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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
What is Arthritis mutilans?
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
List 4 examination signs of psoriatic arthritis
1. Plaques of psoriasis on the skin 2. Pitting of the nails 3. Onycholysis (separation of nail from bed) 4. Dactylitis 5. Enthesitis
27
What is shown on the images below?
1 and 2 = typical psoriatic nail 3 = dactylitis
28
What classification is used for psoriatic arthritis Explain this
29
List 3 extra-articular manifestations of psoriatic arthritis?
1. Conjunctivitis and anterior uveitis 2. Aortitis 3. Amyloidosis
30
What is the the PEST tool?
Psoriasis Epidemiological Screening Tool For patients with psoriasis to screen for psoriatic arthritis - high score = referral to a rheumatologist
31
What is the classic X-ray change to the digits seen in psoriatic arthritis?
“pencil-in-cup appearance” Due to central erosions of the bone beside the joints
32
List 4 X-ray changes seen in Psoriatic arthritis
1. Periostitis thickened and irregular outline of the bone 2. Ankylosis 3. Osteolysis 4. Dactylitis 5. Pencil-in-cup appearance
33
Below is an x-ray of psoriatic arthritis in the hands, what is indicated by the arrows?
Periosteal reactions
34
Management of Psoriatic arthritis
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
What is reactive arthritis?
Synovitis in the joints as a reaction to a recent infective trigger
36
How does reactive arthritis present?
An acute monoarthritis, affecting a single joint in the lower limb (most often the knee) Presenting with a warm, swollen and painful joint
37
List the 2 most common infections that trigger reactive arthritis
1. Gastroenteritis 2. Chlamydia Gonorrhoea commonly causes a gonococcal septic arthritis
38
How soon after initial infection does reactive arthritis present?
1-4 weeks after infection
39
Classic triad of reactive arthritis?
Arthritis, urethritis, and conjunctivitis
40
List 2 ddx for reactive arthritis?
1. Septic arthritis 2. Gout and pseudogout
41
Investigations to rule out ddx for reactive arthritis
Aspirate joint and send for: 1. Gram staining, culture and sensitivity testing - excl septic arthritis 2. Crystal examination - excl gout and pseudogout
42
List 3 extra-articular manifestations of reactive arthritis
1. Bilateral conjunctivitis 2. Anterior uveitis 3. Circinate balanitis dermatitis of the head of the penis 4. Erythema nodosum
43
Management of reactive arthritis?
1. Antibiotics 2. NSAIDs 3. Steroid injections Recurrent cases may require DMARDs (Methotrexate) or anti-TNFs
44
What are Enteropathic arthritises?
Arthropathies associated with disease of large or small intestines: * Crohn’s disease, * Ulcerative colitis
45
Enteropathic arthritis is described as a migratory arthritis What does this mean?
When arthritis symptoms travel from one joint to another
46
State the following about Enteropathic arthritis * Lower/upper extremities * Errosive/non-errosive?
Lower extremities, non-erosive arthritis
47
List 3 rheumatological manifestations in Enteropathic (IBD associated) arthritis?
1. Enthesitis 2. Sacroiliitis 3. Erythema nodosum
48
How do we treat enteropathic arthritis?
DMARDs: SSZ, MTX, Infliximab

MSK block (30 decks)

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