Seronegative Arthropathies

Question 1

What makes a seronegative arthritis?

Answer 1

Associated with HLA-B27 but RF -ve

Question 2

Describe the general presentation of Seronegative arthropathies?

Answer 2

Generally Asymmetric
Involves spine
Common extra-articular features e.g. uveitis, enthesitis or IBD

Question 3

Types of Seronegative Spondyloarthropathies?

Answer 3

Psoriatic Arthritis
Ankylosing Spondylitis
Enteropathic Arthritis
Reactive Arthritis

Question 4

What extraarticular features characterise psoriatic arthritis?

What features on PMH & FH should be asked about?

Answer 4

By Dactylitis & Enthesitis along with nail pitting of psoriasis

Also look for a h/o or Fh/o Psoriasis

Question 5

How is psoriatic arthritis treated?

Answer 5

DMARDs
Cyclosporin 
Biologics (e.g. Anti-TNFalpha or Anti-ILs)
Steroids
Physio & OT

Question 6

How is enteropathic arthritis characterised?

Answer 6

Peripheral or axial disease alongside IBD

Question 7

How do we treat Enteropathic Arthritis?

Answer 7

DMARDs

Steroids

Anti-TNFalpha

NSAIDs

Bowel Resection (can help with peripheral disease)

Question 8

Define Reactive Arthritis?

Answer 8

Sterile Synovitis following a distant infection (i.e. throat, urogenital or GI)

Question 9

What infections commonly cause Reactive Arthritis?

Answer 9

Campylobacter
Salmonella
Shigella
Yersinia
Chlamydia Trachomatis or Pneumoniae
Borellia
Neisseria
Streptococci

Question 10

Whats special about Chlamydia induced Reactive Arthritis?

Answer 10

Often recurrent attacks rather than a single episode

Question 11

How does Reactive Arthritis present?

Answer 11

H/o infection
Arthritis - typically asymmetrical
Involves skin & mucous membranes:
- Keratoderma Blenorrhagica (pale brown lesions on feet)
- Circinate Balanitis (rash on head of penis)
- Urethritis
- Conjunctivits
- Iritis

Question 12

What is Reiter’s Syndrome?

Answer 12

A specific presentation of Reactive Arthritis:
- Conjunctivitis, urethritis, arthritis

Cant see, cant pee, cant bend the knee

Question 13

how is reactive arthritis treated acutely?

Answer 13

NSAIDs & Joint Injection

IF Chlamydia give Abx

Question 14

How is chronic reactive arthritis treated?

Answer 14

NSAIDs

DMARDS e.g. Sulfasalazine & methotrexate

Question 15

Define Ankylosing Spondylitis?

Answer 15

A chronic inflammatory rheumatic disorder with predilection for axial skeleton and entheses
Probably the largest and most important Seronegative Spondyloarthropathy

Question 16

Who gets AS?

Answer 16

Men more than women
Generally onsets in 2nd–>3rd decade
Mostly people of northern european descent

Question 17

What criteria are required to be termed Ankylosing Spondylitis?

Answer 17

The New York Clinical Criteria:

• Inflammatory back pain
• Limited movement at lumbar spine (forward & lateral flexion)
• Limited Chest Expansion
• Bilateral Sacroilitis on X-ray

Question 18

How do we grade Sacroilliitis?

Answer 18

0-4 based on X-ray:
- 0 = normal
1 = suspicious changes
2 = Minimal abnormality (no altered joint width)
3 = Unequivocal abnormality
4 = Severe abnormality (total ankylosis)

Question 19

How do we treat AS?

Answer 19

1) Physio & exercise
1) NSAIDs

DMARDs (Sulfasalazine)
Biologics (e.g. Anti-TNFalpha Infliximab)
Joint replacement or Spinal Surgery

Question 20

If back pain doesn’t meet the NY criteria for AS then it could be another form of Spondyloarthritis with axial involvement, what criteria must it meet for this?

Answer 20

ASAS criteria for Axial Spondyloarthritis:

• 3 or more months of back pain
• <45yrs of age
• Sacroiliitis on X-ray + 1 SpA feature OR HLA-B27 +ve + 2 SpA features

Question 21

What are the SpA (Spondyloarthropathy) features?

Answer 21

Inflammatory back pain
Arthritis

Extra-articular features:

• Enthesitis (mostly in heel)
• Uveitis
• Psoriasis
• Dactylitis

IBD
Responds to NSAIDs
FH of SpA
HLA-B27
Elevated CRP

Question 22

What makes back pain “inflammatory”?

Answer 22

Worse at night
Better on exercise
Insidious onset