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MSK Patrick Stenhouse > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q

What are the two main core clinical issues associated with the spondyloarthropathies?

A
  1. Back pain
  2. Joint pain and swelling
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2
Q

Where does the spondyloarthropathies mainly affect?

A

The spine

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3
Q

Spondyloarthropathies have a degree of genetic involvement. What is the gene responsible for increasing an individual’s risk of developing an associated condition?

A

HLA-B27

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4
Q

What are the 4 spondyloarthritis subgroups?

A
  1. Ankylosing spondylitis
  2. Psoriatic arthritis
  3. Reactive arthritis
  4. Enteropathic arthritis
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5
Q

How does inflammatory back pain differ from mechanical back pain?

A
  1. Onset is usually of age and is insidious
  2. Pain persists longer than 3 months (chronic)
  3. Worsens with immobility (at night and early morning)
  4. Pain/stiffness eases with physical activity and exercise
  5. NSAIDs are very effective
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6
Q

The spondyloarthropathies share many rheumatological features, what are some of these?

A
  • Enthesitis (inflammation at insertion of tendons onto bones)
  • Inflammatory arthritis which is oligoarticular, asymmetrical, and predominatly lower limb
  • Sacroiliac and spinal involvement
  • Dactylitis (inflammation of an entrire digit)
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7
Q

Give an example of enthesitis

A
  1. Plantar fasciitis
  2. Achilles tendinitis
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8
Q

What are the shared extra-articular features of the spondyloarthropathies?

A
  • Ocular inflammation (anterior uveitis, conjunctivitis)
  • Mucocutaneous lesions
  • Aortic incompetence or heart block (rare)
  • No rheumatoid nodules
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9
Q

What is ankylosing spondylitis?

A

A chronic systemic inflammatory disorder primarily affecting the spine

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10
Q

What is the hallmark of ankylosing spondylitis?

A

Sacroiliac involvement

(sacroiliitis)

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11
Q

When will ankylosing spondylitis often present?

A

Late adolescence

Early adulthood

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12
Q

In which sex is ankylosing spondylitis more common?

A

Males

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13
Q

What is the term given to bony outgrowths which cause the fusion of vertebrae in anyklosing spondyloarthritis?

A

Syndesmophytes

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14
Q

Ankylosing spondylitis is often referred to as “A” disease due to the amount of clinical features which begin with A.

List as many as you can

A
  • Anterior uveitis (also conjunctivitis)
  • Aortic valve involvement (leads to aortic regurgitation)
  • Apical pulmonary fibrosis
  • Asymptomatic enteric mucosal inflammation
  • Amyloidosis
  • Achilles tendinitis (also plantar fasciitis)
  • Atlanto-axial subluxation leading to neurological involvement
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15
Q

Which three useful clinical examinations can be used to diagnose ankylosing spondylitis?

A
  • Occiput/tragus to wall
  • Chest expansion
  • Schober’s test
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16
Q

In ankylosing spondylitis, the fusion of spinal vertebrae creates which appearance on X-ray?

A

Bamboo spine

(due to syndesmophytes)

17
Q

Why are X-rays not so useful in preventing the long term effects of ankylosing spondylitis?

A

They usually cannot show the early stages/changes of the disease and only the late presentations

18
Q

How are the best early radiological changes seen in ankylosing spondylitis?

A

MRI

19
Q

What are the treatment options for ankylosing spondylitis?

A
  • Physiotherapy
  • Occupational therapy
  • NSAIDs
  • Disease modifying drugs e.g. salazopyrin or methotrexate when there are peripheral joint involvement (rare)
  • Anti-TNF treatment (in severe AS)
20
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis

N.b - not all patients with psoriatic arthritis have psoriasis

21
Q

Is rheumatoid factor present in psoriatic arthritis?

A

No

22
Q

What are the main clinical features of psoriatic arthritis?

A
  • Sacroiliitis (often asymmetrical and potentially associated with spondylitis)
  • Nail involvement (pitting/onycholysis)
  • Dactylitis
  • Enthesitis
  • Extra-articular features such as eye disease
23
Q

What are the main findings on X-ray for psoriatic arthritis?

