Spondyloarthropathies Flashcards
What does the term spondyloarthropathy describe?
- 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)
What are the 4 spondyloarthropathies (or seronegative spondyloarthropathies)?
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis
What genetic antigen are spondyloarthropathies associated with?
- HLA-B27
What is the pathology of spondyloarthropathies?
- 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)
What are the MSK clinical features of ankylosing spondylitis and examinatoin findings (and what age group and sex does it commonly affect)?
- 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)
What are the extraskeletal features of ankylosing spondylitis?
- Acute anterior uveitis (iritis): eye becomes red and vision blurred (steroid eye drops used to treat)
- Aortitis
- Apical lung fibrosis
- Amyloidosis
- Achilles tendonitis
What investigations should be done for suspected ankylosing spondylitis?
- 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
Radiological findings of ankylosing spondylitis…
What is the criteria for inflammatory back pain?
- 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
What is the management for ankylosing spondylitis?
- physio/exercise (aim to maintain posture and mobility)
- drug treatment: NSAIDs, corticosteroids, biologics (anti-TNFs)
What is psoriatic arthritis?
- psoriatic arthropathy is an inflammatory arthritis associated with psoriasis
What are the clinical features of psoriatic arthritis?
- 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)
What is the CASPAR classification?
- the classification criteria for diagnosing psoriatic arthritis
Psoriatic nails…
- psoriatic nails with hyperkeratosis (thickening of outer layer of skin)
What investigations should be done for suspected psoriatic arthritis?
- Bloods: FBC (may show anaemia of chronic disease), ESR/CRP (elevated)
- Radiological (later findings): pencil-in-cup deformities, erosive changes
Pencil-in-cup deformities (seen in psoriatic arthritis)…
What is the management for psoriatic arthritis?
- NSAIDs
- DMARDs (methotrexate, leflunomide)
- biologics
What is reactive arthritis?
- reactive arthritis = an aseptic arthritis that occurs after an anatomically distant infection
What are the clinical features of reactive arthritis?
- 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)
What is Reiter syndrome?
- triad of arthritis, conjunctivitis, and urethritis
What are the most common infective organisms causing reactive arthritis?
- STIs or GI infection: Chlamydia, Shigella, Yersinia, Salmonella
What is the management for reactive arthritis?
- treat underlying infection with antibiotics
- NSAIDs
- corticosteroid injections (+/- systemic injections)
What is enteropathic arthritis?
- enteropathic arthritis = arthritis occurring with inflammatory bowel disease (IBD)
- (occurs in about 20% of patients with Crohn’s disease or ulcerative colitis)
What are the clinical features of enteropathic arthritis?
- occurs with IBD (Crohn’s disease or ulcerative colitis)
- axial arthritis (inflammatory)
- peripheral arthritis (usually lower limbs)
- enthesopathy: Achilles, patellar, plantar fasciitis
What investigations should be done for suspected enteropathic arthritis?
- Bloods: raised ESR/CRP, -ve Rf, +ve HLA-B27
- MRI: shows inflammation if present
What is the management for enteropathic arthritis?
- 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)
