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MSK > Spondyloarthritis > Flashcards

Spondyloarthritis Flashcards

1
Q

What conditions come under the group SpA?

A 
juvenile idiopathic arthritis 
undifferentiaed SpA
reactive arthritis 
enteropathic arthritis 
psoriatic arthritis 
acute anterior uveitis/iritis
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2
Q

What protein molecule are all the spondoarthropathies assoiciated with?

A 
HLA B27 - human leucocyte antigen class I
part of the antigen presenting unit
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3
Q

Do all people who are HLA B27 + develop SpA?

A

no

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4
Q

What are the three theories that suggest how HLA B27 affects development of SpA

A
  1. molecular mimicry
  2. mis-folding theory
  3. HLA B27 heavy chain homodimer hypothesis
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5
Q

What is the theory of molecular mimicry?

A

an infection generates an immune response that produces Abs. Thew infectious agent has a similar shape to the HLA B27 protein and so autoantibodies are produced

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6
Q

What is the HLA B27 misfolding theory?

A

HLA B27 becomes unfolded and accumulates in the ER of the cell
this triggers an inflammatory cascade and this leads to the release of IL-23 by macrophages
Il-23 is a pro-inflammatory molecules that sets of inflammatory events such as triggering Th17 cells to release IL-17, which triggers IL-17 responsive cells to produce IL-6, IL-1 and TNF-alpha which lead to inflammation

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7
Q

Explain the heavy chain homodimer hypothesis

A

B27 heavy chains can form dimers and accumulate in the ER
this initiates the pro-inflammatory ER unfolded protein response
the heavy chains and dimers can bind to natural killer receptors which causes expression and survival of more proinflammatory leukocytes and as a result production of proinflammatory mediators
there is inhibitors of immune regulatory cells to form a pro-inflammatory response

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8
Q

what are the clinical features of SpA?

A

fusion of vertebrae - axial spondyloarthritis
enthesitis incl. tennis elbow or golfers elbow
acute anterior uveitis (iritis)
peripheral arthritis - often large joint oligoarthritis, but can be small joints as in RA
skin psoriasis
subclinical inflammatory bowel disease

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9
Q

What is the pneumonic to remember the features of SpA?

A 
SPINE ACHE
Sausage digit - dactylitis 
Psoriasis 
Inflammatory back pain
NSAIDs good reponse
Enthesitis

Arthritis
Crohn’s/colitis/elevated CRP
HLA B27 +
Eye - itritis/anterior uveitis

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10
Q

What is ankalosing spondylitis. axial spondyloarthritis?

A

inflammatory arthritis of the spine and rib cage - eventually leading to new bone formation and fusion of the joints

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11
Q

What is the radiological features of the spine called in ankylosing spondylitis?

A

bamboo spine

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12
Q

What makes for a poor prognosis in ankylosing spondylitis?

A 
male
smokers 
B27+
syndesmophytes at presentation
high CRP
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13
Q

What two features are seen on an X-ray of ankylosing spondylitis?

A

syndesmophytes

scaroiliitis

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14
Q

What does are the features of the sacroiliac joint on X-ray in ankylosing spondylitis?

A

sclerosis
erosions
loss of joint space
bone fusion

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15
Q

Where does the pt get the pain with sacroilitis?

A

the middle of their buttock

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16
Q

What radiological scan is used to make the diagnosis of sacroilititis and why?

A

MRI - it may take many years for the changes to be detected on X-ray, so MRI is more sensitive, can make the diagnosis earlier

17
Q

what are the features of sacroiliitis on MRI?

A

inflammation

white patches - show subchondral, periarticular bone marrow oedema

18
Q

what is the name given to the shape of the spine in advanced ankylosing spondylitis?

A

kyphosis

19
Q

what is the sequence of structural damage in ankylosing spondylitis?

A
  1. inflammation of the anterior corners of the vertebrae
  2. get an exagerated immune response, so get erosion
  3. the syndesmophytes grow in the area of inflammation
20
Q

What is the delayed damage theory?

