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MSK + Rheumatology > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q

What is spondyloarthritis?

A

Seronegative Spondyloarthropathies -
Group of overlapping conditions that all share certain clinical features in their joint disease of the vertebral column.

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2
Q

Give 5 conditions that fall under the umbrella term spondyloarthritis.

A
  1. Ankylosing spondylitis.
  2. Reactive arthritis.
  3. Psoriatic arthritis.
  4. Enteropathic / Enteric arthritis.
  5. Juvenile idiopathic arthritis (JIA).
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3
Q

What clinical features do all spondyloarthropathies have in common?

A
  1. Axial inflammation - spine and sacroiliac joints
  2. Asymmetrical peripheral arthritis
  3. Absence of rheumatoid factor hence ‘seronegative’
  4. STRONG ASSOCIATION with HLA-B27 - but aetiological relevance is unclear
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4
Q

With what tissue type are all spondyloarthritis conditions associated?

A

They are all associated with tissue type HLAB27.

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5
Q

What is HLAB27? What is it encoded by?

A

Human Leucocyte Antigen (HLA) B27
- Class I surface antigen - present on all cells, except RBCs
- Encoded by Major Histocompatibility Complex (MHC) on chromosome 6

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6
Q

What is the function of HLAB27?

A

It is an antigen presenting cell.

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7
Q

Epidemiology: where is HLAB27 most commonly found?

A

Most common in the northern hemisphere - 9% in UK, very rare in subSaharan Africa

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8
Q

With which seronegative spondyloarthropathy is HLAB27 particularly associated with?

A

Prevalence of HLA-B27 affects prevalence of ankylosing spondylitis (AS).

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9
Q

Name 3 theories that can explain why HLAB27 is associated with spondyloarthritis.

A
  1. Molecular mimicry.
  2. Mis-folding theory.
  3. HLAB27 heavy chain hypothesis.
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10
Q

Describe the ‘molecular mimicry’ theory for explaining why HLAB27 is associated with spondyloarthritis.

A

Infectious agents have peptides very similar to HLAB27. An auto-immune response is triggered against HLAB27.

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11
Q

What joints tend to be affected in seronegative spondyloarthropathies?

A

Asymmetrical large joints.

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12
Q

What signs would make you think of spondyloarthropathy diagnosis?
HINT: Mnemonic!

A

Think seronegative spondyloarthropathies (SpA) if SPINEACHE:
- Sausage digit (dactylitis)
- Psoriasis
- Inflammatory back pain
- NSAID good response
- Enthesitis (particularly in heel - plantar fasciitis)
- Arthritis
- Crohn’s/Colitis/elevated CRP (can be normal in AS)
- HLA-B27
- Eye (uveitis)

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13
Q

Define Ankylosing spondylitis.

A

Chronic inflammatory disorder of the spine, ribs and sacroiliac joints, with unknown aetiology.

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14
Q

Describe the epidemiology of AS.

A

1, Males > Females (more common + more severe)
2. Young adults (<30 YO)
3. 88% are HLA-B27 positive
4. Women present later and are under-diagnosed
5. Low incidence in African and Japanese people
6. Native North Americans have high incidence

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15
Q

What antibody is NEVER seen with ankylosing spondylitis?

A

Rheumatoid factor

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16
Q

Give 2 risk factors for AS.

A
  1. HLA-B27
  2. Environment:
    * Klebsiella
    * Salmonella
    * Shigella
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17
Q

Does ankylosing spondylitis more commonly affect men or women?

A

Men

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18
Q

Describe the pathophysiology of AS.

A
  1. Inflammation in the anterior corners of the spine
  2. Local erosion of the bone at the attachments of the intervertebral + other ligaments (I.E. enthesitis)
  3. Fat is laid down
  4. Fat is replaced with bone - healed with new bone formation = Syndesmophytes
  5. Irreversible fusion of spine = stiffness!!
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19
Q

What joints does ankylosing spondylitis affect?

A
  1. Sacroiliac joints
  2. Joints of the vertebral column of the spine
  • 1-3 joints
  • Asymmetrical
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20
Q

Give 5 symptoms of ankylosing spondylitis.

