Seronegative Inflammatory Arthropathies Flashcards by Jane Keery

What are the 4 seronegative inflammatory arthropathies?

Ankylosing Spondylitis
Psoriatic arthritis
Enteropathic arthritis
Reactive arthritis

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What are the main features of seronegative inflammatory arthropathies?

Sponyloarthropathy and asymmetric oligoarthritis

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What makes individuals genetically predisposed to seronegative inflammatory arthropathies?

Being HLA-B27 positive

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What is a spondyloarthropathy?

Inflammation/arthritic disease of the spine

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What conditions is HLA B27 associated with?

Ankylosing Spondylitis
Crohn’s Disease
Uveitis
Reactive Arthritis

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Where in the world in HLA-B27 most prevalent?

Northern countries

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If you are HLA-B27 +, does this mean you will definitely have one of the conditions it is associated with?

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What type of pain is associated with seronegative inflammatory arthropathies?

Inflammatory pain

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Describe mechanical pain?

Worsened by activity, better at the end of the day/with rest

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Describe inflammatory pain?

Worse with rest, better with activity, significant early morning stiffness

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What are six shared features of the spondyloarthropathies?

Sacroiliac and spinal involvement
Enthesitis
Dactylitis
Ocular inflammation
Mucocutaneous lesions
Rare aortic impotence or heart block

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What is enthesitis? Give two examples.

Inflammation at the insertion of tendons into bones (e.g. Achilles tendonitis, plantar fasciitis)

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What is an enthesis?

Site of insertion of a tendon, ligament or articular capsule into a bone

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What is enthesopathy?

An alteration at the site of an enthesis

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What type of inflammatory arthritis usually occurs in the seronegative inflammatory arthropathies (excluding back)?

Asymmetric, predominantly lower limb

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What is dactylitis?

‘Sausage digits’- inflammation of an entire digit

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What are some examples of ocular involvement in the seronegative inflammatory arthropathies?

Anterior uveitis, conjunctivitis

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What are the 4 most important things to know about the seronegative inflammatory arthropathies?

Associated with HLA-B27
Affects the spine and other joints
Causes enthesitis
Causes extra-articular features

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Ankylosing spondylitis is a chronic systemic inflammatory disorder primarily affecting where?

The spine and sacroiliac joints

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What can chronic inflammation of the spine and sacroiliac joints lead to?

Eventual fusion of the intervertebral joints and SI joints

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Is peripheral arthritis common in ankylosing spondylitis?

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When does ankylosing spondylitis usually present? Which sex is it most common in?

Late adolescence or early adulthood (ranging 20-40)

More common in men 3:1

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What is the main complaint of patients with ankylosing spondylitis?

Pain and stiffness in the back, and possible hip/knee arthritis

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What improves morning stiffness in ankylosing spondylitis?

Exercise

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What happens to the spine over time in ankylosing spondylitis?

Loss of movement and development of a question mark spine

What happens in a question mark spine?

Loss of lumbar lordosis | Increased thoracic kyphosis

What are the main criteria you muse always have for ASAS classification of ankylosing spondylitis?

3 or more months of back pain, less than 45 years of age

If you have the major criteria, what are the next two steps on the ASAS classification for ankylosing spondylitis?

- Sacroiliitis on imaging and 1 or more SpA features | - HLA B27 positive and 2 or more SpA features

What are the SpA features used for the ASAS classification of ankylosing spondylitis?

- Inflammatory back pain - Arthritis - Enthesitis - Uveitis - Dactylitis - Psoriasis - Crohn's disease - Good response to NSAIDs - Family history - Elevated CRP - HLA B27

What are some extra-articular features of ankylosing spondylitis?

CV, pulmonary or neurological involvement, mucosal inflammation, amyloidosis

What are the features of ankylosing spondylitis using the rule of A's?

- Anterior uveitis - Aortic regurgitation - Achilles tendonitis/plantar fasciitis - Atypical fibrosis - Amyloidosis - IgA nephropathy

What are some tests which may be useful in an examination of possible ankylosing spondylitis?

- Occiput to wall (big gap if AS) - Chest expansion (may be reduced in AS) - Schober's test

What does the Schober's test test?

Lumbar spinal flexion

How is the Schober's test performed?

Measure 5cm below the iliac crests and 10cm above and then ask the patient to bend forward and remeasure the distance which should be beyond 20cm

What blood tests may be useful for ankylosing spondylitis?

