Spondyloarthritis Flashcards
What 7 conditions does the term spondyloarthritis encompass?
Reactive: consequence of GI enteritis or STIs
Psoriatic: associated with those with psoriasis
Enteropathic: experienced in chron’s, UC, coeliac etc.
Anklyosing spondylosis: chronic inflammatory condition of spine and sacroiliac joints
Acute Anterior Uvetis
Undifferentiated spondyloarthritis
Juvenile Idiopathic Arthritis
What is the common association between all the spondyloarthritis conditions?
What function does this play?
What does a positive result signify?
HLA-B27 gene which plays a vital role in self-recognition and immunity.
Positive result increases risk of someone having certain autoimmune condition such as spondyloarthritis.
What percentage of the UK pop are HLA-B27 pos?
What is the risk of someone with HLA-B27 pos developing spondyloarthritis or eye disease?
What percentage of people with AS are HLAB27 pos?
5%
Risk is 4% is they are pos.
85-95% AS patients are HLA-B27 positive.
What are the different hypotheses for HLA-B27 to be linked to disease?
Molecular mimicry
→ infection → immune response → infectious agent has peptides very similar to HLA-B27 molecule → auto-immune response triggered against HLA-B27
Mis-folding
→ HLA can misfold and when it is unfolding it can accumulate in the ER of cells → triggers inflammatory response called ER-unfolded protein response → cytokine cascade (IL23, IL17) → important as drugs now target IL23 and IL17 as these inflammatory cytokines are present in higher amounts in those with SA
Heavy chain homo-dimer hypothesis
→ HLAB27 heavy chains join to form a dimer → accumulate in ER → triggers same ER-unfolded protein response as above.
Clinical features of spondyloarthritis? (SPINEACHE)
Sausage digit (dactylitis) Psoriasis Inflammatory back pain NSAID good response Enthesitis - inflammation of site of insertion of a tendon or ligament into bone (Achilles tendon, heel, tennis or golfers elbow) Arthritis - pathology of spine/sacroiliac joints CRP/chrons/colitis HLAB27 positive - 85% SpA are pos Eye (uvetis)
What is ankylosing spondylitis?
Chronic inflammatory condition of the spine and sacroiliac joints of unknown aetiology (likely strong genetic and environmental factors interplay).
Signs and symptoms of Anklyosing spondylitis?
- Typical patient is male <30 with gradual onset of low back pain, worse during the night with spinal morning stiffness relieved by exercise
- Pain radiates from sacroiliac joints → hips or buttocks and usually improves towards the end of the day
- Progressive loss of spinal movement and therefore, decreased thoracic expansion.
- Other symptoms/signs include enthesitis (esp Achilles tendonitis, plantar fascitis at tibial and ischial tuberosities and iliac crests)
- Anterior mechanical chest pain due to costochondritis and fatigue may feature
- Acute iritis occurs in 1/3 of patients and can lead to blindness if not treated
- Associated with osteoporosis (up to 60%) and aortic valve incompetence (3%)
Diagnosis of ankylosing spondylitis?
- Diagnosis is clinical supported by MRI & XRAY
- MRI shows active inflammation (bone marrow oedema) as well as destructive changes such as erosions, sclerosis and ankylosis
- Xray can show SI joint space narrowing or widening, sclerosis, ankylosis or fusion. Vertebral syndesmphytes are characteristic (often T11-L1 initially), bony proliferations between ligaments and vertebrae.
→ These fuse with the vertebral body above causing anyklosis
→ Later stages = calcification of ligaments with ankylosis lead to bamboo spine appearance - FBC - increased ESR, CRP, HLAB27 pos (95%)
Treatment/management for AS? (oxford notes not lecture)
- Exercise, not rest, for back pain and intense regimens to maintain posture and mobility - physio
- NSAIDs usually relieve symptoms within 48hr
- TNFa blockers (etanercept, adalimumab) are indicated in severe active AS
- Local steroid injections for temporary relief
- Surgery: hip replacement to improve pain and mobility
- Bisphosphonates can be considered as those with AS are higher risk for osteoporotic spinal fractures.
Typical presentation of inflammatory back pain?
- Young
- Usually present for a long time
- Morning stiffness
- Improvement with exercise
- Awakening at night due to pain
- Pain around the rib cage
- Buttock pain - sacroiliac joint fusion pain
Treatment for spondyloarthritis?
- Anti TNF
- IL17 and 23 blockers
What is psoriatic arthritis? What changes do we see and how is it managed?
Occurs in 10-40% patients with psoriasis and can present before skin changes.
- Symmetrical polyarthritis (like RA)
- Asymmetrical oligoarthritis
- Spinal (similar to AS)
- Psoriatic arthritis mutilans (rare)
- *Radiological changes**
- Erosive changes with pencil in cup deformity (hands) in severe cases
- Associated with nail changes in. 80% synovitis
- *Management**
- NSAIDs, sulfasalazinem methotrexatem anti-TNF agents are also effective
What is reactive arthritis?
- Triad of arthritis typically after infection - bacterial gastroenteritis or STI
- Triad: arthritis, conjunctivitis and sterile urethritis
What is enteropathic arthritis?
How is it treated?
- Arthritis associated with UC/C disease, Whipples disease, coeliac and GI bypass
- Arthropathy often improves with treatment of bowel symptoms (beware NSAIDs)
- Same in joint distribution as psoriatic arthritis
- Can occur as flares
- Methotrexate works for both GI and joint flares
- Anti TNF work for both bowel and joints