Seronegative Spondylarthropathies Flashcards

1
Q

what are the Seronegative Spondyloarthropathies

P
E
A
R

what do they all have in common in terms of:

  • Rhf?
  • which gene association?
  • asymmetrical?
  • all involve axial arthritis?
  • extra-articular manifestations?
  • also all have enthesitis and dactylitis - what are they
  • what is dactylitis most strongly associated with?
A

psoriatic
enteropathic
AS
Reactive

  • Rhf -ve
  • HLA B27 gene association
  • all asymmetrical large joint oligoarthritis
  • all have axial arthritis (spine + sacroiliac joints)
  • Psoriasis
  • iritis (anterior uveitis)
  • Inflammatory Bowel Disease (UC/Crohns).
  • Enthesitis – inflammation of site of insertion of tendon/ligament into bone. (i.e. plantar fasciitis, Achilles tendonitis).
  • Dactylitis – sausage finger or toe. Mainly PsA.
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2
Q

Ankylosing Spondylitis

  • most common seronegative spondylarthropathy?
  • what % have a HLA-B27 association?
  • what is it?
    • typical patient ?
  • where is pain/when is worst/how is it improved?
  • where does pain radiate to?
  • where do you get kyphosis and loss of lordosis
A
  • YES
  • 90%
    • Chronic inflam disease of spine and sacroiliac joints.
    • typical patient is a man <30yrs old,
  • with gradual onset of lower back pain, worse at night with morning stiffness relieved by exercise and improves at end of day.
  • pain radiates to buttocks and hips.

questionmark posture (late presentation) – thoracic hyperkyphosis. and loss of lumbar lordosis

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3
Q

Extra-articular features of AS - 5A’s

A
Apical lung fibrosis 
Anterior uveitis 
Achillles tendonitis 
Aortic regurgitation 
Amyloidosis
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4
Q

Ix for AS

  • most useful ix?
  • more sensitive in early stage of disease?
  • what do you see on Xray?
  • what do you see on cxr?
A

Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis.

MRI

  • Sacroilitis is the earliest clinical feature on X-ray,
    ‘bamboo spine’ (late & uncommon)
    dagger spine - interspinous ligament ossification
  • apical lung fibrosis
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5
Q

Mx of AS

  • conservative?
    medical:
  • 1st line
  • what are conditions for DMARDs?
  • if severe + tried 2x trials of NSAIDs?
A
    • Exercise, not rest, with intense exercise regimes to maintain posture and mobility –with physiotherapist.
  • Quit smoking
  • NSAIDs like naproxen or ibuprofen = 1st line
  • DMARDs are not used unless there is peripheral arthritis involvement.
  • if severe - and tried 2x NSAIDs (for 3 months) consider anti-TNF
    (etanercept or adalimumab)
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6
Q

What is BASDAI - bath ankylosing spondylitis disease activity index?

what score means sub-optimal control of AS?

A

measures disease activity by asking 6 questions

> 4

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7
Q

Enteropathic Arthritis

  • what is it?
  • occurs in what % of UC or crohns patients?
  • affects which joints?
  • what will you see on Xray?
  • Mx of Enteropathic arthritis?
A
  • Inflammatory arthropathy occurring in setting of IBD (Crohn’s and UC).
  • mainly lower limbs
  • lead pipe sign of UC and ANKYLOSIS of sacroiliac junction

Mx:

  • treat IBD
  • NSAIDs or intra-articular steroid injections
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8
Q

Psoriatic Arthritis

  • occurs in what % of people with psoriasis?
  • where does it commonly affect?
  • what characteristic features are there?
  • what do you see on Xray?
  • how is it treated?
  • what combination is known to be particularly effective in PsA?
  • what drug can precipitate an exacerbation??
A
  • 10-20%
  • presents like RA in hands and feet but can differentiate as it is Rhf -ve and no nodules
  • oncholysis (nail pitting)
  • dactylitis
  • psoriatic plaques
  • marginal erosions
  • ‘pencil in cup deformity’
  • same as RA (NSAID -> DMARD -> steroid injections -> anti-TNF)
  • MTX + ciclosporin
  • oral steroids -so use corticosteroids as adjunctive therapy
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9
Q

Reactive arthritis

  • what is it?
  • encompasses Reiter’s syndrome - what is it? also known as what catchy phrase?
  • characteristic features?
  • how strong is HLA-B27 association?
  • how does it present?
  • what do you need to rule out?
A
  • arthritis caused by infective trigger
  • triad of urethritis, conjunctivitis, arthritis
  • cant see, pee or climb up a tree
  • keratoderma blennorhagica (black dots on feet)
  • circinate balanitis (painless penile ulceration)
  • 60-80%
  • red, hot, swollen joint
  • septic arthritis
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10
Q

Mx of Reactive Arthritis

treat infection if applicable then:

  • 1st line?
  • if unresponsive?
  • if symptoms last longer than 6 months?
  • if more aggressive and evolving towards AS?
A
  • Require treatment of underlying infection with antibiotics.
  • Joint symptoms can be treated with conventional analgesia and NSAIDs.
  • intra-articular steroid injections or oral sterods if unresponsive
  • Consider methotrexate or sulfasalazine if symptoms are greater than 6 months.
  • Anti-TNF
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11
Q

Causes of Reactive Arthritis

  • GUI infection?
  • GI infection?
A

GUI = chlamydia

GI = shigella, salmonella, camplyobacter

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12
Q

A 28-year-old man is diagnosed with having ankylosing spondylitis. He presented with a six month history of back pain. On examination there is reduced lateral flexion of the spine but no evidence of any other complications. Which one of the following is he most likely to offered as first-line treatment?

exercise regime + NSAIDs
exercise regime + infliximab 
exercise regime + paracetamol 
physiotherapy + etanercept
physiotherapy + sulfasalazine
A

exercise regime + NSAIDs

The anti-TNF drugs are currently only used for patients with severe ankylosing spondylitis which has failed to respond to NSAIDs.

