Spondylarthropathies, Degenerative Joints and Crystal Arthritis

Question 1

What tissue types are all spondyloarthritis conditions associated with?

Answer 1

Tissue type HLAB27 (APC) (Genetic abnormality)

Question 2

What are the 5 main conditions that are termed within spondylarthritis?

Answer 2

1) Ankylosing spondylitis
2) Reactive arthritis
3) Psoriatic Arthritis
4) Enteropathic arthritis
5) Juvenile idiopathic arthritis

Question 3

What is the background on HLAB27?

Answer 3

-APC
MM: Infectious agents w/ peptides similar to HLAB27 causes AI response to be triggered against HLAB27
Either: Molecular mimicry, mis-folding theory or HLAB27 heavy chain hypothesis

Question 4

What are the main S/S of SA?

Answer 4

a) Psoriasis
b) Inflammatory spine/buttock pain
3) Good response to NSAIDs
4) Enthesistis
5) Arthritis
6) Crohn’s/Colitis
7) Uveitis

Question 5

What is the general treatment for SA?

Answer 5

DMARDs and biological agents if DMARDs fail e.g. TNF blocker

Question 6

What is the PP and main investigations for ankylosing spondylitis?

Answer 6

PP: Inflammation of spine –> Erosive damage –> Repair/new bone formation –> irreversible fusion of spine/sacroiliac joints
Inv: X-Ray, MRI and HLAB27

Question 7

What are the main symptoms of AS?

Answer 7

Back pain, morning stiffness, waking in 2nd half of night, buttock pain, insidious onset and <40y/o at onset

Question 8

What is the diagnostic criteria of AS?

Answer 8

> 3 months backpain, aged <45 and SPINEACHE symptom

Question 9

Where does psoriasis usually take place?

Answer 9

Elbows, Knees and Fingers

Question 10

What is reactive arthritis?

Answer 10

Sterile inflammation of synovial membrane, tendons and fascia triggered by infection at a distant site (GI/genital)

Question 11

What infections are usually associated with reactive arthritis?

Answer 11

GUT: Shigella and Salmonella
STI: Chlamydia

Question 12

What are main symptoms of reactive arthritis?

Answer 12

Arthritis, conjunctivitis and urethritis

Question 13

What are main symptoms of reactive arthritis?

Answer 13

Arthritis, conjunctivitis and urethritis

Question 14

What type of SA occurs in 20% patients with IBD?

Answer 14

Enteropathic arthritis

Question 15

What is the criteria for making a clinical diagnosis of juvenile idopathic arthritis?

Answer 15

Joint swelling/stiffness .6 weeks of children under 16 with no other cause

Question 16

What is the aetiology, and main sight to check?

Answer 16

Unknown –> idiopathic (AI so maybe genetic factors)
- Lining of joints and eyes are similar so high chance of child developing uveitis
[Oligoarthritis develops in <4 joints]

Question 17

What are the Med and N-Med treatments of JIA?

Answer 17

Med: Steroid joint injections, NSAIDs, methotrexate and systemic steroids
N-med: Information, education, support, liason with school and physiotherapy

Question 18

What are main consequences of failing to treat JIA?

Answer 18

Damage, deformity, disability, pain, bony overgrowth and uveitis

Question 19

What disease would you associate pencil-in-cup erosion on plain XR?

Answer 19

Psoriatic arthritis

Question 20

What joint normally swells up in psoriatic arthritis

Answer 20

DIP joint (Sausage like fingers)

Question 21

What is a psoriatic plaque?

Answer 21

Pink, scaling lesions on extensor surfaces of limbs

Question 22

How are PA and RA different?

Answer 22

Psoriatic: Psoriatic lesions, sausage like swelling around DIP with pencil in cup erosion on XR and HLAB27 associated
RA: Hands and wrists, peri-articular erosion on XR with rheumatoid nodules

Question 23

What is the physiological pathway that leads to monosodium urate formation?

Answer 23

Purines –> Hypoxanthine –> Xanthine –> Uric acid –> Monosodium urate

Question 24

How is hypoxanthine converted to xanthine?

Answer 24

Xanthine oxidase

Question 25

What factors see an increase in monosodium urate?

Answer 25

1) Increased alcohol, red meat intake
2) Cell turnover (Increased production)
3) Cell damage e.g. from surgery
4) Cell death e.g. from chemotherapy
5) Reduced excretion (renal problems)
6) High insulin
7) Drugs e.g. diuretics (Bendroflumethiazide) –> Impair urate excretion

Question 26

What is the epidemiology and main S/S of gout?

Answer 26

Ep: Men > 75

S/S: Hot and swollen joints (Usually big toe)

Question 27

What other diseases would a patient with gout have a risk of developing?

Answer 27

1) Hypertension
2) CV disease
3) Renal disease
4) Type 2 diabetes

Question 28

Define tophi

Answer 28

Onion like aggregates of urate crystals with inflammatory cells (Proteolytic enzymes released –> enzymes)

Question 29

What is the aim and range of treatment options for Gout?

Answer 29

• Get urate levels <300umol/L
  1) Lifestyle modification
  2) Allopurinol (Block xanthine oxidase)
  3) Colchicine/NSAIDs
  4) Swap bendro… to cosartan
  5) Rasburicase (Rapid urate reduction)

Question 30

What main actors can cause an acute attack of gout?

Answer 30

1) Sudden overload
2) Cold
3) Trauma
4) Sepsis
5) Dehydration
6) Drugs

Question 31

What is the pathophysiology of pyrophosphate arthropathy (Pseudogout)?

Answer 31

Calcium pyrophosphate crystals deposited on joint surfaces (Illiciting an IR)

Question 32

What are the main causes of pseudogout?

Answer 32

1) Hypo/Hyperthyroidism
2) Diabetes
3) Haemochromatosis
4) Magnesium levels

Question 33

What is a main symptom of pseudogout?

Answer 33

Acute, hot and swollen joints (Wrists and Knees)

Question 34

What investigations would be done with someone with pseudogout and what would differential diagnosis be?

Answer 34

Inv: 1) Aspiration: Fluid for crystals and blood cultures
2) X-Rays: Chondrocalcinosis
DD: Infection

Question 35

What is the main treatment for someone with pseudogout?

Answer 35

Treat underlying cause and use methotrexate for inflammation