Spondyloarthritides Flashcards
Shared features of spondyloarthropathies
- RF negative
- Preponderance for extra-articular features
- Classically affect axial skeleton (spine + sacroiliac joints)
- Genetic association with B27
- Affect tendons + tendon insertions (enthesis) - esp Achilles
Presentation of ankylosing spondylitis
Young male gradually worsening back/sacro-iliac (buttock) pain, improves with exercise, worse at night
May progress to kyphosis + neck hyperextension (Q mark posture)
Enthesitis (esp Achilles and pelvis)
Costochondritis
Extra-articular features of AS
Disease of As:
Achilles tendonitis
Anterior uveitis + hypopyon
Apical pulmonary fibrosis
Aortic incompetence
Atlanto-axial subluxation
Osteoporosis
Imaging features of ankylosing spondylitis
Syndesmophytes (bony growths at ligament/tendon insertions)
Shiny corners of bone marrow oedema (Romano’s lesions) on T2-weighted MRI
Fusion of syndesmophytes with vertebral bodies –> ankylosis –> eventually bamboo spine (ONLY ON X-RAY)
T2W MRI investigation of choice –> bone marrow oedema from active inflammation
Affects T11-L1 initially
Management of ankylosing spondylitis
Exercise (w. physio)
NSAIDs symptomatic relief
TNF-a blockers if severe,active; also IL-17 and IL-12/23
NOT B/T-cell blockade, NOT steroids
Consider bisphosphonates for osteoporosis risk
TNF-a blockers for ankylosing spondylitis
Etanacept, adilimumab
Poor prognostic factors for ankylosing spondylitis
ESR >30
age <16
unresponsive to NSAIDs
early hip involvement
early loss of lumbar mobility
Anterior uveitis features in AS
Sight-threatening
Injected
Irregular pupil
Photophobic
Syndesmophyte vs osteophyte appearance
Syndesmophytes grow longitudinally
Osteophytes grow laterally
What is BASDAI
Bath Ankylosing Spondylitis Disease Activity Index
POatient-reported, >4 is bad
What is BASMI?
Bath Ankylosing Spondylitis Metrology Index: for measuring disease progression
Cervical rotation + wall-to-tragus
Lumbar flexion (Schober’s index) + lateral movement
Chest expansion
Inter-malleolar straddle
Presentation of enteric arthropathy
Assoc w/ IBD, coeliac, Whipple’s
Peripheral arthropathy that may be associated with flares, tends to improve with treating bowel symptoms
Sacroiliac arthropathy not associated with bowels
Seulphasalazine if severe
Pathophysiology of reactive arthritis
Autoimmune reaction to GI/GU infection –> symptoms incl. arthritis
Infection may have resolved by this point
Features of Reiter’s syndrome
Conjunctivitis
Arthritis
Urethritis
As autoimmune reaction (falls under reactive arthritis)
Clinical features of reactive arthritis
Large joint (commonly knee)
Keratoderma blennorhagica (brown raised plaques on soles and palms)
Conjunctivitis/anterior uveitis
Circinate balanitis (inflammatory rash on urethral meatus)
Management of reactive arthritis
Steroid injection +/- knee aspiration +/- NSAIDs
Sulphasalazine if >6mo
Features of psoriatic arthritis
Any pattern of joint disease (classically rays rather than rows)
Psoriasis (silver-scale) OR family history of psoriasis
Age 20-40
Dactylitis
Nail disease (pitting, ridging)
DIP joint involvement
Management of psoriatic arthritis
NOT hydroxychloroquine
Methotrexate, sulphasalazine, NSAIDs
Anti-TNF or anti IL-17/IL-12/23 if refractory, also cyclosporin
X-ray features of PsA
Whittling of terminal phalanges
Pencil-in-cup deformity
Ankylosis
Organisms that may produce reactive arthritis post-infection
GI: Salmonella, Shigella, Campylobacter
GU: Chlamydia, gonnorhoea
Rheumatological association of anterior uveitis
Ankylosing spondylitis
Rheum association of conjunctivitis
SLE
(RA to a lesser extent)
Rheum association of keratoconjunctivitis sicca
Sjogren’s
RA
Systemic sclerosis
HLA B27 prevalence in population
5-10%
HLA B27 prevalence in ankylosing spondylitis
90%
Prevalence of spondyloarthropathy in HLA B27 +VE
5-10% AS
20% reactive arthritis
Biologics in PsA/AS
TNF-a blockade: Etanacept, adilimumab, infliximab
IL-17 blockade: secukinimab
IL-12/23 blockade: ustekinumab