A

once inflammation of the spine has occurred in ankylosing spondylitis, the new bone formation is inevitable and so once treatment has started, new bone continues to form for some time after

21
Q

What questions would you ask a pt to diagnose inflammatory back pain in ankylosing spondylitis?

A

a) do they have back stiffness in the morning?
b) does the pain wake them up at night, clasically in the second half of the night due to stiffening up?
c) do they get alternating buttock pain?
d) improvement of pain with exercise?
e) <40 at the age of onset?
if they have 4/5 of these then it is IBP

22
Q

Describe the spectrum of disease within ankylosing spondylitis

A

1) non-radiographic stage -back pain, MRI changes are seen ie sacroiliitis, but XR normal
2) radiographic stage: back pain,XR shows sacroiliitis
3) radiographic stage: back pain, XR shows syndesmophytes

23
Q

Describe a diagnostic tool that is used for ankylosing sponylitis

A 
pts have had >3months back pain 
age of onset <45 yrs old 
sacroiliits on imaging (either MRI or XR)
and >=1 SpA feature ie from SPINE ACHE
---------------------------------------
or 
pts have had >3months back pain 
age of onset <45 yrs old 
HLA-B27 +ve
>=2 SpA features from SPINE ACHE
24
Q

what treatments are available for ankylosing spondylitis?

A

anti-nflammatories
physio
biological therapies - these are disease modifying where the other two are just for symptom control

25
Q

Give some examples of biological therapies used for ankylosing spondylitis

A

TNF inhibitors ie Infliximab

IL-17 and IL-23 blockers

26
Q

What are the five typical patterns of joint involvement in psoriatic arthritis?

A

a) polyarticular symmetrical arthritis - similar pattern to RA
b) large joint oligoarthritis - eg just a knee and an ankle that are swollen
c) arthritis that just affects the DIP
d) mutilating deforming arthritis = arthritis mutilans, ie telescoping of fingers
e) axial disease - like in ankylosing spondylitis but in a pt who has skin psoriasis

27
Q

What types of arthritis can be responsible for arthritis that is just present in the DIP joints?

A

osteoarthritis

psoriatic arthritis

28
Q

What is dactylitis?

A

inflammation of the tendon sheaths and joints of a digit

29
Q

What are the hidden sites for psoriasis?

A 
behind the ears
in the scalp
in the ears 
genitals 
belly button 
multiple pits in nails 
onchycholysis - creamy white discoloration of the nail and nail detachment
30
Q

give some examples of conventional DMARDs

A 
ciclosporin 
cyclophosphamide 
gold injections 
hydroxychloroquine 
methotrexate 
mycophenolate 
sulfasalazine
31
Q

How is psoriatic arthritis managed?

A

a) early intervention with a conventional DMARD
b) anti-TNF drugs eg infliximab
c) IL-17/ IL-23 blockers

32
Q

What is reactive arthritis?

A

STERILE inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GIT infection or STI

33
Q

give example of GIT infections that can cause reactive arthritis

A

Salmonella
Shigella
Yersinia

34
Q

give examples of STIs that cause ReA

A

Chlamydia

Ureaplasma urealyticum

35
Q

what are the clinical features of ReA?

A

classical triad of:
arthritis
conjunctivitis
sterile urethritis

keratoderma blenorrhagica
iritis
circinate balanitis (dermatitis of the glans penis)

36
Q

What are the differential diagnoses of ReA?

A

septic arthritis - ie joint infection

gout

37
Q

How is ReA investigated to exclude other diagnoses?

A

raised ESR/CRP
aspirate joint to exclude infection/crystals
urethral swab, stool culture
contact tracing if necessary

38
Q

Explain what enteropathic arthritis is

A

episodic peripheral synovitis
assymetrical lower limb arthritis
reflects IBD activity

or can have ankylosing spondylitis that is unrelated to IBD activity

39
Q

the arthritis seen in enteropathic arthritis is erosive, T or F?

A

false - it is non-erosive

MSK (12 decks)

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