Seronegative Spondyloarthopathies

Question 1

What is the definition of a seronegative spondyloarthropathies?

Answer 1

inflammatory conditions of the spine and sacroiliac joints without the presence of RF

Question 2

what are the types of seronegative spondyloarthropathies?

Answer 2

Ankylosing spondylitis

Reactive arthritis

Psoriatic arthritis

IBD-related arthropathy

Question 3

what are some features more specific to seronegative spondyloarthropathies when compared to rheumatoid arthritis

Answer 3

dactylitis

Joint ankylosis - stiffening due to joint fusion

enthesitis

Question 4

how does ankylosing spondylitis present

Answer 4

Episodes of pain/stiffness in lower back/buttocks worse in the morning, relieved by exercise

Otherwise asymptomatic

Pain in buttock may alternate between sides

May cause awakening from sleep in the second half of the night

Question 5

what do you find on examination with ankylosing spondylitis

Answer 5

lumbar lordosis with a ‘question mark’ posture

pain on pressure over SIJ

limited lateral and forward flexion of the lumbar spine

reduced shobers test (<5cm)

Question 6

what are some extra articular manifestations for ankylosing spondylitis

Answer 6

Anterior uveitis

Pulmonary fibrosis - Apical

AV node block

Aortitis - Leading to aortic regurgitation and fibrosis

Amyloidosis

Question 7

what investigations should be done in ankylosing spondylitis

Answer 7

ESR - normal in 50%

pelvic XR - bilateral sacroiliitis

Spinal XR - bamboo spine (ossification of annulus fibrosis), squaring of vertebral bodies,

Question 8

how do you manage ankylosing spondylitis

Answer 8

Full dose NSAID 6 weeks

Clinical effectiveness measured with DAS score

No improvement on 2 full does NSAIDs = biologics
e.g. Etanercept, Infliximab (not in US)

Question 9

what is the prognosis for ankylosing spondylosis

Answer 9

80% remain in long term employment with long term chronic generalised back stiffness

Question 10

what % of patients with psoriasis get psoriatic arthritis

Answer 10

8%

Question 11

what are the 5 subtypes of psoriatic arthritis

Answer 11

Symmetrical polyarthritis (40%)

Asymmetrical oligoarticular arthritis (30%)

DIPJ predominant disease (10%)

Spondylisis

Arthritis mutilans (5%)

Question 12

what are features of psoriatic symmetrical polyarthritis

Answer 12

Similar to RA

DIPJ involvement instead

Less severe deformity

Question 13

what are features of psoriatic asymmetrical oligoarticular arthritis

Answer 13

<5 joints

Often one large joint plus smaller hand/foot joints

Question 14

what are features of psoriatic DIPJ predominant disease

Answer 14

Typical, associated with psoriatic nail changes
Pitting
Subungal hyperkeratosis
Onicholysis

Rarely disabling

May cause dactylitis

Question 15

what are features of psoriatic spondylisis

Answer 15

Affecting spine

+/- SIJs as per AS

Question 16

what are features of arthritis mutilans

Answer 16

Severe form

Marked joint destruction

Marked deformity

Classically involving telescoping of the finger joints

Question 17

what are radiological signs of arthritis mutilans

Answer 17

Erosions, similar to RA but with comparatively little osteopenia

Erosions tend to be more central than RA leading to a ‘pencil in a cup’ appearance

Question 18

what joint involvement is specific to psoriatic arthritis

Answer 18

early DIPJ involvement

Question 19

how do you manage psoriatic arthritis

Answer 19

1 joint
Full dose NSAIDS +/- steroid injections

Multiple joints
Treat as per RA but prognosis is better
Methotrexate is useful as it helps skin psoriasis
DMARDS tend not to help spinal symptoms

Question 20

what is the usual history of a reactive arthritis

Answer 20

Acute asymmetrical lower limb arthritis 4-40 days following a bacterial infection, usually a GU or GI infection

Question 21

what common pathogens cause reactive arthritis

Answer 21

Chlamydia

Salmonella

Campylobacter

Question 22

how does reactive arthritis present

Answer 22

‘cant see can’t pee cant climb a tree’ - classic triad

conjunctivitis
dysuria
lower limb oligoarthritis

enthesitis also common 
skin lesions (Keratoderma blenorrhaggia - psoriasis-like plaques, Balantitis in the uncircumcised male) also common

Question 23

whats the management of reactive arthritis

Answer 23

Full dose NSAIDS +/- steroids

Sulfasalazine is second line for more extensive disease

Question 24

whats the prognosis of reactive arthritis

Answer 24

30-50% have chronic arthritis

Reactive arthritis lasts from anywhere from 3-12 months

Question 25

what % of patients with IBD get IBD-related arthropathy

Answer 25

10-15%

Question 26

how does IBD related arthropathy present

Answer 26

symmetrical arthritis affecting lower limb joints

5% have SIJ involvement

Question 27

how does IBD related arthropathy change with effective IBD treatment

Answer 27

UC = remission of disease leads to remission of joint disease

crohns = remission of gut disease does not lead to remission of joint disease

Question 28

how is IBD related arthopathy treated

Answer 28

MDT related

Discussion between rheumatologists and gastroenterologis

Question 29

what conditions have anterior uveitis as an extra articular feature

Answer 29

psoriatic arthritis

ankyosing spondylitis

Question 30

what are symptoms of anterior uveitis

Answer 30

Acute pain

Photophobia

Constricted pupil

Possibly irregular due to anterior/posterior synechiae

Circumcorneal redness

Treated with topical steroids and a dilating eye drop

Question 31

what causes more pain, episcleritis or scleritis

Answer 31

scleritis = extreme pain

episcleritis = tenderness

Question 32

what is the treatment for extra articular disease affecting the eye

Answer 32

anti-inflammatory eye drops