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13
Q

A 25-year-old man presents with back pain. Which one of the following may suggest a diagnosis of ankylosing spondylitis?

rapid onset 
gets worse following exercise
bone tenderness
pain at night 
improves with rest
A

pain at night

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14
Q

A 16-year-old male presents with lower back pain of 5 months duration, worse at night, with morning stiffness. He finds the pain improved with exercise. There is no history of trauma. He is given a clinical diagnosis of ankylosing spondylitis. Which of the following findings on examination would be most associated with this diagnosis?

cervical kyphosis
development of scoliosis
schobers test of 4 cm
osteomyelitis

A

schobers test of 4 cm

Schober’s test <5cm is suggestive of ankylosing spondylitis. This is an indication of reduced lumbar flexion.

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15
Q

AS

what special test can you do at bedside for diagnosis?

what score indicates AS

A

Schober’s test

<5cm = indication of reduced lumbar flexion.

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16
Q

A 24-year-old man is investigated for chronic back pain. Which one of the following would most suggest a diagnosis of ankylosing spondylitis?

reduced lateral flexion of lumbar spine 
pain gets worse during the day 
pain on straight leg raising 
loss of thoracic kyphosis 
accentuated lumbar lordosis
A

reduced lateral flexion of lumbar spine

Reduced lateral flexion of the lumbar spine is one of the earliest signs of ankylosing spondylitis

17
Q

what is one of the earliest signs of ankylosing spondylitis?

A

Reduced lateral flexion of the lumbar spine

18
Q

A 36-year-old man presents with progressive lower back pain for the past six months. The pain is worse in the mornings and tends to ease with exercise and the passage of the day. He has tried paracetamol but this does not fully controlled his pain.

What is the most appropriate first-line treatment

MTX
Vit D
naproxen
infliximab

A

naproxen

NSAIDs are the first-line drug treatment in an ankylosing spondylitis. Regular exercise is also very important

19
Q

Which one of the following statements regarding ankylosing spondylitis is correct?

schober’s test assess chest expansion

HLA-B27 association is +ve in 50% of patients

M=F

Achilles tendonitis is an association

A

Achilles tendonitis is an association

20
Q

Stephen is a 57-year-old man who has late ankylosing spondylitis. What pulmonary feature might you see on his chest radiograph?

apical fibrosis
basal fibrosis
peripheral granulomas
bilateral hilar lymphadenopathy

A

apical fibrosis

21
Q

Which of the following is least likely to be associated with ankylosing spondylitis?

apical fibrosis 
achilles tendonitis 
amyloidosis 
achalasia 
heart block
A

achlasia

Ankylosing spondylitis features - the 'A's 
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
22
Q

A 23-year-old man comes to see his GP complaining of a sore knee for 1 week. On further questioning, he mentions that he has also had pain on urination and itchy, sore eyes. He has no past medical history and other than a stomach bug 2 weeks ago he is otherwise fit and well. Which of the following is the best treatment option for this man?

ibuprofen 
MTX
sulfasalazine 
6 months of oral prednisolone 
5 days of oral prednisolone
A

ibuprofen

Acute reactive arthritis can be treated with NSAIDs, as long as there are no contraindications

23
Q

Need to differentiate septic from reactive arthritis - therefore when you aspirate synovial fluid - what colour will septic fluid be?

A

The turbid-grey-coloured joint aspirates with organisms detected on culture indicate a septic joint

24
Q

Question 3 of 6
A 25-year-old woman presents with a swollen first finger and wrist pain associated with a 4 month history of generalised fatigue. She has no other symptoms including no skin changes, and no previous medical history. Her mother suffers from psoriasis. She had the following blood tests as part of her investigations.

Rheumatoid Factor Negative
Antinuclear Antibody Negative

What is the most likely diagnosis?

gout 
Rheumatoid arthritis 
SLE
PsA
OA
A

PsAWhilst SLE and rheumatoid arthritis can affect females of this age group, the most likely option is psoriatic arthritis as the patient has dactylitis and a first- degree relative with psoriasis.

25
Q

A 45-year-old lady presents with a 6 month history of pain in the joints of her right hand. On examination she has tenderness in the right distal interphalangeal joints. An X-ray shows erosions in the centre of the right distal interphalangeal joints, which are described as having a pencil in cup appearance.

What is the most likely diagnosis?

OA
Rheumatoid Arthritis 
SLE
PsA
Gout
A

PsA

Psoriatic arthropathy has many types. The one described in this case is the asymmetrical oligoarthritis type which typically affects hands and feet. Pencil-in-cup deformity is the description given to one of the appearances on plain radiograph in psoriatic arthritis. The appearance results from periarticular erosions and bone resorption giving the appearance of a pencil in a cup.

26
Q

A 25-year-old man presents with a painful, swollen left knee. He returned 4 weeks ago from a holiday in Spain. There is no history of trauma and he has had no knee problems previously. On examination he has a swollen, warm left knee with a full range of movement. His ankle joints are also painful to move but there is no swelling. On the soles of both feet you notice a waxy yellow rash. What is the most likely diagnosis?

Rheumatoid Arthritis 
PsA
Gout 
Reactive Arthritis 
Gonococcal Arthritis
A

Reactive Arthritis

The rash on the soles is keratoderma blenorrhagica. His reactive arthritis may be secondary to either gastrointestinal infection or Chlamydia.