Spondyloarthopathies Flashcards
What is the definition of a spondyloarthropathy?
- inflammatory arthritis
- involves spine and joints
- genetically predisposed
What genetic predisposition is commonly seen in spondyloarthropathies?
HLA B27
only important if patients also have symptoms
What subgroups of spondyloarthopathies exist?
Ankylosing Spondylitis
Psoriatic Arthritis
Reactive Arthritis
Enteropathic Arthritis
What is the difference between mechanical and inflammatory back pain?
Mechanical:
- worsened by activity
- worst at end of day
- better with rest
Inflammatory
- worse with rest
- better with activity
- early morning stiffness (>30 minutes)
What rheumatological features are common to all of the spondyloarthropathies
- Sacroiliac and spinal involvement
- Enthesitis: inflammation at insertion of tendons into bones eg Achilles tendinitis, plantar fasciitis
- Inflammatory arthritis
- Dactylitis - inflammation of entire digit
What extra articular features are common to all spondyloarthropathies
- Ocular inflammation (Anterior uveitis, conjuntivitis)
- Mucocutaneous lesions
- Rare Aortic incompetence or heart block
In what age group does ankylosing spondylitis usually present?
Late adolescence or early adulthood
What is the ratio of ankylosing spondylitis in males:females
More common in men 3-5:1
What is the classification criteria for ankylosing spondylitis?
EITHER:
- sacroilitis on imaging
- 1 spA feature
OR
- HLA B27 positive
- 2 spA features
What are the main clinical features of ankylosing spondylitis?
- Back pain (neck, thoracic, lumbar)
- Enthesitis
- RARE Peripheral involvement (shoulders,hips)
What extra articular features are often present in ankylosing spondylitis?
uveitis Cardio = (aortic valve/root ) Resp = (fibrosis upper lobes) GI = Enteric mucosal inflammation Neurological = (Rarely A-A subluxation) Amyloidosis
Why is ankylosing spodylitis known as the ‘A’ disease?
Axial Arthritis Anterior Uveitis Aortic Regurgitation Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis Plantar Fasciitis
What is it called when the vertebrae fuse?
Syndesmophytes
What examinations can be used to check for ankylosing spondylitis?
Examination:
- Tragus/occiput to wall
- Chest expansion
- Modified Schober test
Bloods
- Inflammatory (ESR, CRP, PV)
- HLA B27
X-rays
- Sacroiliitis
- Syndesmophytes
- “Bamboo” spine due to fusion
What is the drawback of using X-Rays in ankylosing spondylitis?
usually show changes after a long period of time
=> irrelevant in early disease
What X-Ray changes are often seen in ankylosing spondylitis?
Reduced bone density
Shiny corners
Flowing Syndesmophytes
Fusion (Bamboo spine)
Why are MRIs more useful in early AS?
Can detect early manifestations
- bone marrow oedema
- enthesitis
What treatments are used in AS?
- Physiotherapy/ Occupational therapy
- NSAID
- Disease modifying drugs (e.g. MTX)
- Biologics = Anti TNF treatment e.g. Infliximab
NEW = Secukinumab( anti-IL17)
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis
** 10 -15% of patients can have PsA without psoriasis
What clinical features are usually present in psoriatic arthritis?
- Sacroiliitis
- Nail involvement
- Dactylitis
- Enthesitis
- Extra articular features (eye disease)
Name each of the 5 subgroups of psoriatic arthritis
1) Confined to distal interphalangeal joints (DIP)
2) Symmetric polyarthritis (similar to RA)
3) Spondylitis (spine involvement) +/- peripheral joint involvement
4) Asymmetric oligoarthritis with dactylitis
5) Arthritis mutilans
What investigations are useful in diagnosing psoriatic arthritis?
Bloods:
- Inflammatory markers (raised)
- Negative RF
X-rays
- Marginal erosions and “whiskering”
- “Pencil in cup” deformity
- Osteolysis
- Enthesitis
What medical treatments are available to treat psoriatic arthritis?
NSAIDs
Corticosteroids/joint injections
Disease Modifying Drugs (Methotrexate, Sulfasalazine, Leflunomide)
Anti TNF in severe disease unresponsive to NSAIDs and Methotrexate
Secukinumab (anti-IL17)
What non-medical treatments are available to treat psoriatic arthritis?
Physiotherapy
Occupational Therapy
Orthotics, Chiropodist
What is reactive arthritis?
synovitis secondary to infection Symptoms 1-4 weeks after infection Most common infections: Urogenital eg. Chlamydia Enterogenic eg. Salmonella, Shigella, Yersinia
At what age is reactive arthritis most commonly seen?
Young adults (20-40) Equal sex distribution
What genetic factor is commonly seen in reactive arthritis?
HLA B27 positive
What is Reiter’s syndrome?
Form of reactive arthritis
TRIAD
- Urethritis
- Conjuntivitis/Uveitis/Iritis
- Arthritis
What medical treatment is used to treat Reiter’s syndrome?
** 90% resolve spontaneously within 6 months**
Medical:
NSAIDs
Corticosteroids (Oral or Inj. once sepsis ruled out)
Eye drops
Antibiotics for underlying infection eg respiratory/ GI
DMARDs (SZP) - If resistant/chronic
What is enteropathic arthritis?
Associated with IBD
Arthritis in several joints:
- knees ankles, elbows, and wrists
- sometimes in the spine, hips, or shoulders
Worsening of symptoms during flare-ups of IBD
What clinical symptoms can present in enteropathic arthritis
GI - loose, watery stool with mucous and blood Weight loss, low grade fever Eye involvement ( uveitis) Skin involvement ( pyoderma gangrenosum) Enthesitis Oral- apthous ulcers
What investigations can be carried out to determine if a patient has enteropathic arthritis
Upper and lower GI endoscopy with biopsy showing ulceration/ colitis
Joint aspirate- no organisms or crystals
Raised inflammatory markers- CRP, PV
X ray/ MRI showing sacroiliitis
USS showing synovitis/ tenosynovitis
What treatments are used in enteropathic arthritis?
primarily treat IBD
NSAID usually not good idea as may exacerbate IBD
=> Normal analgesia eg Paracteamol, Co-codamol
=> Steroids ( oral, IA, IM)
=> Disease Modifying Drugs (Methotrexate, Sulfasalazine)
=> Anti-TNF e.g. Infliximab licensed for both Crohn’s disease and inflammatory arthritis
