Seronegative Spondyloarthritis

Question 1

Name some common features of all seronegative spondarthritidies?

Answer 1

• Affect spine and proximal large joints
• HLA-B27 +ve, Rh and CCP -ve
• Class I HLA type
• Often FH

Question 2

What are the extrarticular features which may be seen in seronegative spondlyoartropathies?

Answer 2

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)

Question 3

Which conditions are included in the seronegative spondyloarthropathies?

Answer 3

Ankylosing Spondilitis

Reactive Arthiritis

Psoriatic Arthiritis

Enteropathic Arthiritis (IBD associated)

Question 4

What is the classical first presentation of ankylosing spondylitis?

Answer 4

• 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.

Question 5

How may a patient with chronic Ankylosing Spondylitis present?

Answer 5

• 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)

Question 6

What are the vertebral complications of Ankyloing Spondilitis?

Answer 6

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)

Question 7

Describe the X ray changes in Psoriatic arthritis?

Answer 7

Xray

• Causes erosions (similar to RA) without periarticular osteopenia.
• Eroisions are more central than RA and give ‘pencil in a cup’ appearence

Question 8

Describe the classical features of reactive arthirtis?

Answer 8

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

Question 9

How should the seronegative spondyloarthropathies be managed?

Answer 9

• 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

Question 10

What is the significance of HLA-B27?

Answer 10

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,

Question 11

Which features are common and which feature differ in psoriatic vs rheumatoid arthiritis?

Answer 11

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.

Question 12

Answer 12

Keratoderma Blemorrhagica (histologically the same as psoriasis)

Question 13

Answer 13

Enthesopathy of the achiles tendon

Question 14

Answer 14

Iritis

Notice the iris bombe

Question 15

Answer 15

Dactylitis

Can occur in both RA and psoriatic arthiritis

Question 16

Answer 16

Conjunctivitis

May be associated with reactive arthiritis

Question 17

Answer 17

Bamboo Spine seen in Ank Spond

Question 18

Answer 18

Assymmetrical polyarthiritis with nail changes (most likely psoriatic arthiritis)

Question 19

Answer 19

Sacroilitis

Question 20

Answer 20

Monoarthiritis of the knee

Question 21

Answer 21

Nail pitting

Question 22

Answer 22

Left: Squaring of the vertebrae

Right: Symdesmophytes

Question 23

Answer 23

Erosions of the distal interphalangeal joint without periarticular osteopenia.

AKA psoriatic arthiritis xray findings

Question 24

What are the extra-articular manifestations of anylosing spondylitis

Answer 24

Pulmonary APICAL fibrosis
Amyloidosis
Neurological signs (cauda equina)
Iritis
CV (valve disease)

Question 25

Describe the Xray changed assocoated with Anylosing Spondylitis?

Answer 25

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

Question 26

Describe the different types of psoriatic arthritis?

Answer 26

• Symmetrical polyarthritis (both hands)
• Spondylitis (Hips, uniliteral)
• Asymmetrical oligoarticular arthritis (hand, foot)
• DIPJ (sausage fingers)
• Arthritis mutilads (severe form, telescoping of the didgits)

Answer 27

Extrarticular:

Psoriasis plaques

Dactylitis (sausage digits)

Nail changes (oncholysis/nail pitting)

Question 28

How will IBD related arthropthy present?

Answer 28

Usually symmetrical arthritis affecting lower limbs

Remission of UC causes remission of joint disease however in Crohns arthritis may persist despite remission