- Inflammatory markers (CRP, PV) | - HLA-B27

What are some x-ray features of ankylosing spondylitis?

- Can be normal - Sacroiliitis - Bamboo spine - Syndesmophytes

What are syndesmophytes?

Bony spurs from vertebral bodies

Why are MRIs preferred over x-rays?

Safer and more accurate

What features can MRI detect that x-rays cannot?

- Bone marrow oedema | - Enthesitis of spinal ligaments

How can you tell ankylosing spondylitis from osteoarthritis?

AS is inflammatory while OA is not | AS will cause reduced bone density while OA will be normal or increased

What are the main treatments for ankylosing spondylitis?

NSAIDs, physiotherapy, occupational therapy, exercise

What role do DMARDs have in ankylosing spondylitis?

No role in spinal disease but can be used if there is peripheral joint inflammation

Are biologics ever used for ankylosing spondylitis?

Yes, if there is aggressive disease. You would use anti-TNF e.g. infliximab or anti-IL17 e.g. sucukinumab

What % of patients with psoriasis get an inflammatory arthritis?

30%

What % of patients have psoriatic arthritis without psoriasis?

10%

What are 5 possible features of psoriatic arthritis?

- Sacroiliitis (often asymmetric) and maybe spondylitis - Nail involvement - Datylitis - Enthesitis - Extra articular features e.g. eye disease

What are 2 examples of nail involvement in psoriatic arthritis?

Pitting and onycholysis

Psoriatic arthritis can be confined to what joints of the hands and feet?

DIPs

What is arthritis mutilans?

A subtype of psoriatic arthritis which is very aggressive and destructive very quickly

What are bloods tested for in psoriatic arthritis?

Raised inflammatory markers | Negative antibodies

What may x-rays show in psoriatic arthritis?

Erosions Osteolysis Enthesitis

Treatment of psoriatic arthritis is similar to what? What is this treatment?

Rheumatoid arthritis- DMARDs, usually methotrexate, and anti-TNF if unresponsive

What is reactive arthritis?

An infection induced systemic illness characterised by synovitis from which viable microorganisms cannot be cultured

When do symptoms of reactive arthritis tend to occur?

1-4 weeks after the original infection

What joints are mostly affected by reactive arthritis?

Large joints e.g. knee

What are the most common infections to cause reactive arthritis?

Uro-genital e.g. chlamydia or enterogenic e.g. salmonella

Who does reactive arthritis usually occur in?

Young adults (20-40) with equal sex distribution

Are individuals with reactive arthritis HLA-B27 positive?

Yes

What is Reiter's Syndrome?

A form of reactive arthritis made up of a triad of urethritis, conjunctivitis/uveitis/iritis and arthritis

What are some clinical features of reactive arthritis?

- General symptoms (fever, malaise, fatigue) - Asymmetrical mono/oligoarthritis - Enthesitis - Mucocutaneous lesions - Ocular lesions - Visceral manifestations

What are bloods tested for in reactive arthritis?

- Inflammatory markers - Us + Es, FBCs - HLA-B27

What investigations are used in reactive arthritis with regards to infection?

- Blood, urine, stool cultures | - Joint fluid analysis

Is there normally bacteria in the joint in reactive arthritis?

What is treatment aimed at in reactive arthritis?

The underlying infectious cause and symptomatic relief

How many cases of reactive arthritis resolve spontaneously?

90% of cases within 6 months

What medical treatments are used for reactive arthritis?

- NSAIDs - Corticosteroids - Antibiotics if still infected

When are DMARDs used in reactive arthritis?

In resistant or chronic cases

What is enteropathic arthritis associated with?

IBD

Enteropathic arthritis patients present with arthritis where?

Peripheral joints (knees, ankles, elbows, wrists) and sometimes spine

When will symptoms of enteropathic arthritis worsen?

During flare ups of IBD

What % of IBD patients will experience spine/joint problems?

10-20%

What are some clinical features of enteropathic arthritis?

- GI features - Weight loss, fever - Eye involvement - Skin involvement - Enthesitis

What is the name of the skin condition associated with IBD and enteropathic arthritis?

Pyoderma gangrenosum

How do you treat enteropathic arthritis?

- Treat IBD - Analgesia - Steroids - DMARDs - Biologics (anti-TNF)

What medication should you not give in enteropathic arthritis and why?

NSAIDs- may exacerbate IBD