A
  • Mariginal erosions
  • Pencil in cup deformity
  • Osteolysis
  • Enthesitis
24
Q

How can psoriatic arthritis be treated?

A
  • Physiotheraphy, occupational therapy, orthotics, podiatry
  • NSAIDs
  • Corticosteroid drug injections
  • Disease modifying drugs e.g. methotrexate, sulfasalazine, leflunomide
  • Anti-TNF (in severe disease and unresponsive to other treatment)
  • Secukinumab (anti-IL17)
25
Q

What is reactive arthritis?

A

A systemic illness induced by infection and characterised primarility by an inflammatory synovitis

(micro-organisms cannot be cultured)

26
Q

How long does it take symptoms to come on after infection in recative arthritis?

A

1-4 weeks

27
Q

What are the most common infections to induce reactive arthritis?

A

Urogenitial - chlamydia

Enterogenic - salmonella, shigella, yersinia

28
Q

What age group is affected by reactve arthritis?

A

20-40

(equal sex distribution)

29
Q

What is Reiter’s syndrome?

A

A form of reactive arthritis

Encompasses a triad of conditions:

  1. Urethritis
  2. Conjuctivitis/uveitis/iritis
  3. Arthritis
30
Q

What are the clinical features of reactive arthritis?

A
  • General malaise, fever and fatigue
  • Asymmetrical monoarthritis or oligoarthritis
  • Enthesitis
  • Mucocutaneous lesions (oral ulcers, hyperkeratotic nails, keratoderma blennorrhagicum, circinate balanitis)
  • Occular lesions (uni or bilateral)
  • Visceral manifestations e.g. mild renal disease, carditis
31
Q

What is keratoderma blennorrhagicum and which condition is it associated with?

A

Vesico-pustular waxy skin lesions commonly found on the palms and soles but which may spread to the scrotum, scalp and trunk.

The lesions may resemble psoriasis.

Associated with reactive arthritis

32
Q

What is the most common dermatological manifestation of reactive arthritis?

A

Circinate balanitis

This is a specific dermatitis of the glans penis

33
Q

How can reactive arthritis be diagnosed?

A
  • History + Examination
  • Bloods - inflammatory markers, FBS, U+Es, HLA B27
  • Cultures of blood, urine or stool
  • Joint fluid analysis (rules out infection)
  • X-ray of affected joints
  • Opthamology opinion
34
Q

How to treat reactive arthritis?

A

Most cases spontaneously resolve within 6 months

  • NSAIDs
  • Corticosteroids
  • Antibiotics
  • DMARDs - Salazopyrin
  • Physiotherapy and occupational therapy
35
Q

Enteropathic arthritis is associated with what other chronic condition(s)?

A

Inflammatory bowel disease

  • Crohn’s disease
  • Ulcerative colitis
36
Q

Where does arthritis present in patients with enteropathic arthritis?

A

Knee, ankles, elbows and wrists

Often spine, hip and shoulder involvement occurs

37
Q

What are the clincal symptoms of enteropathic arthritis?

A
  • Loose watery stool with mucous and blood
  • Weight loss
  • Low-grade fever
  • Pyoderma gangrenosum
  • Enthesitis
  • Apthous ulcers
  • Arthritis in several joints (polyarthritis)
38
Q

Which investigations are appropriate for enteropathic arthritis?

A

GI endoscopy

Joint aspirate (to rule out infection or crystals)

Raised inflammatory markers

X-ray/MRI to show sacroiliitis

Ultrasound scan (showing synovitis/tenosynovitis)

39
Q

How is enteropathic arthritis controlled?

A
  • Treat IBD (controls symptoms)
  • No NSAID use - can worsen IBD
  • Analgesia
  • Steroids (oral, IM, IA)
  • Disease modifying drugs (methotrexate, sulfasalazine, azathioprine)
  • Anti-TNF (infliximab, adalimumab)

MSK Patrick Stenhouse (60 decks)

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