Spondyloarthopathies Flashcards
What are the spondyloarthropathies
Group of related chronic inflammatory conditions.
What do they affect
Axial skeleton
What clinical features do they share? SPONDYLARTHOPIES
- Seronegativity (rheumatoid factor negative)
- HLA-B27 association*
- Axial arthritis - pathology in spine and sacroiliac joints
- Asymmetrical large-joint oligoarthritis or monoarthritis
- Enthesitis - inflammation at the site of insertion of a tendon or ligament into a bone
- Dactylitis - infammation of entire digit e.g. sausage fingers
- Extra-articular manifestations e.g. iritis (inflammation of eye), psoriaform rashes, oral ulcers, aortic valve incompetence, inflammatory bowel disease
What percentage of the UK population have these disease?
Around 5% of the UK population is HLA-B27 positive but most do not have the disease. The chances of developing disease in this group of people is 1 in 4.
Common assosciations with these conditions
- Ankylosing spondylitis - 85-95% of people are HLA-B27+
- Acute anterior uveitis - 50-60% of people are HLA-B27+
- Reactive arthritis - 60-85% of people are HLA-B27+
- Enteric arthropathy - 50-60% of people are HLA-B27+
- Psoriatic arthritis - 60-70% of people are HLA-B27+
Pathology theory
infection triggers an immune response and the infectious agent has peptides very similar to the HLA-B27 molecules so there is an auto-immune response triggered against HLA-B27.
Pneumonic for suspected spondyloarthropathies:
SPINEACHE
SPINEACHE
- Sausage digit (dactylitis)
- Psoriasis
- Inflammatory back pain
- NSAID good response
- Enthesitis (particularly in heel - plantar fasciitis)
- Arthritis
- Crohn’s/Colitis/elevated CRP (can be normal in AS)
- HLA-B27
- Eye (uveitis)
What is Ankylosing spondylitis (AS)
chronic progressive inflammatory arthropathy. Mainly affects the spine and causes progressive stiffness and pain.
What is ankylosis?
abnormal stiffening and immobility of joint due to fusion of bones
Epidemiology of AS
- M>F
- Most commonly presents in late teens/ twenties
- Women present later and are under-diagnosed
- 90% are HLA-B27 positive
RF for AS
- HLA-B27
- Family history of ankylosing spondylitis
Pathophysiology of AS
Lymphocyte and plasma infiltration occurs with local erosion of bone at the attachments of the intervertebral and other ligaments which heals with new bone (syndesmophyte) formation.
Can progress to kyphossi, neck hyperextension and spino-cranial ankylosis
Signs of AS
- Enthesitis - inflammation at point of insertion of tendons and ligaments in bones
- Dactylitis - inflammation of entire digit
- Bamboo spine on x-ray due to fusion of the joints
Typical presentation of AS
Young teen or male on 20’s
-Pain and stiffness of joints
- Lower back pain
- Sacroiliac pain (buttock region)
- Pain worst at night and in the morning (>30 minutes of stiffness in morning)
- Pain worst with rest and improves with movement
- Systemic symptoms e.g. weight loss and fatigue
- Chest pain - related to costovertebral and costosternal joints
Investigations for AS
- FBC - normocytic anaemia
- CRP and ESR - elevated
- Genetic testing - HLA-B27?
-
X-ray - of spine and sacrum
- MRI of spine
Schober’s test
General examination of spine (especially lumbar spine) to assess mobility.
Patient stands straight. Find L5 vertebrae and mark a point 10cm above this and 5cm below. Ask patient to bend forward, and measure distance between two points.
If distance between the two points is less than 20cm, this indicates restriction in the lumbar movements.
-
Differential diagnosis for AS
- Osteoarthritis
- Psoriatic arthritis
- Reactive arthritis
- Vertebral fracture
Medical management (IN ORDER) of AS
- NSAIDs e.g. ibuprofen or naproxen (2-4 weeks. If no improvement, switch to another NSAID)
- Steroids - used during flares (oral, IM or directly into joints)
- Anti-TNF e.g. etanercept or monoclonal antibodies against TNF e.g. infliximab, adalimumab
- Monoclonal antibodies targeting IL-7 - e.g. secukinumab
Conservative measures for AS
Physiotherapy
Avoid smoking
Bisphosphates
Treatment for complications
Surgery
Complications for AS
- Vertebral fractures
- Osteoporosis
- Anaemia
- Anterior uveitis (eye inflammation)
- Aortitis (inflammation of aorta)
- Heart block - fibrosis of the heart conduction system
- Restrictive lung disease - due to restrictive movement of chest wall
- Pulmonary fibrosis - especially upper lobes of lungs
- Inflammatory bowel disease
What is psoriatic arthirits
Psoriatic arthritis is a chronic inflammatory joint disease associated with psoriasis, although it can occur without arthritis.
epidemiology of psoriatic arthiritis
- Psoriatic arthritis occurs in approximately 10% of patients with psoriasis
- Usually occurs within 10 years of skin changes
- Typically affects people in middle age
RF for Psoriatic arthiris
- Psoriasis
- Family history of psoriasis or psoriatic arthritis
Pathophysiology of psoriatic arthritis
falls under the category ofseronegative spondyloarthropathies. These conditions are allrheumatoid factor negative, associated withHLA-B27, and can affect theaxial skeleton.
Psoriatic arthritis has a strong genetic component and, although its pathogenesis is not fully understood, activation ofCD8+ T cellsis thought to play a critical role.
