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MSK block > Seronegative spondyloarthropathies (R3) > Flashcards

Seronegative spondyloarthropathies (R3) Flashcards

1
Q

What are seronegative spondyloarthropathies?

A

Group of inflammatory joint disorders characterised by:

  1. Lack of RF (‘seronegative’)
  2. Axial skeleton involvement (sacroiliitis and spondylitis)
  3. HLA-B27 association
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2
Q

State the following about seronegative spondyloarthropathies:

  1. Familial/Hereditary
  2. Number of joints involved
  3. Symmetric/asymmetric
  4. Intra/Extra articular features? (incl examples)
A
  1. Familial aggregation
  2. Oligo-arthritis
  3. Asymmetrical
  4. Extra-articular features
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3
Q

List 4 Extra-articular manifestations of seronegative spondyloarthropathies

A
  1. uveitis
  2. pulmonary fibrosis (upper zone)
  3. amyloidosis
  4. aortic regurgitation
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4
Q

List 4 features of seronegative spondyloarthropathies

A
  1. Peripheral joint involvement- asymmetrical, lower extremities
  2. Uveitis
  3. Enthesitis: Inflamed insertion sites of tendons, eg. Achilles (image below)
  4. Dactylitis: Inflammation of tendons in fingers and toes
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5
Q

What 5 features define Inflammatory Back Pain in axial SpA

A
  • Back pain >3 months
  • Age<40
  • Insidious onset
  • Improvement with exercise, worse with rest
  • Pain at night
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6
Q

What 6 conditions comprise seronegative spondyloarthropathies?

A
  1. Ankylosing spondylitis
  2. Reactive arthritis
  3. Enteropathic arthritis
  4. Psoriatic arthritis
  5. Behcet’s disease (different to above, a/w HLA-B51)
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7
Q

Compare and contrast 4 differences between the various spondyloarthropathies

A
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8
Q

Explain the ASAS classification for axial SpA

A
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9
Q

Below is an x-ray and MRI of axial SpA, List 4 features seen

A

Sacroiliitis ➞ erosions, subchondral oedema, sclerosis

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10
Q

Below is an x-ray and MRI of axial SpA, List 4 features seen

A

Spondylitis: square vertebral, syndesmophytes, Romanus lesion

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11
Q

What is ankylosing spondylitis?

A

Inflammatory arthritis involving the axial spine and sacroiliac joints with enthesitis

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12
Q

What age group and gender are most commonly affected by AS?

A

Typical presentation is a young adult male in their late teens or 20s

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13
Q

How does AS present?

A
  1. slow onset > 3 month history
  2. stiffness >30 mins in the morning
  3. lower back pain and sacroiliac pain in buttock region
  4. worse with rest, improves with movement
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14
Q

List 4 extra-articular manifestations of AS

(the ‘A’s)

A
  1. Anterior uveitis
  2. Aortitis (can lead to aortic regurgitation)
  3. Apical pulmonary fibrosis
  4. Achilles tendonitis
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15
Q

List 3 clinical examination tests for AS

Incl findings

A
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16
Q

Explain the Schober’s Test

A

Patient standing straight

Mark two points, 10cm above and 5cm below the L5 vertebrae (15cm between these)

Ask patient to bend forward maximally and measure distance between the points

< 20cm, indicates a restriction in lumbar movement → ankylosing spondylitis

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17
Q

List 4 investigations for AS

A
  1. Inflammatory markers (CRP and ESR)
  2. HLA B27
  3. Xray of the spine and sacrum
  4. MRI of the spine (bone marrow oedema in early disease)
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18
Q

What is the typical X-ray description of an AS spine?

A

“Bamboo spine”

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19
Q

List 4 X-ray findings seen in AS?

A
  1. Squaring of vertebral bodies
  2. Subchondral sclerosis and erosions
  3. Syndesmophytes
  4. Ossification of ligaments, discs and joints
  5. Fusion of the facet, sacroiliac and costovertebral joints
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20
Q

What is the BASDAI score for ankylosing spondylitis?

A

Bath AS Disease Activity Index ➞ form completed by patient

Gold standard for measuring and evaluating disease activity

21
Q

Medical management of AS?

A
  1. NSAIDs
  2. Steroids (during flares)
  3. Anti-TNFs ie. etanercept, Infliximab, adalimumab
  4. Secukinumab (monoclonal antibody against IL-17)
22
Q

Additional management of AS

A
  1. Physiotherapy
  2. Exercise and mobilisation
  3. Avoid smoking
  4. Bisphosphonates to treat osteoporosis
  5. Treatment of complications
  6. Surgery (occasionally required for deformities)
23
Q

What is Psoriatic arthritis?

