Spondyloarthritides

Question 1

List the Spondyloarthritides?

Answer 1

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteric arthropathy

Question 2

What are the features of the Spondyloarthritides?

Answer 2

Seronegative - Rh factor negative

HLA B27

Axial arthritis: spine and sacro-iliac joints

Asymmetrical large joint oligoarthritis (less than 5)

Enthesitis

Dactylitis

Extra-articular manifestations

Question 3

Define

• enthesitis
• dactylitis

Answer 3

Enthesitis: inflammation of the site of insertion of the tendon or ligament into the bone. E.g. plantar fasciitis, achilles tendonitis, costochondritis

Dactylitis: inflammation of entire digit (sausage digit)
Caused by soft tissue oedema, tenosynovial and joint inflammation

Question 4

What are the extra-articular manifestations of the Spondyloarthritides?

Answer 4

• anterior uveitis
• psoriaform rashes
• ulcers
• aortic valve incompetence
• IBD

Question 5

What is ankylosing spondylitis?

Answer 5

Chronic inflammatory disease of the axial skeleton: spine and sacroiliac joints
Unknown aetiology

Question 6

Presentation of ank spond? Who?

Answer 6

Young men (below 30) HLA B27
Gradual onset lower back pain
Stiffness worse in the morning and eases through day
Loss of ROM of spine
Enthesitis: plantar fasciitis, achilles tendonitis, costochondritis

Extra-articular - 6As

• Anterior uveitis
• Apical fibrosis
• Aortic valve incompetence
• Achilles tendonitis
• Atlanto-axial subluxation
• Amyloidosis

Question 7

Investigations of ank spond?

Answer 7

Clinical supported by imaging

• MRI is best
• XR

Bloods: Rh factor negative, HLA B27, raised ESR and CRP, normocytic anaemia

Question 8

Signs of ank spond on imaging?

Answer 8

Sacroiliitis
Erosions, irregularities, sclerosis
Vertebral syndesmophytes

Bony proliferations due to enthesitis, which fuse with one above resulting in bamboo spine

Question 9

Which is the childhood disease that precipitates ank spond?

Answer 9

Enthesitis related JIA

Question 10

Management of ank spond?

Answer 10

Exercise! Intense regimens to maintain posture and mobility with physiotherapist

Long term NSAIDs: ibuprofen, naproxen

TNF-a blockers: etanercept, adalimumab if severe and not responsive to NSAIDs

Intra-articular steroids

Surgery: hip replacement

Question 11

What condition are ank spond patients are higher risk of that you might want to treat?

Answer 11

Osteoporosis

Consider bisphosphonates

Question 12

What indicates a poor prognosis in ank spond?

Answer 12

Onset before 16 years
ESR over 40
Poor response to NSAIDs

Question 13

What is enteric arthropathy?

Management?

Answer 13

Arthropathy that is associated with inflammatory bowel disease

• Crohn’s
• UC
• Coeliac

Usually improved as IBD is treated
If resistant try methotrexate

Question 14

Which biologics are used in ank spond?

Answer 14

TNF-a blockers

• etanercept
• adalimumab
• golimumab

Question 15

What is psoriatic arthritis?

Answer 15

Arthritis associated with psoriasis

10-40% of psoriasis patients

Question 16

Features of psoriatic arthritis?

Answer 16

Symmetrical polyarthritis (like RA)
Can also be asymmetrical

Distal interphalangeal joints

Dactylitis

Psoriatic arthritis mutilans (severe deformity, rare)

Nail changes: pitting, onycholysis, leukonychia

Question 17

You see a patient with arthritis in their DIP, you suspect an inflammatory arthritis. Which one?

Answer 17

DIP unlikely to be affected in RA

More likely to be osteoarthritis, or psoriatic

Question 18

Signs on XR of psoriatic arthritis?

Answer 18

Erosive changes

Pencil in cup deformity

Question 19

Management of psoriatic arthritis?

Answer 19

NSAIDs

DMARDs: sulfasalazine, methotrexate, ciclosporin

Anti-TNF agents: infliximab, etanercept, adalimumab