Seronegative Spondyloarthritis Flashcards
Name some common features of all seronegative spondarthritidies?
- Affect spine and proximal large joints
- HLA-B27 +ve, Rh and CCP -ve
- Class I HLA type
- Often FH
What are the extrarticular features which may be seen in seronegative spondlyoartropathies?
Eyes: Uveitis
Skin: Psoriasis/keratoderma blemorhagica/erythema nodosum/pyoderma gangrenosum
Other:
- Balantis
- Sacroilitis
- Dactylitis
Rare complications:
- Pulmonary fibrosis (apical)
- Cardiac involvement (aortic root fibrosis, conduction defects)
Which conditions are included in the seronegative spondyloarthropathies?
Ankylosing Spondilitis
Reactive Arthiritis
Psoriatic Arthiritis
Enteropathic Arthiritis (IBD associated)
What is the classical first presentation of ankylosing spondylitis?
- Young adult male.
- Sacroilitis + buttock pain/ back pain and stiffness
- Worse in the morning relieved by exercise
- 1/3 of patients suffer from iritis and may present with this.
How may a patient with chronic Ankylosing Spondylitis present?
- Syndephmosites = ossifications of the vertebral ligaments.
- Thoracic kyphosis, lumbar lordosis.
- Most patients will also suffer from a peripheral arthiritis and enthesopathies.
On examination:
- Tender SIJs
- Limited lateral and forward flexion of the lumbar spine (Shobers test)
- Other joins may be involved (including chostrochondral)
What are the vertebral complications of Ankyloing Spondilitis?
Fusion of the spine (therefore posture is very important)
Vertebral fractures
Spinal cord injury (one vertebrae may not have symdesmophytes and acts as a pivot causing spinal cord damage)
Describe the X ray changes in Psoriatic arthritis?
Xray
- Causes erosions (similar to RA) without periarticular osteopenia.
- Eroisions are more central than RA and give ‘pencil in a cup’ appearence
Describe the classical features of reactive arthirtis?
An assymetrical mono/oligo inflammatory arthiritis that occurs 4-40 days following a GI/STI/UTI infection.
Associated with:
- Conjunctivitis
- Balanitis
- Assymetrical sacroilitis
Symptoms last 4-6 months
15% become chronic
25% get repeaded infections
How should the seronegative spondyloarthropathies be managed?
- Multidisciplinary team (Physio particularly with posturing in Ank spond)
- Symptomatic treatment NSAIDs
- Corticosteroid injections if one joint
- Disease modifying therapy
- Methotrexate doesn’t work for AS
- Sulfsalazine used for reactive arthritis
•Ant-TNF Therapy (often very effective)
- etanercept for AS
What is the significance of HLA-B27?
It is a sensitive test but very unspecific.
Aka 90% of those with Ank Spond will be HLA-B27 positive but many without Ank Spond will also be positive,
Which features are common and which feature differ in psoriatic vs rheumatoid arthiritis?
Different distribution of joints affected:
- RA affects PIP.
- Psoriatic affects DIP.
Both cause eroisions but:
- RA also causes periarticular osteopenia.
- Psoriatic does not.
Extraarticular features
- Skin and nail changes are seen in psoriatic but not in rheumatoid.
- Both cause dactylitis.
Keratoderma Blemorrhagica (histologically the same as psoriasis)
Enthesopathy of the achiles tendon
Iritis
Notice the iris bombe
Dactylitis
Can occur in both RA and psoriatic arthiritis
Conjunctivitis
May be associated with reactive arthiritis
Bamboo Spine seen in Ank Spond
Assymmetrical polyarthiritis with nail changes (most likely psoriatic arthiritis)
Sacroilitis
Monoarthiritis of the knee
Nail pitting
Left: Squaring of the vertebrae
Right: Symdesmophytes
Erosions of the distal interphalangeal joint without periarticular osteopenia.
AKA psoriatic arthiritis xray findings
What are the extra-articular manifestations of anylosing spondylitis
Pulmonary APICAL fibrosis
Amyloidosis
Neurological signs (cauda equina)
Iritis
CV (valve disease)
Describe the Xray changed assocoated with Anylosing Spondylitis?
Pelvis XR:
- indistinct narrow joint line (moth eaten) which eventually fuses
Spinal XR:
- Squared vertebral bodies, ossification of ligaments can give a ‘bamboo spine’ appearence
Describe the different types of psoriatic arthritis?
- Symmetrical polyarthritis (both hands)
- Spondylitis (Hips, uniliteral)
- Asymmetrical oligoarticular arthritis (hand, foot)
- DIPJ (sausage fingers)
- Arthritis mutilads (severe form, telescoping of the didgits)
Extrarticular:
Psoriasis plaques
Dactylitis (sausage digits)
Nail changes (oncholysis/nail pitting)
How will IBD related arthropthy present?
Usually symmetrical arthritis affecting lower limbs
Remission of UC causes remission of joint disease however in Crohns arthritis may persist despite remission