A

Inflammatory arthritis affecting joints and CT causing pain, stiffness, swelling, and possible joint destruction

Associated with psoriasis of the skin or nails (30%)

24
Q

List the 5 sub-types of affected joints in Psoariatic arthritis

A
  1. Asymmetrical oligoarthritis
  2. Symmetrical polyarthritis
  3. Spondylitis
  4. DIP arthritis
  5. Arthritis mutilans
25
Q

What is Arthritis mutilans?

A

Most severe form of psoriatic arthritis

Osteolysis around the joints in the phalanxes. Leads to progressive shortening of the digit causing the skin to fold → “telescopic finger” appearance

26
Q

List 4 examination signs of psoriatic arthritis

A
  1. Plaques of psoriasis on the skin
  2. Pitting of the nails
  3. Onycholysis (separation of nail from bed)
  4. Dactylitis
  5. Enthesitis
27
Q

What is shown on the images below?

A

1 and 2 = typical psoriatic nail

3 = dactylitis

28
Q

What classification is used for psoriatic arthritis

Explain this

A
29
Q

List 3 extra-articular manifestations of psoriatic arthritis?

A
  1. Conjunctivitis and anterior uveitis
  2. Aortitis
  3. Amyloidosis
30
Q

What is the the PEST tool?

A

Psoriasis Epidemiological Screening Tool

For patients with psoriasis to screen for psoriatic arthritis - high score = referral to a rheumatologist

31
Q

What is the classic X-ray change to the digits seen in psoriatic arthritis?

A

“pencil-in-cup appearance”

Due to central erosions of the bone beside the joints

32
Q

List 4 X-ray changes seen in Psoriatic arthritis

A
  1. Periostitis thickened and irregular outline of the bone
  2. Ankylosis
  3. Osteolysis
  4. Dactylitis
  5. Pencil-in-cup appearance
33
Q

Below is an x-ray of psoriatic arthritis in the hands, what is indicated by the arrows?

A

Periosteal reactions

34
Q

Management of Psoriatic arthritis

A
  1. NSAIDs
  2. DMARDS ie. methotrexate, leflunomide, sulfasalazine
  3. Anti-TNFs ie. etanercept, infliximab or adalimumab
  4. Ustekinumab (last line) monoclonal antibody against IL 12 and 23
35
Q

What is reactive arthritis?

A

Synovitis in the joints as a reaction to a recent infective trigger

36
Q

How does reactive arthritis present?

A

An acute monoarthritis, affecting a single joint in the lower limb (most often the knee)

Presenting with a warm, swollen and painful joint

37
Q

List the 2 most common infections that trigger reactive arthritis

A
  1. Gastroenteritis
  2. Chlamydia

Gonorrhoea commonly causes a gonococcal septic arthritis

38
Q

How soon after initial infection does reactive arthritis present?

A

1-4 weeks after infection

39
Q

Classic triad of reactive arthritis?

A

Arthritis, urethritis, and conjunctivitis

40
Q

List 2 ddx for reactive arthritis?

A
  1. Septic arthritis
  2. Gout and pseudogout
41
Q

Investigations to rule out ddx for reactive arthritis

A

Aspirate joint and send for:

  1. Gram staining, culture and sensitivity testing - excl septic arthritis
  2. Crystal examination - excl gout and pseudogout
42
Q

List 3 extra-articular manifestations of reactive arthritis

A
  1. Bilateral conjunctivitis
  2. Anterior uveitis
  3. Circinate balanitis dermatitis of the head of the penis
  4. Erythema nodosum
43
Q

Management of reactive arthritis?

A
  1. Antibiotics
  2. NSAIDs
  3. Steroid injections

Recurrent cases may require DMARDs (Methotrexate) or anti-TNFs

44
Q

What are Enteropathic arthritises?

A

Arthropathies associated with disease of large or small intestines:

  • Crohn’s disease,
  • Ulcerative colitis
45
Q

Enteropathic arthritis is described as a migratory arthritis

What does this mean?

A

When arthritis symptoms travel from one joint to another

46
Q

State the following about Enteropathic arthritis

  • Lower/upper extremities
  • Errosive/non-errosive?
A

Lower extremities, non-erosive arthritis

47
Q

List 3 rheumatological manifestations in Enteropathic (IBD associated) arthritis?

A
  1. Enthesitis
  2. Sacroiliitis
  3. Erythema nodosum
48
Q

How do we treat enteropathic arthritis?

A

DMARDs: SSZ, MTX, Infliximab

MSK block (30 decks)

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