Seronegative spondylarthropathy Flashcards
What are they?
Rheumatoid factor negative arthritis affecting the axial skeleton:
- Ank spond (axial spondylarthritis - AS)
- Reactive arthritis
- Psoriatic arthritis
- Enteropathic arthritis
What is the axial skeleton made up of?
the skull bones, the ossicles of the middle ear, the hyoid bone, the rib cage, sternum and the vertebral column.
What are the common features of the SPAs?
- Rh factor -ve
- HLA B27 associated
- Axial arthritis
- Asymmetrical large joint oligoarthritis (≥5) or monoarthritis
- Enthesitis
- Dactylitis
- Extra-articular manifestations
what is enthesitis? Give examples
inflammation at site of where tendon or ligament inserts into bone
e.g. plantar fasciitis, achilles tendonitis, costochondritis
What is dactylitis?
inflammation of entire digit due to soft tissue oedema + tendosynovial + joint inflammation
What are the signs nd sx of AS?
- Pain - gradual onset, lower, worse at night, can radiate to hips/buttocks
- Spinal morning stiffness relieved by exercise
- Progressive loss of spinal movement - reduced thoracic expansion
What are the extra articular features of AS?
A's: Anterior uveitis (iritis) Apical fibrosis Achilles tendonitis Aortic regurgitation
What can be found on examination in AS?
Reduced lateral + forward flexion (schobers)
Reduced chest expansion
who does AS tend to affect?
young men
What are the investigations for AS? what would you find?
Imaging:
- Spinal XR:
i. sacroiliac - joint space narrowing/widening, sclerosis, erosions, ankylosis/fusion
ii. Vertebral syndesmophytes
iii. Bamboo spine - CXR - apical fibrosis
- MRI - active inflammation, destructive changes (erosions, sclerosis, ankylosis)
- Bloods - FBC (normocytic), raised ESR, CRP
What are syndesmophytes?
bony proliferation due to enthesitis between ligaments and vertebrae, fuse w vertebral body above cause ankylosis
What is a bamboo spine/
calcification of ligaments w ankylosis ,result of the syndesmophytes
When does AS carry a worse prognosis?
ESR >30
Onset <16yrs
Early hip involvement
Poor response to NSAIDs
What is the conservative and pharmacological management of AS?What drugs are 1st line?
- exercise - intense exercise regimes
- 1st line NSAIDS
- TNF alpha blockers e.g. etanercept, adalimumab in severe active AS
- local steroid injections for temp relief
- bisphosphonates - increased risk of osteoporotic spinal fractures
What is the surgical management of AS and when is it indicated?
Hip replacement if increased pain and reduced mobility when hips are involved
What is enteropathic arthropathy associated w?
IBD
GI bypass
Coeliac
Whipples disease
What is the rx of enteropathic arthropathy?
treat bowel sx, usually improves arthropathy
beware NSAIDS
DMARDs for resistant cases
What % of pts w psoriasis does psoriatic arthritis occur?
10-40
Do psoriasis and arthritis have to occur together for it to be PS?
no
What are the different types of psoriatic athritis?
- Rheumatoid like - symmetrical
- DIP joints
- Asymmetrical oligoarthritis - typically hands and feet
- Spinal - like AS
- psoriatic arthritis mutilans
What are the associated features of psoriatic arthritis?
- nail dystrophy
- dactylitis
- acneiform rashes
- palmoplantar pustulosis
What radiological changes can be seen in PS
erosive changes - pencil in cup deformity if severe
What is the treatment of PS
NSAIDs
sulfasalazine
methotrexate
anti-tnfs
What is reactive arthritis?
arthritis that develops following an infection where the organism cannot be recovered from the joint.
How does reactive arthritis present/
Reiters syndrome: 1. urethritis 2. arthritis 3. conjunctiviits 'cant see pee or climb a tree' - circinate balanitis - painless penile ulcers secondary to chlamydia - keratoderma blenorrhagia - brown raised papule on soles and palms - iritis - mouth ulcers - enthesitis usually lower limbs
how long do sx generally last for in reactive arthritis? how soon after infection does it tend to develop[/
4-6months
4 weeks after inf
What are the causative organisms in reactive arthritis?
- post dysenteric - shigella flexneri, salmonella, campylobacter,
- post STI - chlamydia trachomitis
What tests would you do in RS?
- ESR + CRP
- Stool culture if diarrhoea
- Infectious serology
- Sexual health review
XR -enthesitis w periosteal reaction
What is the management of RS?
No specific cure
NSAIDs or local steroid inj
Splint affected joint
if >6m - sulphasalazine or methotrexate
