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Musculoskeletal > Seronegative Spondyloarthropathies > Flashcards

Seronegative Spondyloarthropathies Flashcards

1
Q

What is Spondyloarthritis?

A

An umbrella term for a group of inflammatory disorders that involve the joints and the entheses

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2
Q

What does seronegative mean?

A

Negative for rheumatoid factor

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3
Q

Name some seronegative spondyloarthropathies.

A 
Ankylosing Spondylitis
Psoriatic arthritis
Reactive arthritis
Juvenile Idiopathic arthritis
Enteropathic arthritis
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4
Q

What are entheses?

A

The sites where ligaments and tendons attach to the bones

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5
Q

The seronegative spondyloarthropathies are associated with a particular tissue type. Which one?

A

HLA B27

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6
Q

What is HLA B27?

A

Human Leukocyte Antigen type B27

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7
Q 
HLA class I antigens are found on all cells of the human body?
True or false?
A

False, not on red blood cells

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8
Q

Do all people with HLA B27 get seronegative spondyloarthropathies?

A

No

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9
Q

Name the theories that explain why HLA B27 is linked with seronegative spondyloarthropathies?

A
  1. Molecular mimicry
  2. Misfolding
  3. Heavy Chain theory
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10
Q

What is the ‘molecular mimicry’ theory?

A

Infection with an agent with similar shaped antigens to B27 molecules

The body makes antigens against the pathogen’s antigens

But they attack the (very similar) B27 antigen

Immune system is attacking its own cells

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11
Q

What is the ‘misfolding’ theory?

A

Unfolded proteins get trapped in the endoplasmic reticulum of macrophages

This causes a response involving IL-23 and IL-17

These cause inflammation and damage to joints

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12
Q

What is the ‘heavy chain’ theory?

A

B27 chains tend to dimerise and accumulate in the ER

This initiates a response involving IL-23 and IL-17

These cause inflammation and damage to joints

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13
Q

What are the general features of the seronegative spondyloarthropathies?

A

HLA B27 association

Axial arthritis: axial skeleton

Asymmetrical large joint affecting a few or 1 joint

Enthesitis

Dactylitis

Extra-articular manifestations

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14
Q

What is meant by ‘axial arthritis’?

A

Affecting the axial skeleton:

  • spine
  • ribs
  • pelvis
  • sacroiliac joints
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15
Q

What is enthesitis?

A

Inflammation of the entheses (attachments of tendons + ligaments to bone)

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16
Q

What is dactylitis?

A

Inflammation of the entire digit

Featuring soft tissue oedema, tenosynovial + joint inflammation

Sausage digit

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17
Q

What is sausage digit?

A

A digit affected by dactylitis: oedema and swelling make the digit resemble a sausage shape

Painful

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18
Q

What are some extra-articular manifestations of the seronegative spondyloarthropathies?

A 
Anterior uveitis
Psoriaform rash
Oral ulcers
Aortic valve incompetencies
IBD
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19
Q

What is a good mnemonic to remember the general features of the seronegative spondyloarthropathies?

A

SPINEACHE

S - sausage digit
P - psoriasis
I - inflammatory back pain
N- NSAIDs good response
E - enthesitis
A - arthritis
C - crohn’s / colitis (or family history of it) / raised CRP
H - HLA B27
E - eye (uveitis)
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20
Q

What is anterior uveitis?

A

Inflammation of the uvea

Uvea = middle part of the eye that consists of the iris, ciliary body and choroid

21
Q

What is ankylosing spondylitis?

A

Chronic inflammation of the spine + sacro-iliac joints

22
Q

Who is affected with ankylosing spondylitis?

A

Young adults, peak onset 20-30 years

Men more than women

90% of patients are HLA B27

23
Q

Clinical features of ankylosing spondylitis?

A

Gradual onset of low back pain

Pain worse at night

Spinal morning stiffness relived by exercise

Pain in sacroiliac joints radiates to hips + buttocks

In time, rigid spine - bone has fused together after years of inflammation

If severe: stooped posture, neck hyperextension

Anterior uveitis

Asymmetric peripheral arthritis

Osteoporosis

24
Q

What are the symptoms + signs of anterior uveitis?

