Seronegative inflammatory arthritis Flashcards
List the different types on inflammatory arthritis
- RA
- Undifferentiated inflammatory arthritis
- Spondyloarthritis
Outline the different types of spondyloarthritis
Axial SpA: -ankylosing spondylitis -Non radiographic axial SpA Peripheral SpA: -psoriatic arthritis -Enteropathic arthritis -Reactive arthritis -Juvenile onset SpA
What is enthesitis
-Inflammation of the entheses, the sites where tendons or ligaments insert into the bone
What is enteropathic arthritis
A form of chronic, inflammatory arthritis associated with the occurrence of an IBD eg Crohn’s or UC
Outline the characteristics of axial spondyloarthritis (AxSpA)
-Men 3:1
-Age 20-40
-HLA B27+ (~5% of patients)
Symptoms=
-chronic low back pain
-Buttock/hip/neck pain
-Improves with exercise
-Night pain
-Morning stiffness>30mins
-Peripheral arthritis
-Enthesitis
-Dactylitis
-Elevated CRP
How can you diagnose non radiographic axial SpA?
- MRI changes
- PLUS clinical suspicion
What are the features of SpA fractures?
-Inflammatory back pain
-Arthritis
-enthesitis(heel)
-uveitis
-dactylitis
-psoriasis
Crohn’s/colitis
-good response to NSAIDs
-Family history of SpA
-HLA-B27
-elevated CRP
How can we manage SpA?
- NSAIDs
- Exercise(physio& hydrotherapy)
- Biologics eg Adalimumab may be used
How does psoriatic arthirits affect the synovial joints?
- Inflammed synovial membrane
- Enthesitis
- Pannus
What is a pannus and what does it consist of?
- An abnormal layer of fibrovascular tissue or granulation tissue
- Major cell types= T lymphocytes, macrophages
- Minor cell types= Fibroblasts, Neutrophils, dendritic cells, mast cells
What are the clinical features of psoriatic arthritis?
- Peripheral arthritis
- Axial disease
- Enthesitis
- Dactylitis
- Skin & nail disease
What are the 3 main types of psoriatic arthritis?
- ) Polyarticular:
- Involvement of many small joints usually in hands& feet
- Most common
- Rarely get rapid joint damage (Arthritis mutilans) - )Oligoarticular:
- Affects a few large joints
- eg knee,ankle,elbow - ) Spondyloarthritis:
- Involvement of the sacroiliac joints& spine
- Sometimes with an oligoarticular peripheral arthritis
What joint inflammation may occur in PsA?
- DIP synovitis
- PIP synovitis
- Dactylitis
- Asymmetric oligoarthritis
Outline the use of PsA in joint arthroscopy
A type of keyhole surgery used to diagnose and treat joint problems.
Outline the use of ultrasound in PsA
- We use peri doppler
- Within the inflammed joint you get increased blood flow& angiogenesis. We can use this to see how active/inflammed the joint is at a particular point in time
- Black stuff= fluid within the joint
Outline the challenges in PsA
- Diversity in clinical manifestations of psoriatic diease
- Musculoskeletal manifestations & abnormal blood results not so obvious and may be difficult to diagnose
- Many patients with PsA remain undiagnosed
- Delays in diagnosis can lead to progression of the disease
Outline the management of PsA
-NSAIDs
-DMARDS eg methotrexate,sulphasalazine
-Treatment escalation: 3 tender & 3 swollen joints; failure of 2 DMARDs
USE (as means of escalation) Apremilast & biologics
What are fumaric ester acids used for
-Used in the treatment of psoriasis
Outline the characteristics of reactive arthritis
-Asymmetric oligo-arthritis
-1 to 4 weeks post infection:
gastrointestinal& urogenital affected
-Good pneumonic to remember = ‘cant see(conjunctivitis). can’t pee(urethritis). Can’t climb a tree(Arthritis)
Which bacteria can affect the GI system and so lead to reactive arthriris
- Salmonella
- Shigella
- Yersinia
- Campylobacter
- C diffiicile
What bacteria can affect the urogenital system and so lead to reactive arthritis
- Chlamydia trachomatis
- Chlamydia pneumoniae
Describe the muscular manifestations of PsA
- Peripheral arthritis- often knee joint
- Enthesitis
- Dactylitis
- Axial( low back pain)
extra articular:
- Ocular( conjunctivitis, anterior uveitis, episcleritis, keratitis)
- GU(dysuria, pelvic pain etc)
- GI(diarrhoea)
- Oral lesions, skin lesions, nail changes
- Sometimes concomitant infection ( stool cultures; urine & genital swab)
- Elevated acute phase reactants
- HLA B27+ (30-50%)
- Radiological changes
Describe the management and prognosis of reactive arthritis
- Clinical diagnosis
- Treat with NSAIDs, steroids. DMARDs
VARIABLE PROGNOSIS:
- Typically lasts 3-5 months
- Complete resolution within 6-12months
- 15-20% experience more persistent chronic arthritis
- Can differentiate into another form of SpA
Outline enteropathic arthritis
UC & Crohn’s disease:
- Estimated to occur in 6-46% of patients with IBD
- Peripheral arthritis (relapsing remitting)
- Axial involvement
- Enthesitis & dactylitis
- Manage with NSAIDs& glucocorticoids
Outline the genetics of SpA
- Strong MHC class 1 pathway association(eg HLA-B27 Region)
- SNPs
- 30-40% heritability in twin studies
- IL-17A(one of the most important inflammatory cytokines in this condition) is secreted by many cells including TH17 and Tc17 cells
- Clear role for the IL17/23 pathway-similar to spondyloarthritis& psoriasis
List the key inflammatory cytokines in inflammatory arthritis
IL-17/23 = psoriasis, PsA, SpA
IL-6= RA &GCA
TNF-alpha: JIA/AID
IL-1: gout
What are tissue resident memory T cells?
- Memory T cells that remain persistent in tissues& organs in the absence of antigen stimulation
- Respond rapidly to pathogen challenge
- Shown to express markers including CD69 & CD103
Outline the characteristics of reactive arthritis
-Asymmetric oligo-arthritis
1 to 4 weeks post infection:
- GI (Salmonella, Shigella, Yersinia, Campylobacter, C difficile)
- Urogenital (Chlamydia Trachomatis. Chlamydia pneumoniae)
-CAN’T SEE; CAN’T PEE; CAN’T CLIMB A TREE
Conjuncvitis
Urethritis
Arthritis
How can we diagnose reactive arthritis
-Sometimes concomitant infection: take stool cultures, urine and genital swab
-Elevated acute phase reactants
HLA B27+ 30-50%
-Radiological change s
