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Year 2 Clinical > Spondylarthropathies > Flashcards

Spondylarthropathies Flashcards

1
Q

Defing spondylarthropathies?

A

Family of inflammatory arthritides characterized by inv. of both the spine and joints, principally in genetically predisposed (HLA-B27 +ve) individuals

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2
Q

Types of spondylarthropathies?

A
  1. Ankylosing spondylitis
  2. Enterpathic arthritis
  3. Reactive arthritis (Reiter’s syndrome is part of this)
  4. Psoriatic arthritis
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3
Q

Usefulness of HLA-B27 screening?

A

Autosomal dominant inheritance but the background prevalence varies depending on location

It is not a useful screening/diagnostic test, unless the patient has symptoms as well

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4
Q

Compare the symptoms of mechanical and inflammatory back pain?

A

Mechanical:
• Worsened by activity and better with rest
• Typically worse at the end of the day

Inflammatory:
• Worsened by rest and better with activity
• Significant early morning stiffness (> 30 mins)

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5
Q

Rheumatological features that are shared by all spondylarthropathies?

A

Sacroiliac and spinal inv.

Enthesitis (inflammation at insertion of tendons into bones), e.g: Achilles tendonitis or plantar fasciitis

Inflammatory arthritides that are oligoarticular, asymmetric and mostly affect the lower limb

Dactylitis can occur (inflammation of entire digits) and results in “sausage fingers/toes”

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6
Q

Extra-articular features shared by the spondylarthropathies?

A
  • OCULAR INFLAMMATION (anterior uveitis, conjuntivitis)
  • Mucocutaneous lesions
  • Rarely, aortic incompetence or heart block
  • NO RHEUMATOID NODULES
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7
Q

What is ankylosing spondylitis?

A

Chronic systemic inflammatory disorder that primarily affects the spine

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8
Q

Occurrence of ankylosing spondylitis?

A

Tends to be late adolescence or early adulthood

It is more common in men (

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9
Q

Hallmark of ankylosing spondylitis?

A

Sacroiliac joint involvement (sacroiliitis)

Peripheral arthritis (shoulder and hip) is uncommon

Enthesitis

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10
Q

What are the features of spondylarthropathies (SpA)?

A
  • Inflammatory back pain (neck, thoracic, lumbar, etc)
  • Peripheral arthritis (shoulders, hips), enthesitis, uveitis, dactylitis
  • Psoriasis
  • Crohn’s/colitis
  • Good response to NSAIDs
  • FH of SpA
  • HLA-B27
  • Elevated CRP
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11
Q

Define the diagnosis of SpA with the ASAS classification?

A

Sacroiliitis on imaging AND ≥ 1 SpA feature

OR

HLA-B27 +ve AND ≥ 2 SpA features

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12
Q

Extra-articular features of ankylosing spondylitis?

A
  • Anterior uveitis
  • CV inv.
  • Pulmonary inv. (e.g: fibrosis of upper lobes)
  • Asymptomatic enteric mucosal inflammation
  • Neurological inv. (rarely, A-A subluxation)
  • Amyloidosis (deposition of abnormal proteins)
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13
Q

What are the 7 As of ankylosing spondylitis?

A 
Axial arthritis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis/Ig A neuropathy
Achilles tendonitis
PlAntar fasciitis
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14
Q

Describe what occurs in a spine with ankylosing spondylitis

A

Syndesmophytes (fusion of vertebrae) leads to question mark posture

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15
Q

Examination of a patient with ankylosing spondylitis?

A

Tragus/occiput to wall (straighten the neck while pressed against a wall)

Chest expansion (to check if fusion of the costovertebral joints had occurred)

Modified Schober test (bend to check lumbar flexure)

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16
Q

Blood tests for ankylosing spondylitis?

A

Inflammatory proteins (ESR, PV and CRP) are raised

HLA-B27 (may/may not be +ve)

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17
Q

X-rays search for what in ankylosing spondylitis?

A

Sacroiliitis

Syndesmophytes

“Bamboo” spines

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18
Q

Limitations of X-rays?

A

Usually show changes after a long period of time, e.g: late changes inc. sacroiliac sclerosis, vertebral fusion and erosions

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19
Q

Differences between signs seen on a spinal X-ray in ankylosing spondylitis and osteoarthritis

A

In AS:
• Bone density is normal in early stages but reduced in late disease
• Shiny corners due to initial syndesmophyte formation
• Flowing syndesmophytes
• Fusion forms a “bamboo spine”

In OA:
• Bone density is normal
• Reduced joint space
• Subchondral sclerosis
• Sunchondral cyst formation
• Osteophyte formation assoc. with neural foraminal narrowing
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20
Q

Advantages of MRI in ankylosing spondylitis?

A

Shows early radiological changes, e.g:
• Bone marrow oedema, which indicates inflammation
• Enthesitis

21
Q

Non-pharmacological treatment of ankylosing spondylitis?

A

Physiotherapy & exercise

Occupational therapy

22
Q

Pharmacological treatment of ankylosing spondylitis?

A
  • NSAIDs
  • Disease modify drugs are only useful if there is peripheral joint inv.
  • Anti-TNF treatment, e.g: infliximab, in severe AS
  • Secukinumbar (anti IL-17) is newly licensed
23
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis but, sometimes, the arthritis can precede skin signs

24
Q

Signs of psoriatic arthritis?

