondritis
How would you clinically assess for AS?
Clinical Diagnosis - decreased spinal mobility and chest expansion
- Modified Schoeber
- Lateral spinal flexion
- Occiput to wall and tragus to wall
- Cervical rotation
What imaging would you do to assess for AS?
Imaging
-
X-ray
- Sacroiliitis
- Vertebral syndesmophytes - bony proliferations originating inside a ligament due to enthesitis between ligaments and vertebrae
- Ankylosis - fusion of vetebral bodies as a result of bony proliferations from enthisitis
- BAMBOO SPINE
What are the more systemic features of AS?
- Anterior uveitis
- Aortitis
- Aortic Regurg
- AV node block
- Apical pulmonary fibrosis
- Amyloidosis
- Achilles tendonitis
What are the clinical features of PsA
- Dactylitis
- Enthesitis
- Oligoarthritis - particularly in weight-bearing joints
- DIP joint involvement - usually in association with psoriatic nail disease
- Sacro-iliitis
- Osteolysis - leading to ‘telescoping’ of digits following loss of bone from phalanges
- Nail changes - onycholysis, ridging, pitting
What bloods could help with determining a diagnosis of AS?
Bloods
- FBC (normocytic anaemia)
- ESR, CRP - can be raised
- HLA-B27 +ve - not diagnostic
How would you manage someone with a diagnosis of AS?
- Physiotherapy
- NSAIDs
- DMARDs - Sulfasalazine
- Anti-TNF
- Treatment of osteoporosis
- Surgery - joint (inc hip) replacements & spinal surgery
What is Psoriatic arthritis?
Inflammatory arthritis that is associated with psoriasis (occurs in 10-40% of those with psoriasis)
HLA-B27 positive - 60-75%
Consistent differences in synovial histology between psoriatic arthritis (PsA) and RA
- More prominent angiogenesis
- Less expanded lining area
- Increased neutrophil infiltration in PsA
What investigations can be done to confirm PsA?
Bloods
- RF - negative
- HLA-B27 - 60-75% +ve
Imaging
- X-ray - Osteolysis of digits → Pencil cup deformity
What are the extra-articular features of Reactive arthritis?
- Skin - keratoderma blennorrhagica (brown, raised plaques on soles or hands), circinate balanitis (prepuce)
- Eyes - Conjunctivitis, uveitis (rarely)
- GU - Urethritis
- GI - mouth ulcers
How do you treat PsA?
- DMARDs - Sulfasalazine, Methotrexate, Leflunomide
- Cyclosporine
- Anti-TNF therapy
- Steroids
- Physio + OT
- Axial disease treated similar to AS
What is reactive arthritis?
A form of spondyloarthritis, typically affecting the lower limbs, that is usually triggered by specific infections of the gastrointestinal (e.g dynsentry) or GU tract (urethritis). Can also occur after infections of the throat.
Incidence - approx. 40–50 per million for reactive arthritis triggered by either enteric infection or Chlamydia trachomatis.
What are the primary organisms which cause reactive arthritis?
- Salmonella
- Shigella
- Yersinia species
- Campylobacter species
- Chlamydia trachomatis or pneumoniae
- Borrelia
- Neisseria and streptococci
What are the arthritic clinical features of Reactive Arthritis
Acute arthritis - needs to have been previous infection
- Oligoarticular arthritis - predilection for weight-bearing joints
- Joints swollen and hot - septic arthritis and crystal arthritis principal DDx
- Backache and/or sacro-iliac joint tenderness
What is Reiter’s syndrome?
This is a classic triad of symptoms which is seen in Reactive Arthritis:
- Conjunctivitis
- Urethritis
- Arthritis
CAN’T SEE, CAN’T PEE, CAN’T BEND THE KNEE
What tests can be done in the context of suspected reactive arthritis?
Bloods
- ESR, CRP - raised
- Infectious serology
Other
- Culture stool if diarrhoea
- STI review
Imaging
- X-Ray - enthisitis
How would you treat Reactive Arthritis?
Acute
- NSAID
- Joint injection (if infection excluded)
- Antibiotics - chlamydia infection (contacts as well)
Chronic
- NSAID
- DMARDs
What is Enteropathic Arthritis?
Many patients with inflammatory bowel disease (IBD) also have an inflammatory arthritis, usually with features that are associated with other forms of spondyloarthritis.
Approximately 10% have peripheral arthritis, and a further 5% have AS-like disease.
How does Enteropathic Arthritis Present?
Types
-
Type I - associated with active bowel disease
- Oligoarticular - asymmetrical
-
Type II - not related to the activity of the bowel disease.
- Polyarticular (>5) - symmetrical
Enthesopathy - common in both subtypes.
Extra-articular features - uveitis, skin lesions (e.g. erythema nodosum and pyoderma gangrenosum)
How would you manage someone with Enteropathic Arthritis?
- Treatment of bowel disease - can improve arthropathy
- DMARDS - in resistant disease
- Steroids
- Anti-TNF
What are the clinical subtypes of psoriatic arthritis?
- Asymmetrical large joint oligoarticular arthritis.
- Symmetrical polyarthritis.
- Distal interphalangeal arthropathy.
- Arthritis mutilans.
- AS with or without sacroiliitis.
What symptoms would you ask which may occur before symptoms of arthropathy if you suspected reactive arthritis?
- Diarrhoea - enteritis
- Dysuria, haemturia, frequency, urgency, discharge - Urethrtitis/STI
What differentials would you consider for someone presenting with symptoms of reactive artritis?
- Septic arthritis
- Lyme disease