A 
Painful red eye
Irregular pupil
White cells floating in vitreous fluid
Photophobia
Cloudy vision
25
Q

What is the pathogenesis of ankylosing spondylitis?

A

Inflammation caused by auto-immune response against body cells

Bone marrow oedema in anterior corners of the vertebrae

Excessive + erosive repair process is triggered by the inflammation

Syndesmophytes (bony growths)form, they grow and ultimately fuse together

26
Q

What are syndesmophytes?

A

Small growths of bone on corners of bone
Like stalactites and stalagmites

The grow and ultimately fuse together

27
Q

Investigations of ankylosing spondylitis?

A

MRI: best choice of imaging

Imaging: look for fusion of spine, bamboo spine

Bloods:

  • raised ESR and CRP
  • are they HLA B27?
28
Q

Management of ankylosing spondylitis?

A

Exercise not rest!

  • physiotherapy
  • hydrotherapy

Anti-inflammatories, NSAIDs

Methotrexate not useful

Anti-TNF drugs are very effective

Surgery: replacement of fused hip joint

29
Q

Name some anti-TNF drugs?

A

Adalimumab

Golimumab

30
Q

Is methotrexate used in ankylosing spondylitis?

A

Patients don’t respond to methotrexate very well

31
Q

What is psoriatic arthritis?

A

Inflammatory arthritis linked with the autoimmune skin condition psoriasis

32
Q

How many patients with psoriasis get psoriatic arthritis?

A

About 20%

33
Q

What are the clinical features of psoriatic arthritis?

A

Symmetrical polyarthritis

Sacroiliac joints affected: unilateral or bilateral

Distal interphalangeal joints affected

Arthritis mutilans (telescoping)

Dactylitis

Spinal arthritis

Psoriasis rash
Nails are affected

34
Q

What is arthritis mutilans?

A

Bone completely loses its architecture and telescopes

Painless

35
Q

Which areas can a psoriasis rash be hiding?

A

Behind ears
Umbilical region
Vulval / penile

36
Q

What happens to the nails in psoriatic arthritis?

A

Pitting of nails (dimples)

Hyperkeratinitis: keratin build up, nails lift up

Creamy white lesions in corners of nails

37
Q

Investigation of psoriatic arthritis?

A

If they have psoriatic rash its likely to be psoriatic arthritis

If they have dactylitis, this is a classic sign of psoriatic arthritis

X-ray:

  • signs of erosion
  • pencil in cup deformity (erosion has caused the bone to become pointed)

http://i1.wp.com/boneandspine.com/wp-content/uploads/2008/03/pencil-in-cup-deformity-psoriatic-artthritis.jpg

38
Q

Management of psoriatic arthritis?

A

Physio, joint support

NSAIDs

DMARDs: methotrexate good for skin as well

Anti-TNF drugs

39
Q

What is reactive arthritis?

What is another name for it?

A

An autoimmune condition that develops in response to an infection in another part of the body

The arthritis and synovitis itself is sterile

Formerly known as Reiter’s disease

40
Q

Which infections trigger reactive arthritis?

A

Gut infections:
- salmonella, Shigella

GU infections:
- chlamydia

41
Q

How long does it take for reactive arthritis to develop after an infection?

A

Anytime between 2 days and 2 weeks post-infection

42
Q

What are the clinical features of reactive arthritis?

A

Can’t see: conjunctivitis

Can’t pee: urethritis

Can’t climb a tree: arthritis

43
Q

What skin lesions occur with reactive arthritis?

A

Keratoderma blenorrhagica

Lesions which resemble psoriasis lesions

44
Q

Investigations of reactive arthritis?

A

Blood:

  • ESR and CRP raised
  • serology shows evidence of recent infection

X-ray
- shows inflammatory effects on the bone

45
Q

Management of reactive arthritis?

A

Steroids to manage short term

If persistent DMARDs

46
Q

What is enteropathic arthritis?

A

Arthritis linked with IBD

47
Q

Clinical features of enteropathic arthritis?

A

Asymmetrical lower limb arthritis

Usually reflects IBD activity, so in a flare up of IBD you’ll get a flare up of arthritis

48
Q

Management of enteropathic arthritis?

A

DMARDs

Don’t give NSAIDs as they will set off IBD

Musculoskeletal (15 decks)

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