Spondyloarthropathies

Question 1

What does the term spondyloarthropathy describe?

Answer 1

• a group of related inflammatory joint diseases of the spine or vertebral column
• note: sometimes referred to as axial spondyloarthritis and seronegative spondyloarthropathies (found in patients who don’t have rheumatoid factor)

Question 2

What are the 4 spondyloarthropathies (or seronegative spondyloarthropathies)?

Answer 2

• ankylosing spondylitis
• psoriatic arthritis
• reactive arthritis
• enteropathic arthritis

Question 3

What genetic antigen are spondyloarthropathies associated with?

Answer 3

• HLA-B27

Question 4

What is the pathology of spondyloarthropathies?

Answer 4

• entheses are the key sites of inflammation
• initially inflammation and erosions are followed by fibrosis and ossification (bone formation), which can result in ankylosis (abnormal stiffening and immobility of joints due to fusion of the bones)
• the characteristic squaring of vertebral bodies is a result of destructive osteitis and repair
• ossification leads to the formation of syndesmophytes (bony bridges)

Question 5

What are the MSK clinical features of ankylosing spondylitis and examinatoin findings (and what age group and sex does it commonly affect)?

Answer 5

• men, <50yrs
• inflammatory back pain: EMS, better with movement, alternating buttock pain
• peripheral enthesitis: Achilles tendonitis and plantar fasciitis common
• examination: sacroiliac tenderness, reduced spinal movements (as disease progresses, more kyphotic)

Question 6

What are the extraskeletal features of ankylosing spondylitis?

Answer 6

• Acute anterior uveitis (iritis): eye becomes red and vision blurred (steroid eye drops used to treat)
• Aortitis
• Apical lung fibrosis
• Amyloidosis
• Achilles tendonitis

Question 7

What investigations should be done for suspected ankylosing spondylitis?

Answer 7

• Bloods: FBC (may show anaemia of chronic disease), ESR/CRP elevated, serological tests for rheumatoid factor are negative, HLA-B27 is sensitive but not specific
• x-ray of lumbar / sacroiliac joints (later findings): squaring of vertebrae, formation of syndesmophytes (‘bamboo spine’), sacroiliitis
• MRI: can see sacroiliitis well (MRI for younger patients to avoid x-ray of pelvis)
• note: diagnosis is clinical

Question 8

Radiological findings of ankylosing spondylitis…

Answer 8

Question 9

What is the criteria for inflammatory back pain?

Answer 9

• chronic back pain (>3 months) with onset of first symptoms before 50yrs of age
• morning stiffness for at least 30 mins
• improves with exercise, but not with rest
• back pain awakens patient during second half of the night

Question 10

What is the management for ankylosing spondylitis?

Answer 10

• physio/exercise (aim to maintain posture and mobility)
• drug treatment: NSAIDs, corticosteroids, biologics (anti-TNFs)

Question 11

What is psoriatic arthritis?

Answer 11

• psoriatic arthropathy is an inflammatory arthritis associated with psoriasis

Question 12

What are the clinical features of psoriatic arthritis?

Answer 12

• family or personal hx of psoriasis: psoriatic nail involvement
• synovitis and dactylitis (sausage fingers)
• patterns of joint involvement: distal arthritis (involving DIPs), asymmetrical oligoarthritis, symmetrical arthritis (similar to RA), spondylitis, arthritis mutilans (severe and rare)

Question 13

What is the CASPAR classification?

Answer 13

• the classification criteria for diagnosing psoriatic arthritis

Question 14

Psoriatic nails…

Answer 14

• psoriatic nails with hyperkeratosis (thickening of outer layer of skin)

Question 15

What investigations should be done for suspected psoriatic arthritis?

Answer 15

• Bloods: FBC (may show anaemia of chronic disease), ESR/CRP (elevated)
• Radiological (later findings): pencil-in-cup deformities, erosive changes

Question 16

Pencil-in-cup deformities (seen in psoriatic arthritis)…

Answer 16

Question 17

What is the management for psoriatic arthritis?

Answer 17

• NSAIDs
• DMARDs (methotrexate, leflunomide)
• biologics

Question 18

What is reactive arthritis?

Answer 18

• reactive arthritis = an aseptic arthritis that occurs after an anatomically distant infection

Question 19

What are the clinical features of reactive arthritis?

Answer 19

• typically asymmetrical peripheral arthritis and/or axial arthritis (sacroiliac and lumbar region)
• dactylitis (sausage fingers)
• conjunctivitis: this is sterile
• urethritis: dysuria and urethral discharge
• skin and mucosal lesions
• (Reiter syndrome: triad of arthritis, conjunctivitis, and uveitis)

Question 20

What is Reiter syndrome?

Answer 20

• triad of arthritis, conjunctivitis, and urethritis

Question 21

What are the most common infective organisms causing reactive arthritis?

Answer 21

• STIs or GI infection: Chlamydia, Shigella, Yersinia, Salmonella

Question 22

What is the management for reactive arthritis?

Answer 22

• treat underlying infection with antibiotics
• NSAIDs
• corticosteroid injections (+/- systemic injections)

Question 23

What is enteropathic arthritis?

Answer 23

• enteropathic arthritis = arthritis occurring with inflammatory bowel disease (IBD)
• (occurs in about 20% of patients with Crohn’s disease or ulcerative colitis)

Question 24

What are the clinical features of enteropathic arthritis?

Answer 24

• occurs with IBD (Crohn’s disease or ulcerative colitis)
• axial arthritis (inflammatory)
• peripheral arthritis (usually lower limbs)
• enthesopathy: Achilles, patellar, plantar fasciitis

Question 25

What investigations should be done for suspected enteropathic arthritis?

Answer 25

• Bloods: raised ESR/CRP, -ve Rf, +ve HLA-B27
• MRI: shows inflammation if present

Question 26

What is the management for enteropathic arthritis?

Answer 26

• treatment of the IBD is priority and will help with peripheral arthritis
• corticosteroids and sulfasalazine help with both bowel and joint disease
• anti-TNFs: very effective for both bowel and joint disease
• (note: not NSAIDS, they will worsen GI symptoms)