Spondyloarthritis Flashcards

1
Q

What 7 conditions does the term spondyloarthritis encompass?

A

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

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2
Q

What is the common association between all the spondyloarthritis conditions?
What function does this play?
What does a positive result signify?

A

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.

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3
Q

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?

A

5%
Risk is 4% is they are pos.
85-95% AS patients are HLA-B27 positive.

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4
Q

What are the different hypotheses for HLA-B27 to be linked to disease?

A

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.

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5
Q

Clinical features of spondyloarthritis? (SPINEACHE)

A
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)
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6
Q

What is ankylosing spondylitis?

A

Chronic inflammatory condition of the spine and sacroiliac joints of unknown aetiology (likely strong genetic and environmental factors interplay).

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7
Q

Signs and symptoms of Anklyosing spondylitis?

A
  • 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%)
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8
Q

Diagnosis of ankylosing spondylitis?

A
  • 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%)
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9
Q

Treatment/management for AS? (oxford notes not lecture)

A
  • 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.
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10
Q

Typical presentation of inflammatory back pain?

A
  • 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
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11
Q

Treatment for spondyloarthritis?

A
  • Anti TNF

- IL17 and 23 blockers

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12
Q

What is psoriatic arthritis? What changes do we see and how is it managed?

A

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
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13
Q

What is reactive arthritis?

A
  • Triad of arthritis typically after infection - bacterial gastroenteritis or STI
  • Triad: arthritis, conjunctivitis and sterile urethritis
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14
Q

What is enteropathic arthritis?

How is it treated?

A
  • 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
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