A
  1. Lower BACK PAIN!
  2. Sacroiliac pain in the buttock region.
  3. Morning stiffness (takes at least 30 mins to improve)
  4. Stiffness worsens with rest + improves with movement.
  5. Waking in the second half of the night.
  6. Insidious onset - Slow onset -> 3 months.
  7. Usually <40 YO at onset.
  8. Enthesitis - Achilles tendinitis, plantar fasciitis (under heel) and tenderness around the pelvis and chest wall
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21
Q

Describe the back pain experienced in ankylosing spondylitis.

A

Radiating from sacroiliac joints to hips/buttocks.
Worse at night, improves towards end of day.

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22
Q

What is the time course of ankylosing spondylitis?

A

At least 3 months
With flares/remitting

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23
Q

Describe the severe clinical features of ankylosing spondylitis.

A

Severe disease - kyphosis and neck hyperextension - question mark posture - Bamboo spine

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24
Q

Give 2 characteristic spinal abnormalities in ankylosing spondylitis.

A

2 characteristic spinal abnormalities:

  1. Loss of lumbar lordosis + Increased kyphosis
    - Lordosis = Normal inward curve of spine)
    - Kyphosis = curvature of spine that causes top of back to appear more rounded than normal
  2. Limitation of lumbar spine mobility in both sagittal and frontal planes
    → Reduced spinal flexion is demonstrated by the SCHOBER TEST.
    → A mark is made at the 5th lumbar spinous process and 10cm above, with the patient in the erect position.
    → On bending forward, the distance should increase to more than 15cm in normal individuals.
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25
Q

What is the Schober’s test?
Explain how to do Schober’s test.

A

This is a test used as part of a general examination of the spine to assess how much mobility there is in the spine.

Have the patient stand
Locate L5 vertebrae
Mark a point 10 cm above and 5 cm below
Ask pt to bend over as far as they can
Measure the new distance
Less than 20 cm is positive for AS

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26
Q

What is the typical clinical presentation of ankylosing spondylitis?

A

Typical patient is a man < 30 yrs with gradual onset of low back pain, worse at night, with spinal morning stiffness that is relieved by exercise.

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27
Q

Give 3 non-articular features of AS.

A

Non-articular features:
1. Anterior uveitis - inflammation of middle layer of eye
2. Associated with osteoporosis
3. Rarely; aortic incompetence, cardiac conduction defects and apical lung fibrosis, amyloidosis and IgA nephropathy

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28
Q

Name 2 diseases associated with ankylosing spondylitis.

A
  1. Osteoporosis
  2. Aortic valve incompetence
  3. Pulmonary fibrosis
29
Q

What investigations might you do in someone who you suspect to have ankylosing spondylitis?

A
  1. Bloods
    * ESR and CRP raised - NOTE: CRP can be normal
    * Normocytic anaemia
    * HLA-B27 positive - NOT DIAGNOSTIC
  2. X-ray
  3. MRI
30
Q

What changes would you see on x ray in ankylosing spondylitis? (5)

A

Fusion of the spine leads to the classical “bamboo spine” appearance on X-rays.

  1. Squaring of the vertebral bodies
  2. Subchondral sclerosis and erosions
  3. Syndesmophytes
    - Areas of bone growth where the ligaments insert into the bone.
    - They occur related to the ligaments supporting the intervertebral joints.
  4. Ossification of the ligaments, discs and joints
    - This is where these structures turn to bone.
  5. Fusion of the facet, sacroiliac and costovertebral joints
31
Q

What would a MRI scan show for ankylosing spondylitis?

A

With gadolinium, it can show bone marrow oedema + sacrolitis early in the disease BEFORE there are any X-ray changes.

32
Q

What is the diagnostic criteria for ankylosing spondylitis?

A
  1. > 3 months back pain.
  2. Aged <45 at onset.
  3. Plus one of the SPINEACHE symptoms.
33
Q

Treatment for ankylosing spondylitis.

A

infliximab
Nsaids
steroids

  1. Morning exercise to maintain posture and spinal mobility
  2. Analgesia - NSAIDs - useful at night
    - e.g. IBUPROFEN or NAPROXEN
  3. METHOTREXATE to help with peripheral arthritis but NOT with spinal disease
  4. TNF-a blocker
    * Can improve spinal and peripheral joint inflammation
    - The earlier you start, the less syndesmophytes form
    * E.g INFLIXIMAB (IV), ETANERCEPT (SC) or ADALIMUMAB (SC)
    - Give Secukinumab (mAb againSt IL-17) if the response to NSAIDs + TNF-a blockers is inadequate
  5. Local steroid injections for temporary relief
    - Used during flares to control symptoms
    - Oral, IM slow release injections, joint injections
  6. Surgery
    - e.g. hip replacement to improve pain and mobility
34
Q

What provides the best relief for the symptoms associated with ankylosing spondylitis?

