Spondyloarthropathies

Question 1

What are spondyloarthropathies?

Answer 1

Group of conditions that affect the spine and peripheral joints and are associated with HLA-B27 gene.

• Ankylosing spondylitis
• Enteropathic arthritis
• Psoriatic arthritis
• Reactive arthritis

Question 2

What are the common clinical features of spondyloarthropathies?

Answer 2

• Sacroiliac/axial disease (back/buttock pain)
• Inflammatory arthropathy of peripheral joints
• Enthesitis (inflammation of tendon insertion(
• Extra-articular features (skin/gut/eye)

Question 3

What is the usual presentation of ankylosing spondylitis?

Answer 3

Young males, bilateral buttock pain, chest wall and thoracic pain

Question 4

What can be seen on examination of someone with AS?

Answer 4

Normal but later on in disease: lumbar lordosis and exaggerated thoracic kyphosis.

Schober’s test - mark skin 10cm above and 5cm below PSIS, get patient to bend forwards with straight legs - a distance increase of 20cm or more is normal, less implies AS

Reduced chest expansion

Question 5

What investigations do you do for AS?

Answer 5

CRP - raised but often normal

MRI spine and SI joints

Question 6

What is the treatment for AS?

Answer 6

NSAIDs and physio

TNF inhibitors or IL-17 inhibitors

Question 7

Which patients have psoriatic arthritis?

Answer 7

10% of those with psoriasis

Male = Female

Question 8

What are typical examination findings for PA?

Answer 8

• Oligo-arthritis with dactylitis/”sausage” digit
• Symmetrical or mono-arthritis
• Severe deformities - arthritis mutilans in 5% of cases

Question 9

What investigations do you do for PA?

Answer 9

• CRP - raised
• USS/MRI - central joint erosions
• X-ray - pencil in cup appearance

Question 10

What is the treatment for PA?

Answer 10

NSAIDS, DMARDs, TNF inhibitors, IL-17 inhibitors, IL12/23 inhibitors

Question 11

What is reactive arthritis?

Answer 11

Sterile synovitis occurring after a distant infection e.g. post dysentery (Salmonella, Shigella, Campylobacter) or urethritis/cervicitis (Chlamydia trachomatis)

Question 12

How does reactive arthritis present?

Answer 12

A few days to 2 weeks post infection
Acute asymmetrical lower limb arthritis develops

Skin - circinate balanitis, keratoderma blennorrhagica
Eye - conjunctivitis, uveitis
Enthesitis

Question 13

What investigations are done for reactive arthritis?

Answer 13

Serology/microbiology
Inflammatory markers - raised
Joint aspiration to rule out septic/crystal arthritis

Question 14

What is the treatment for reactive arthritis?

Answer 14

Treat underlying infection
NSAIDs and joint injections
Most resolve in 2 years, those that don’t require DMARDs

Question 15

Who gets enteropathic arthritis?

Answer 15

10-20% patients with IBD get arthropathy, 2/3rds of these get peripheral arthritis and 1/3 axial disease

Question 16

What are the two types of peripheral disease in enteropathic arthritis?

Answer 16

Type 1 - oligoarticular, asymmetric and correlated with IBD flares

Type 2 - polyarticular, symmetrical and less correlated with IBD flares

Question 17

How is enteropathic arthritis treated?

Answer 17

DMARDs or TNF inhibitors

NSAIDs may flare the IBD

Question 18

What are extra-articular manifestations of AS? (all As)

Answer 18

• Anterior uveitis
• Aortic incompetence
• AV block
• Apical lung fibrosis
• Amyloidosis

Question 19

Features of inflammatory back pain: (mnemonic IPAIN)

Answer 19

Insidious onset
Pain at night 
Age at onset under 40
Improvement with exercise
No improvement with rest