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Medicine Phase 2a MSK and Rheumatology > Seronegative spondyloarthropathies > Flashcards

Seronegative spondyloarthropathies Flashcards

1
Q

Examples

A

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
(Enteropathic arthritis e.g. Crohns UC)

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2
Q

What is ankylosing spondylitis

A

Inflammatory arthritis of the spine and ribcage (eventually leading to new bone formation and fusion of the joints - bamboo spine)

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3
Q

5 main traits of all seronegative spondyloarthropathies

A 
Predilection for axial inflammation
Asymmetrical peripheral arthritis
Absence of rheumatoid factor
Inflammation of the enthesis 
Strong association with HLA-B27
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4
Q

Pathophysiology of ankylosing spondylitis

A

Syndesmophytes form following inflammation and ankylosis therefore occurs.
This leads to the fusion of the vertebrae.
The cause of the inflammation is not known, but thought to involve CD8 T cells.

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5
Q

Clinical presentation of ankylosing spondylitis

A 
Typically starts in late teenage years/20s 
Increasing pain and prolonged morning stiffness in the lower back (*inflammatory back pain) and buttocks. 
Improves with exercise. 
Progressive loss of spinal movement. 
Characteristic abnormalities: 
-Loss of lumbar lordosis
-increased kyphosis
-Limitation of lumbar spine mobility
*ALSO:
Asymmetrical (large joint) arthritis
Skin Psoriasis
IBD
Inflammatory eye disease
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6
Q

Aetiology of ankylosing spondylitis

A

Unknown - strong genetic association

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7
Q

Epidemiology of ankylosing spondylitis

A

Usually young males

More common and severe in males

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8
Q

Diagnostic tests of ankylosing spondylitis

A

X-ray - normal or shows erosion and sclerosis of the margins of the sacroiliac joints -> ankylosis
‘Bamboo spine’ from rehealing of enthesitis

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9
Q

Treatments of ankylosing spondylitis

A

NSAIDs, TNF-alpha inhibitors (infliximab)

Surgery - can correct spinal deformities to repair damage (possible hip/shoulder replacement)

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10
Q

Complications of ankylosing spondylitis

A

Small chance of spinal fusion -> severe kyphosis

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11
Q

What is Psoriatic arthrtis

A

Inflammatory arthritis associated with psoriasis (skin condition that causes red, flaky, crusty patches of skin covered with silvery scales)

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12
Q

Clinical presentation of psoriasis arthritis

A

Ranges from mild synovitis to severe progressive erosive arthropathy, usually preceded by the rash.
Skin disease can be as minor as an occult rash.
Nail changes are characteristic

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13
Q

Aetiology of psoriasis arthritis

A

Autoimmune mediated, with defined HLA associations (HLA-B27, -B17, -CW6, -DR4, -DR7)

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14
Q

Epidemiology of psoriasis arthritis

A

20% of patients with psoriasis

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15
Q

What is psoriasis

A

skin condition that causes red, flaky, crusty patches of skin covered with silvery scales

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16
Q

Diagnostic tests of psoriatic arthritis

A

X-ray - pencil in cup deformity

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17
Q

Treatment of psoriatic arthritis

A

Drugs: NSAIDs, DMARDs, TNF-alpha (infliximab)

Surgical - cant correct deformed joints

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18
Q

Complications of psoriatic arthritis

A

Joint destruction

Psycho-social damage

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19
Q

What kind of infection is followed by reactive arthritis usually

A

GI or GU infection

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20
Q

Types of reactive arthritis

A

Post-enteric

Post-venereal

21
Q

Pathophysiology of reactive arthritis

A

Persistent bacterial antigen in the inflamed synovial of affected joints is thought to drive the inflammation

22
Q

Clinical presentation of reactive arthritis

A

*Arthritis typically 2 days to 2 weeks post infection (Acute onset)
Malaise, fatigue, fever
Low back pain common
Asymmetrical, oligo/monoarthritis (no more than 6 joints -> large joints)
*Conjunctivitis, Urethritis, Arthritis (enthesitis/ dactylitis/ sacroiliitis) - can’t see, can’t pee, can’t climb a tree - classical triad
*Psoriatic like skin lesions (keratoderma)

23
Q

Aetiology of Post-enteric reactive arthritis

A

Usually infection by Campylobacter, Salmonella and Shigella

24
Q

Aetiology of Post-veneral reactive arthritis

A

usually infection by Chlamydia, Trachomatis or HIV

25
Q

Epidemiology of reactive arthritis

A

Typically affects young males

26
Q

Diagnostic tests of reactive arthritis

A

Serum antibodies
Diagnosis based on clinical features.
(Once arthritis discovered cultures show negative)
May test for Chlamydia infection (urine sample or genital swab) or test for the HLA-B27 gene
Raised ESR/CRP
Aspirate joint to exclude infection/crystals
Urethral swab, stool culture