Signs of psoriatic arthiritis
Joint tenderness, warmth and reduced range of motion - DIP joints
- Dactylitis: swelling of an entire digit
- Enthesitis: inflammation of the plantar fascia and Achilles’ tendon (back of foot)
- Psoriasis: psoriatic lesions, scalp and nail symptoms (pitting of nails, onycholisis - separation of nail from nail bed)
Symptoms of psoriatic arthritis
-
Joint pain and stiffness:
- Symptoms worse in the morning and improve on movement is typical of an inflammatory arthropathy
- Swollen fingers or toes
- Back pain if axial skeleton involved
Types of psoriatic arthiritis
symmetric polyarthritis (rheumatoid-like)
Asymmetric oligoarthritis
Distal arthritis (DIP joint disease)
Spondyloarthritis (sacroiliitis)
Arthritis mutilans
What and who does Symmetric polyarthritis effect
- Affects ≥ 5 joints
- Affects hands, wrists, ankles, DIP joints
- Symmetrical distribution
- More common in women
- Resembles rheumatoid arthritis
Asymmetric oligoarthritis affects what part of the body
- Affects ≤ 4 joints
- Asymmetrical distribution
- Typically affects the hands and feet
Distal arthritis (DIP joint disease)
- Affects distal interphalangeal joints of hands and/or feet
- Usually occurs alongside other types
spondyloarthritis (sacroiliitis)
- Primarily involves spine, sacroiliac joints and atlanto-axial joint
- More common in men
Arthritis mutilans
- Most severe and least common form
- Deforming and destructive subtype
- Occurs in the digits
- Osteolysis around the phalynxes
- Skin around the bones, folds in on itself as the bones get shorter (telescopic finger)
Investigations for PA
CASPAR criteria - need 2 or more points
PEST - Psoriasis epidemiological screening tool
x RAYS SHOW what in psoriatic arthritis
- Periostitis - inflammation of the periosteum
- Ankylosis - bones fuse together
- Osteolysis - bone loss
- Dactylitis - inflammation of the entire digit
- Pencil-in-cup appearance - central erosions of bone which causes the appearance of one bone being hollow and looking like a cup, and the other bone looking narrow and pencil-like.
Differential diagnosis for PA
- Rheumatoid arthritis
- Gout
- Reactive arthritis
- Erosive osteoarthritis
Treatment for mild PA
- NSAIDs and physiotherapy: first-line options to reduce inflammation, improve range of motion and strengthen muscles
- Intra-articular steroids - for intra-articular synovitis
Progressive PA treatment
- Disease-modifying antirheumatic drugs (DMARDs): used in addition to the above for patients with polyarthritis or joint erosions.Methotrexateis first-line, whilstsulfasalazineis used in patients who are intolerant to methotrexate
- Biologic agents: TNF-α inhibitors, such as etanercept or infliximab, should be considered in patients with oligoarthritis or polyarthritis following the failure of 2 DMARDs
- Ustekinumab - used to treat psoriasis - monoclonal antibody that targets IL-12 and IL-23 to dampen down inflammation
Complications of PA
higher chance of IHD and hypertension
Aortitis
Amyloidosis
Conjunctivitis
- Methotrexate hepatotoxicity
- Treatment related malignancy
What is reactive arthritis?
synovitis occurring due to a recent infective trigger. This is an autoimmune response to infection elsewhere in the body. This usually presents as acute monoarthritis.
Epidemiology of RA
- Males who are HLA-B27 positive have an 30-50 fold increased risk
- Women less commonly affected
- Mainly occurs in adults
- The prevalence is thought to be 30 to 40 cases per 100,000 adults
Aetiology of RA
Gastroenteritis - Salmonella, shigella, Yersinia enterocolitica
STI - Chlamydia, ureaplasm urealyticum, Gonorrhea
RF for RA
- HLA-B27 gene
- Male sex
- Preceding chlamydial or gastrointestinal infection
Pathophysiology of RA
Reactive arthritis is one of the seronegative spondyloarthropathies, and is linked to the HLA-B27 gene.
The immune system is responding to the recent infection. This response also results in antibodies or inflammation that also affect the joints.
In reactive arthritis, there are no actual joint infections (as seen in septic arthritis). The infection is at another site!
Key presentations of RA
Acute, asymmetrical monoarthritis, typically in the lower leg.
Patients may present with triad of - urethritis, arthritis and conjunctivitis ‘Can’t see, pee or climb a tree’
Signs of RA
- Warm and swollen joint
- Iritis - swelling and irritation of eye
- Keratoderma blenorrhagica - painless, red, raised plaques and pustules
- Circinate balanitis - dermatitis of the head of the penis
- Enthesitis - inflammation of the site where tendons and ligaments insert into the bone
- Nail dystrophy
Symptoms of RA
- Warm, swollen, painful joint
- Mouth ulcers
Investigations for RA
- ESR and CRP - elevated
- Infectious serology
- If diarrhoea - culture stool
- Aspirate joint - MCS and crystal examination - to rule out septic arthritis and crytalopathies
- Sexual health review
- X-ray - may show enthesitis with periosteal reaction
Differential diagnosis for RA
- Septic arthritis
- Gout
- Pseudogout
- Ankylosing spondylitis
- Psoriatic arthritis
If patient presents with acute, warm, swollen and painful joint what do you do?
-
Hot joint policy - presume patient has septic arthritis until its excluded
- Antibiotics
- Aspirate joint - MCS & crystal examination
After excluding septic arthritis what would you do?
- NSAIDs
- Steroid injections
- Systemic steroids, if needed (multiple joints may be affected)
Treatment of Recurrent/ persistent reactive arthritis
- DMARDs e.g. methotrexate or sulfasalazine
- ## Anti-TNF
Complications for RA
- Eyes
- Bilateral conjuctivitis (non-infective)
- Anterior uveitis
- Genital tract
- Circinate balanitis (dermatitis of the head of the penis)
- Keratoderma blennorrhagica