A

No rheumatoid nodules and rheumatoid factor is negative

25
Q

5 clinical features of psoriatic arthritis?

A
  1. Sacroiliitis (often asymmetric and can be assoc. with ankylosing spondylitis as well)
  2. NAIL inv.
  3. Dactylitis
  4. Enthesitis
  5. Extra-articular features, e.g: uveitis
26
Q

5 clinical sub-groups of psoriatic arthritis?

A
  1. Confined to DIPs of the hands/feet
  2. Symmetric polyarthritis (similar to RA)
  3. Spondylitis (spine inv.) with/without peripheral joint inv.
  4. Assymetric oligoarthritis with dactylitis
  5. Arthritis mutilans
27
Q

X-ray signs of psoriatic arthritis?

A
  • Marginal erosions and “whiskering”
  • “Pencil in cup” deformity
  • Osteolysis (disappearance of bone tissue)
  • Enthesitis
28
Q

Non-pharmacological treatment of psoriatic arthritis?

A
  • Physiotherapy
  • Occupational therapy
  • Orthotics, chiropodist
29
Q

Pharmacological treatment of psoriatic arthritis?

A
  • NSAIDs
  • Corticosteroids/joint injections
  • Disease Modifying Drugs (methotrexate, sulfasalazine, leflunomide)
  • Anti-TNF in severe disease unresponsive to NSAIDs and methotrexate
  • Secukinumab (anti IL-17)
30
Q

What is reactive arthritis?

A

Infection-induced systemic illness characterised primarily by an inflammatory synovitis, from which viable micro-organisms cannot be cultured

Symptoms occur 1-4 weeks after infection

31
Q

Most common infection causing spondylarthropathies?

A

Urogenital, e.g: Chlamydia

Enterogenic, e.g: Salmonella, Shigella and Yersinia

32
Q

Occurrence of reactive arthritis?

A

Tends to be young adults (20-50 years) with an equal sex distribution

People tend to be HLA-B27 +ve

33
Q

What is Reiter’s syndrome?

A

A form of reactive arthritis which is defined by a triad of features:
• Urethritis
• Conjunctivitis/uveitis/iritis
• Arthritis (tends to affect the knee but can be anywhere)

34
Q

Clinical features of reactive arthritis?

A

General symptoms, e.g: fever, fatigue, malaise

Asymmetrical mono/oligoarthritis

Enthesitis

Mucocutaneous lesions, like

Occular lesions (uni/bilateral)

Visceral manifestations

35
Q

Examples of mucocutaneous lesions in reactive arthritis?

A
  • Keratoderma blenorrhagica (vesico-pustular waxy lesion with a yellow brown colour, commonly on the palms and soles)
  • Circinate balanitis (annular dermatitis of the glans penis)
  • Painless oral ulcers
  • Hyperkeratotic nails
36
Q

Examples of occular lesions in reactive arthritis?

A

Conjunctivitis and iritis

37
Q

Examples of visceral manifestation of reactive arthritis?

A

Mild renal disease

Carditis

38
Q

Blood tests in reactive arthritis?

A

Raised inflammatory markers

FBC shows raised WCC

HLA-B27 (rarely necessary)

39
Q

Other tests done in reactive arthritis?

A

Cultures (blood, urine, stool)

Joint fluid analysis (rule out infection)

X-ray of affected joints

Ophthalmology opinion

40
Q

Outcome of reactive arthritis?

A

Most resolve spontaneously within 6 months

41
Q

Pharmacological treatment of reactive arthritis?

A

NSAIDs

Corticosteroids (intra-articular, if sepsis is ruled out, oral and eye drops)

Antibiotics for underlying infection, e.g: respiratory/GI

DMARDs if it is resistant/chronic

42
Q

Non-pharmacological therapy of reactive arthritis?

A

Physiotherapy

Occupational therapy

43
Q

What is enteropathic arthritis?

A

Assoc. with IBD, e.g: Crohn’s (usuaully), UC

44
Q

Presentation of enteropathic arthritis?

A

Arthritis in several joints, esp. knees, ankles, elbows and wrists; occasionally in the spine, hips of shoulders

45
Q

When do symptoms of enteropathic arthritis worsen?

A

During flare-ups of IBD

46
Q

Clinical symptoms of enteropathic arthritis?

A

GI:
Loose, watery stools with mucous and blood

Weight loss adn low grade fever

Eye inv. (uveitis)

Skin inv. (pyoderma gangrenosum)

Enthesitis (achilles tendonitis, plantar fasciitis, lateral epicondylitis)

Oral (aphtous ulcers)

47
Q

Ix for enteropathic arthritis?

A

Upper and lower GI endoscopy + biopsy (ulceration/colitis)

Joint aspirate (no organisms or crystals)

Raised inflammatory markers (CRP, PV)

X-ray/MRI showing sacroiliitis

USS showing synovitis/tenosynovitis

48
Q

Treatment of enteropathic arthritis?

A

Treat IBD in order to control arthritis

NSAIDs are usually not recommended as they may exacerbate IBD; use normal analgesia instead, e.g: paracteamol, co-codamol

Steroids (oral, intra-articular, intramuscular)

Disease Modifying Drugs
(methotrexate, sulfasalazine), azathioprine)

Anti-TNF licensed for both Crohn’s disease and inflammatory arthritis

Year 2 Clinical (119 decks)

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