Spondylarthropathies

Question 1

What percentage of patients with psoriasis get psoriatic arthritis?

Answer 1

10-40%

Question 2

What are the different seronegative spondylarthropathies?

Answer 2

Ankylosing spondylitis
Enteric arthropathy
Psoriatic arthritis
Reactive arthritis

Question 3

What are the seven hallmarks of spondylarthropathies?

Answer 3

1) Seronegative
2) HLA B27 association
3) Axial arthritis
4) Asymmetrical large joint arthritis or monoarthritis
5) Enthesitis (inflammation of the site of insertion of tendon or ligament into bone)
6) Dactylitis
7) Extra articular manifestations

Question 4

Describe the pathophysiology behind psoriatic arthritis

Answer 4

TNF, IL-12 and IL-23 are released which stimulate keratinocytes and fibroblasts to form psoriatic plaques

In addition, osteoblasts and osteoclasts are affected which stimulates joint erosion and ossification

Question 5

What are the five different types of psoriatic arthritis?

Answer 5

1) Oligoarticular (<5)
2) Polyarticular or rheumatoid pattern (>5)
3) Spondyloarthritis (asymmetric, spine and sacroiliac)
4) Distal interphalangeal predominant (causes sausage fingers or dactylitis)
5) Arthritis mutilans (opera glass hand)

Question 6

How do you diagnose psoriatic arthritis?

Answer 6

Radiology: erosive changes, 'pencil in cup' changes
Nail changes in 80%
Dactylitis
Acneiform rashes
Presence of psoriasis

Question 7

How do you manage psoriatic arthritis?

Answer 7

NSAIDs 
Sulfasalazine
Methotrexate 
If these don't work,
Biologics such as infliximab

Question 8

What are the main joints that are affected in ankylosing spondylitis?

Answer 8

Sacroiliac joints
Joints of vertebral column

Causes pain, stiffness and ultimately fusion in these joints

Question 9

What are the risk factors for ankylosing spondylitis?

Answer 9

Having the HLA B27 gene. 90% of those who have AS have the gene. 2% of people who have the gene have AS.
If you have a first degree relative who has the condition your risk greatly increases.

Question 10

What is the typical presentation of ankylosing spondylitis?

Answer 10

Young adult male
Late teens and 20’s
Low back pain and stiffness. Sacroiliac pain.

Worse with rest, improves with movement
>30mins morning stiffness

Vertebral fractures are a common complication of AS

Can also present with: chest pain due to fusion of costovertebral joints and weight loss and fatigue. Also, enthesitis (where the ligaments join the bones in the ankle). Also, dactylitis, anterior uveitis, restricted lung disease

Question 11

What is the test that examines the movement of the lumbar spine region?

Answer 11

Schober’s test
Find the L5 vertebrae, mark 10cm above and 5cm below and ask them to bend forward and measure the difference between the two. If the difference is <20cm = restriction

Question 12

What are the investigations for ankylosing spondylitis?

Answer 12

Raised ESR and CRP
Genetics: HLA B27
X-Ray Spine & Sacrum 
MRI Spine: early changes such as bone marrow oedema
Normocytic anaemia

Question 13

What X-Ray changes may you be able to see in ankylosing spondylitis?

Answer 13

Squaring of vertebral bodies
Syndesmophytes (bony growths where ligaments insert into bone)
Subchondral sclerosis
Subchondral erosions
Ossification

Question 14

What is the management of ankylosing spondylitis?

Answer 14

Physiotherapy
Avoiding smoking 
1) NSAIDs: Ibuprofen/Naproxen
2) Steroids: IM/PO/Joint
3) Anti TNFa: Etanercept. 
    Monoclonal antibodies: Infliximab/Adalimubab

Question 15

List some complications of ankylosing spondylitis

Answer 15

Pulmonary fibrosis
Enthesitis
Anterior uveitis
Kyphosis

Question 16

What happens in reactive arthritis?

Answer 16

Arthritis and other clinical manifestations follow a GI or urogenital infection, 1-6 weeks later.

Starts with malaise, fatigue and fever.
Asymmetrical, lower limb, oligoarthritis (<6) is the most common major symptom.
Symptoms last approximately 6m.

Balanitis can occur, enthesitis, mouth ulcers and keratoderma blenorrhagica

A normocytic anaemia will be seen

Question 17

What are the common organisms that cause reactive arthritis?

Answer 17

Post enteric: Campylobacter, Salmonella, Shigella

Post venereal: Chlamydia, HIV

Question 18

What is Reiter’s syndrome?

Answer 18

Subtype of Reactive Arthritis
Triad: urethritis, conjunctivitis and arthritis following illness

‘Can’t see, can’t pee, can’t climb a tree’

Question 19

What do investigations show in Reactive Arthritis?

Answer 19

Raised ESR & CRP
Culture stool if diarrhoea
X-Ray may show enthesitis
Synovial fluid: high WCC

Question 20

What is the management of Reactive Arthritis?

Answer 20

Splint affected joints acutely
Treat with NSAIDs or local steroid injections
Sulfasalazine or methotrexate if >6m