A

Exercise.

35
Q

What is reactive arthritis?

A

Sterile inflammation of the synovial membrane (synovitis), tendons and fascia triggered by an infection at a distant site, usually gastro-intestinal or genital

36
Q

Give some possible causative organisms of reactive arthritis.

A
  • GI infections:
  • Salmonella
  • Shigella
  • Yersinia enterocolitica
  • Campylobacter jejuni
  • Sexually acquired:
  • Urethritis from chlamydia trachomatis
  • Ureaplasma urealyticum
37
Q

What gut infections are associated with reactive arthritis?

A

Salmonella, shigella.

38
Q

What sexually transmitted infections are associated with reactive arthritis?

A

Chlamydia.

39
Q

What is the triad of symptoms for reactive arthritis?

A

Reiter’s Triad -

Can’t see, can’t wee, can’t climb a tree:

  1. Conjunctivitis
  2. Sterile Urethritis
  3. Arthritis.
40
Q

What is the arthritis like in reactive arthritis?

A

Acute
Asymmetrical
Lower leg

41
Q

List some clinical features of reactive arthritis.

A
  1. Asymmetrical joint involvement, generally of lower limbs.
  2. Skin lesions may resemble psoriasis.
  3. Iritis.
  4. Keratoderma blenorrhagica (bown plaques on soles and palms).
  5. Mouth ulcers.
  6. Enthesitis.
42
Q

Diagnosis of reactive arthritis.

A
  1. Bloods
    - ESR & CRP raised in acute phase
  2. Culture stool if diarrhoea
  3. Sexual health review
  4. Aspirated synovial fluid is sterile with a high neutrophil count:
    * If the joint is hot and swollen can exclude crystal arthritis i.e gout and septic arthritis i.e. infection using aspiration
  5. X-ray
    - May show enthesitis
43
Q

How would you treat reactive arthritis?

A
  1. Joint inflammation - NSAIDs and corticosteroid injections
  2. Treat persisting infection with antibiotics
  3. Relapsing cases - Methotrexate / Sulfasalazine
    - If disease is severe + persistent;
  4. Then use: TNF-a blocker e.g. Etanercept + Golimumab
  5. Screen sexual partners
  • Majority of individuals with reactive arthritis have a single attack that settles, but a few develop disabling relapsing and remitting arthritis.
44
Q

Define psoriatic arthritis.

A

An inflammatory arthritis associated with psoriasis. This can vary in severity.
Can occur WITHOUT psoriasis!

45
Q

Describe the epidemiology of psoriatic arthritis.

A
  1. Occurs in 10-40% with psoriasis and can present before skin changes
  2. Within 10yrs of getting psoriasis
  3. Typically middle aged
46
Q

What are the 5 main patterns of psoriatic arthritis?

A
  1. Symmetrical polyarthritis
    - Hands, wrists, ankles, DIP
    - Women
    - Closely resembling RA
  2. Asymmetrical oligoarthritis
    - Hands + feet
  3. Spondylitis
    - Unilateral or bilateral sacrolitis and early cervical spine
    involvement
    - Men
  4. Distal interphalangeal arthritis
    - DIPJs involvement ONLY
    - MOST TYPICAL PATTERN of joint involvement in psoriasis
    - Often with adjacent nail dystrophy, reflecting enthesitis extending into the nail root
    - Dactylitis (sausage fingers)
  5. Arthritis mutilans
    - Most severe form of psoriatic arthritis
    - Occurs in the phalanxes
    - Periarticular osteolysis (bone resorption) -> progressive bone shortening -> ‘telescopic fingers’
47
Q

Psoriatic arthritis commonly involves swelling of what joint?

A

DIP joint.

48
Q

How would describe the swelling of fingers seen in psoriatic arthritis?

A

Dactylitis, sausage like swelling.

49
Q

Is there morning stiffness in psoriatic arthritis?

A

Yes

50
Q

Give 3 extra articular features of psoriatic arthritis.

