Spondyloarthritis Flashcards
Definition of spondyloarthritis
Group of inflammatory arthropathies that share distinctive clinical, radiological and genetic features, SPA is characterised by enthesitis (inflammation at insertion of tendon, ligament or capsule into bone) as well as synovitis and occurs in patient who are sero-negative for RF.
Features of spondyloarthritis
- inflammatory arthirtis of spine
- Sacrolitis seen radiologically
- seronegative peripheral arthritis
- usually asymmetrical peripheral arthritis
- genetics- HLA B27 present
- Enthesitis
- extra-articular features
Disease classified as spondyloarthritis
- anjylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- arthritis associated with inflammatory bowel disease
- undifferentiated
Ankylosing spondylitis definition
Chronic inflammatory disease of the spine and sacroiliac joints of unknown aetiology
AS epidemiology
- usually <40
- 3 x more likely in men
- caucasians more commonly affected
- 90-95% of patients HLA b27 positive
AS clinical features (MSK)
- Insidious lower back pain
- early morning stiffness/stiffness with immobility
- better with exercise and anti-inflammatories
- buttock pain, often alternating
- peripheral joint involvement - hips and shoulders especially
- entesitis - heel, plantar, chest pain
- constitutional - fatigue, weight loss, low grade fever, anaemia
Extra-articular clinical features of AS
All the A’s
- Achilles tendonitis
- Anterior uveitis - eye becomes painful, red and vision is blurred. Can cause blindness
- Aortic regurgitation
- Aortic valve disease
- Aortitis
- AV node block
- Apical fibrosis
- Amyloidosis
Examination of AS
- Lumbar spine movement
- schober’s test
- cervical spine movement
- tragus- wall (ask patient to stand flat against wall and try to get back of neck as close to wall as possible - measure tragus to wall distance <10cm is normal)
- occiput - wall
- chest expansion - involvement of thoracic spine and ethesistis at costochondral junctions may cause chest pain and reduce chest expansion
- sacroiliac joint tenderness
- Normal lumbar lordosis is lost and thoracic and cervical spine become increasinly kyphotic
- extra-articular features
AS investigations
Bloods
- ESR/CRP may be raised
- HLA B27 not helpful diagnostically
X-ray
- Sacroiliitis
- Squaring of vertebrae
- Syndesmophytes
- Bamboo spine
- Dagger sign
CT
Isotope bone scan
MRI- Most sensitive for SI joint and lumbar spine involvement
Diagnosis for AS
- Definite AS if radiological and clinical criterion
- Probable AS if 3 clinical criterion or a radiological criterion without signs or symptoms satisfying the clinical criterion
AS management
- Education/ self help groups
- Analgesia – paracetamol, NSAIDs, COX-2
- Regular exercise
- Physiotherapy
- Hydrotherapy
- DMARDs for peripheral arthritis only – sulphasalazine
- Intra-articular steroids
- Biologicals – anti-TNF
- Surgical
Psoriatic arthritis definiton
Psoriatic arthropathy is an inflammatory arthritis associated with psoriasis
Epidemiology of Psoriatic arthritis (PsA)
- about 10% of patients with psoriasis develop inflamamtory arthritis
- joint disease can predate skin disease
- Males and females affected equally
- usually age of onset 20-40 years
- RF positive in up to 10% patients
PsA clinical features
Variable clinical patterns:
- asymmetrical oligoarthritis
- DIP joint disease
- Sacroilitis - inflammation of one or more of your sacroiliac joints
- symmetrical polyarthritis
- arthritis mutilans - extremely severe, destructive form of arthritis
Dactyliis - inflammation of entire digit “sausage shaped”
Enthesitis - inflammation of the entheses (sites where tendon/ligament connects to bone) & Tenosynovitiis - Inflammation and swelling of a tendon
Psoratic nail and skin changes
PsA investigation
Bloods
- CRP/ESR
- HLA B27 present in 50% of those with spinal involvement
XRAYs
- DIP disease
- Lysis of terminal phalanges “whittling”
- Assymetry
- “pencil in cup” deformity
- skylosis
- periostitis
- spondylitis
PsA management
- Need to treat skin and joints
- NSAIDs
- methotrexate- good for skin and joints
- sulasalazine - useful when axial and peripheral joint involvmeent
- intra-articular steroids
- Anti-TNF
- Psoriatic arthritis res[onse criteria (PSARC) management
Prognosis PsA
- Generally runs a more benign course
- About 20% have chronic, progressive, destructive disease
- Reduced quality of life
- Reduced employments rates
- Increased morbidity and mortality
- Mainly due to increased cardiovascular morbidity/mortality
Reactive arthritis definition
Reactive arthritis is an aspetic arthiritis that develops after an anatomicallly distant infection. It mainly affects young adults and triggering infeciton is usually of the GI or GU tract. Associated with inflammatory bowel disease.
Common organisms associated with reactive arthritis
- salmonella
- campylobacter jejuni and coli
- yersinia enterocolitica
- shigella
- chlamydia trachomatis
- C.Diff
Aetiology of REA
- not fully understood
- HLA B27 positive people have increased risk - 20-25%
- Joint culture negative for organism
REA clinical features
- Acute onset
- Usually oligoarticular – especially weight bearing joints
- Hot and swollen joint
- Inflammatory back pain/ sacro-iliac joint tenderness
- Systemic symptoms – malaise, fever
- Extra-articular features
- Good history
- Recent infection
- New sexual partner
REA investigation
- Bloods
- ESR/CRP raised
- Exclude differentials
- Joint aspiration
- Stool culture
- Urethral culture
- PCR for chylamydia
- IgM antibodies/ IgG or IgA for enteric infection
- HLA B27 – prognostic value
REA treatment and prognosis
- NSAIDs
- intra-articular steroids
- DMARDs- methotrexate/sulfasalazine
- Long term antibiotics
Arthritis associated with IBD
- Many patients with IBD also have inflammatory arthritis
- 10% peripheral
- 5% axial (AS like disease)
- Unknown aetiology/ pathogenesis
- Gut flora likely play a role – impaired gut mediated immunity, increased bowel permeability
- Peripheral arthritis divided into:
- Type I – oligoarticular, asymmetrical, related to activity of IBD
- Type II – polyarticular, symmetrical, unrelated to disease activity
- Enthesopathy and extra-articular features common
- Treatment – similar to that for other forms of spondyloarthritis
- Sulfasalazine is DMARD of choice
- Anti-TNFα beneficial in Crohn’s disease but not UC
