Seronegative Spondylarthropathies Flashcards
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?
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.
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
- 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
Extra-articular features of AS - 5A’s
Apical lung fibrosis Anterior uveitis Achillles tendonitis Aortic regurgitation Amyloidosis
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?
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
Mx of AS
- conservative?
medical: - 1st line
- what are conditions for DMARDs?
- if severe + tried 2x trials of NSAIDs?
- 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)
What is BASDAI - bath ankylosing spondylitis disease activity index?
what score means sub-optimal control of AS?
measures disease activity by asking 6 questions
> 4
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?
- 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
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??
- 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
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?
- 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
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?
- 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
Causes of Reactive Arthritis
- GUI infection?
- GI infection?
GUI = chlamydia
GI = shigella, salmonella, camplyobacter
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
exercise regime + NSAIDs
The anti-TNF drugs are currently only used for patients with severe ankylosing spondylitis which has failed to respond to NSAIDs.
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
pain at night
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
schobers test of 4 cm
Schober’s test <5cm is suggestive of ankylosing spondylitis. This is an indication of reduced lumbar flexion.
AS
what special test can you do at bedside for diagnosis?
what score indicates AS
Schober’s test
<5cm = indication of reduced lumbar flexion.
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
reduced lateral flexion of lumbar spine
Reduced lateral flexion of the lumbar spine is one of the earliest signs of ankylosing spondylitis
what is one of the earliest signs of ankylosing spondylitis?
Reduced lateral flexion of the lumbar spine
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
naproxen
NSAIDs are the first-line drug treatment in an ankylosing spondylitis. Regular exercise is also very important
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
Achilles tendonitis is an association
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
apical fibrosis
Which of the following is least likely to be associated with ankylosing spondylitis?
apical fibrosis achilles tendonitis amyloidosis achalasia heart block
achlasia
Ankylosing spondylitis features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis
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
ibuprofen
Acute reactive arthritis can be treated with NSAIDs, as long as there are no contraindications
Need to differentiate septic from reactive arthritis - therefore when you aspirate synovial fluid - what colour will septic fluid be?
The turbid-grey-coloured joint aspirates with organisms detected on culture indicate a septic joint
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
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.