A
  1. Plaques of psoriasis on the skin
  2. Pitting of the nails
  3. Onycholysis (separation of the nail from the nail bed)
  4. Dactylitis (inflammation of the full finger)
  5. Enthesitis (inflammation of the entheses, which are the points of insertion of tendons into bone)
51
Q

Give 2 associated conditions of psoriatic arthritis.

A

Other Associations:
1. Eye disease (conjunctivitis and anterior uveitis)
2. Aortitis (inflammation of the aorta)
3. Amyloidosis

52
Q

Describe a psoriatic plaque.

A

Pink, scaling lesions. Occur on extensor surfaces of the limbs.

53
Q

Give 3 locations that psoriasis commonly occurs at.

A
  1. Elbows.
  2. Knees.
  3. Fingers.
54
Q

Give 3 hidden sites for psoriasis.

A

Hidden sites for psoriasis:
1. Behind ear/inside ear
2. Scalp
3. Pitting in nails or onokylisis - where the nail lifts off the nail bed and looks brittle and flaky
4. Umbilicus, natal cleft and penile psoriasis - genitals

55
Q

Investigations for psoriatic arthritis.

A
  1. Bloods and ESR are often normal
  2. X-ray:
    * Psoriatic arthritis is erosive but the erosions are central in the joint, not juxta-articular
  • May be a ‘pencil in cup’ deformity in the interphalangeal joints (IPJs) - bone erosions create a pointed appearance and the articulating bone is concave
  • Skin and nail disease can be mild and may develop AFTER arthritis
56
Q

Give 3 X-ray features of psoriatic arthritis.

A

Pencil in cup - due to central erosion of bone
Osteolysis
Fusion

Soft tissue swelling
Periostitis

57
Q

Give 3 differences between RA and psoriatic arthritis.

A
  • Psoriatic: psoriatic lesions; sausage like swelling around DIP joint; pencil in cup erosion on XR; HLAB27 associated.
  • RA: hands and wrists typically affected; peri-articular erosion on XR; rheumatoid nodules.
58
Q

How would you treat psoriatic arthritis?

A

Similar to that of RA

  1. NSAIDs
    - For pain relief
    - But can occasionally worsen the skin lesions
  2. Intra-articualr corticosteroid injections
    - Local synovitis responds to this
  3. DMARDs - Methotraxate / Sulfaslazine / Leflunomide with immunusuppressant (e.g. Ciclosporin)
    - Early intervention with DMARDs can help skin lesions
  4. If methotrexate failed -> use anti-TNF agents
    - ETANERCEPT and GOLIMUMAB
    - Highly effective and safe for severe skin and joint disease
    - Last one to try = Ustekinumab
59
Q

What is ustekinumab?

A

IL12 and IL-23 inhibitor biologic - used for inflammatory arthritis

60
Q

What type of spondyloarthritis occurs in 20% of patients with IBD?

A

Enteropathic arthritis.

61
Q

What is the criteria for making a clinical diagnosis of juvenile idiopathic arthritis?

A

Joint swelling/stiffness >6 weeks in children <16 and no other cause is identified.

62
Q

What is the aetiology of JIA?

A

Unknown - idiopathic!
However, it is autoimmune, so there are genetic factors associated.

63
Q

Why is it important to check the eyes in JIA?

A

The lining of the eyes and the joints is very similar. Children with JIA are at a high risk of developing uveitis!

64
Q

What type of JIA affects <4 joints and is usually ANA positive?

A

Oligoarthritis.

High risk of developing uveitis!

65
Q

What JIA is similar to adult ankylosing spondylitis?

A

Enthesitis related JIA - inflammation of where the tendon joins a bone. HLAB27 positive.

66
Q

Describe the non-medical treatment for JIA.

A
  1. Information.
  2. Education.
  3. Support.
  4. Liaison with school.
  5. Physiotherapy.
67
Q

Describe the medical treatment for JIA.

A
  1. Steroid joint injections.
  2. NSAIDS.
  3. Methotrexate.
  4. Systemic steroids.
68
Q

Give 5 potential consequences that can occur if you fail to treat JIA.

A
  1. Damage.
  2. Deformity.
  3. Disability.
  4. Pain.
  5. Bony overgrowth.
  6. Uveitis.

MSK + Rheumatology (22 decks)

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