27
Q

Treatment of reactive arthritis (similar to enteropathic arthritis)

A 
Aspirate synovial effusions
Physiotherapy
NSAIDs
Corticosteroids
Antibiotics or causative organism
28
Q

Complications of reactive arthritis

A

Minority may develop destructive enthesitis or spondylitis

High recurrence by new infection or stress

29
Q

**What is HLA B27

A

Human Leucocyte Antigen B27
Class I surface antigen (all cells, except red blood cells)
Patients are either HLA B27 +ve or -ve

Encoded by Major Histocompatibility Complex (MHC) on chromosome 6
Antigen presenting cell

30
Q

**Why is HLA B27 linked with disease (3 main theories)

A

Mis-folding theory
HLA B27 heavy chain homodimer hypothesis
“Molecular mimicry” (AI response against HLA B27 could be triggered)

31
Q

What is meant by molecular mimicry with HLA B27 disease

A

Infection
> Immune response
> Infectious agent has peptides very similar to HLA B27 molecule
> Auto-immune response triggered against HLA B27

32
Q

What is the HLA B27 heavy chain homodimer hypothesis

A

Suggests that B27 heavy chains can form stable dimers, which tend to dimerize and accumulate in the endoplasmic reticulum. In turn, this initiates the proinflammatory ERUPR.
In addition, these heavy chains and dimers can bind to other regulatory immune receptors such as the natural killer receptors (NKRs).
This causes the expression and survival of more proinflammatory leukocytes and subsequent production of proinflammatory mediators.

33
Q

What is the HLA B27 misfolding theory

A

Unfolded HLA-B27 proteins accumulate in the endoplasmic reticulum (ER).
A proinflammatory stress response called the endoplasmic reticulum unfolded protein response (ERUPR) ensues.
As a result, interleukin 23 (IL-23) is released, activating a proinflammatory response via interleukin-17+ T lymphocytes.

34
Q

What would be worst prognosis scenario in ankylosing spondylitis

A 
Male
Smoker
B27 +ve
Syndesmophytes at presentation 
High CRP
35
Q

Presentation of scaroiliitis (on X-RAY and other imaging)

A

X-ray:
Sclerosis; Erosions; Loss of joint space; Fusion
On general imaging:
Active (acute) inflammation on MRI highly suggestive of sacroiliitis with SpA
Definite radiographic sacroiliitis according to mod NY criteria

36
Q

Classifaction criteria of Ankylosing/Axial spondylitis

A

At least 3 months of back pain and age onset <45 years:
Saroiliitis on imaging plus at least 1 SpA (spondyloarthritis) feature
HLA-B27 plus at least 2 other SpA features

37
Q

SpA (spondyloarthritis) features

A 
Inflammatory back pain
Arthritis
Enthesitis (heel)
Uveitis (inflamed uvea in eye)
Dactylitis (entire finger/digit inflamed)
Psoriasis
Crohns/colitis
good response to NSAIDs
SpA Family Hx
HLA-B27
elevated CRP
38
Q

What is enthesis and thus enthesitis

A

Enthesis is connective tissue between ligament/tendon and bone
Inflammation of this

39
Q

Treatment of spondyloarthritis

A

Originally long term NSAIDs (but side effects)
Physio can be used in combination
TNFi (NICE approved)

40
Q

Side effects of NSAIDs

A

Gastric ulcer
Vascular disease
Renal damage

41
Q

Management of psoriasis arthritis

A

(similar to RA)
Early intervention with DMARDs
-MTX, leflunomide, ciclosporin, sulfasalazine
-DMARDs often help skin disease

Anti TNF drugs (Etanercept, adalimumab, golimumab, certolizumab, infliximab)

IL12/23 blockers (ustekinumab)

42
Q

Example of DMARD

A

MTX (Methotrexate)

leflunomide

43
Q

Example of anti TNF drug

A

Etanercept

44
Q

Example IL12/23 blocker

A

Ustekinumab

45
Q

Psoriatic like skin lesions in Reactive Arthritis

A

Keratoderma

Circinate Balanitis

46
Q

Differential diagnosis of reactive arthritis

A

Hot swollen joint

exclude septic arthritis and gout

47
Q

What is enteropathic arthritis

A

a chronic, inflammatory arthritis associated with the occurrence of an inflammatory bowel disease (IBD)

48
Q

Clinical presentation and differential diagnosis of enteropathic arthritis

A

Asymmetric lower limb arthritis

20% of patients with IBD show episodic peripheral synovitis

49
Q

SpA features: what does SPINEACHE stand for

A 
Sausage digit
Psoriasis / Positive family Hx of SpA
Inflammatory back pain
NSAID good response
Enthesitis (heel)
Arthritis
Crohn's/Colitis disease-elevated CRP
HLA-B27
Eye (uveitis)

Medicine Phase 2a MSK and Rheumatology (18 decks)

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