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Musculoskeletal > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q
A
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2
Q

What are spondyloarthropathies?

A

They are a family of inflammatory arthitides, characterised by involvement of both the spine and joints, principally in genetically predisposed (HLA B27) indiviuals

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3
Q

What are the 4 sub-types of spondyloarthropathy?

A
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis
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4
Q

How does mechanical back pain differ from inflammatory back pain

A

Mechanical back pain is worsened by activity
Inflammatory back pain is worse with rest

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5
Q

What is ankylosing spondylitis?

A

This is a chronic systemic inflammatory disorder that primarily affects the axial skeleton (Mainly spine and sacroiliac joints), leading to partial or complete fusion and rigidity of the spine

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6
Q

Who is most at risk of developing ankylosing spondylitis?

A

Males (4:1)
Aged 20-40
HLA-B27 positive

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7
Q

Describe the pathophysiology of ankylosing spondylitis

A

Ankylosing spondylitis causes chronic inflammationof the ligaments, joints and entheses (Connection between bone and tendon)

This leads to the formation of bony protuberances called syndesmophytes, which eventually leads to fusion of the spine

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8
Q

How will ankylosing spondylitis usually present?

A

Ankylosing spondylitis usually presents with articular symptoms of the spine, neck and lower back

These articular symptoms are:

  • Gradual onset, dull progressive pain
  • Morning stiffness >30 minutes (Improves with activity)
  • Peripheral arthritis
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9
Q

What are some clinical signs of late stage ankylosing spondylitis?

A

Loss of lumbar kyphosis
Pronounced cervical lordosis (question mark posture)
Positive Schober’s test
Reduced chest expansion
Inflamed entheses
Occiput:wall not at 0

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10
Q

What are some extra articular features of ankylosing spondylitis? (7A)

A
  • Axial arthritis
  • Anterior uveitis
  • Aortic regurgitation
  • Apical fibrosis
  • Amyloidosis/IgA neuropathy
  • Achilles tendinitis
  • plAntar fasciitis
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11
Q

What are some non-A features of ankylosing spondylitis?

A

Chest pain caused by costovertebral joint inflammation
Dactylitis (Whole finger swelling)

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12
Q

What test is performed to help in diagnosis of ankylosing spondylitis?

A

Schober’s test

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13
Q

What does Schober’s test entail?

A

The superior iliac crests are marked with a pen, then a dot 5cm below and 10cm above are placed

The patient should then be asked to bend as far forward as possible, before the distance between the 2 new dots is measures

This should be above 20cm in normal cases

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14
Q

What are the key tests performed in ankylosing spondylitis diagnosis?

A

Inflammatory markers - CRP, ESR, PV
HLA-B27 genetic testing
Spinal X-ray
Spinal MRI

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15
Q

What will X-ray show in cases of ankylosing spondylitis?

A

Bamboo spine (Fusion of sacroiliac and spinal joints)
Squaring of vertebral bodies
Suchondral sclerosis and erosion
Syndesmophytes (Bony protuberances)
Ossification of soft tissue

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16
Q

What will be shown on MRI in ankylosing spondylitis that isn’t shown on X-ray?

A

Bone marrow oedema in early disease

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17
Q

What diagnostic criteria is used in ankylosing spondylitis?

A

ASAS criteria

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18
Q

What are the 2 pathways of the ASAS criteria?

A
  • Sacroiliitis on imagine AND ≥SpA feature

OR

  • HLA-B27 positive AND ≥2 other SpA features
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19
Q

Who is tested using the ASAS criteria?

A

Patients with ≥3months back pain
Age of onset <45

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20
Q

What SpA features are used in the ASAS criteria?

A
  • Inflammatory back pain
  • Arthritis, enthesitis, uveitis and dactylitis
  • Psoriasis
  • Crohn’s
  • HLA-B27 positive
  • Good response to NSAIDs
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21
Q

What pharmacological treatment is used in ankylosing spondylitis?

A

1st - NSAIDs - Ibuprofen, Naproxen
2nd - Anti-TNF - Infliximab, Entanercept
3rd - Anti-IL7 - Secukinumab, Ixekizumab
3rd - JAK inhibitor - Upadacitinab

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22
Q

What are some non-pharmacological managements of ankylosing spondylitis?

A

Physiotherapy
Exercise therapy
Orthotics
Smoking cessation

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23
Q

When may surgery be performed in ankylosing spondylitis?

A

In cases of severe joint deformity

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24
Q

What is psoriatic arthritis?

A

This is an inflammatory arthritis associated with psoriasis (10-15% may not have psoriasis)

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25
Q

What are the 5 main clinical subgroups of psoriatic arthritis?

A
  • Distal interphalangeal predominant
  • Symmetric polyarthritis
  • Spondylitis with or without peripheral joint involvement
  • Asymmetric oligoarthritis with dactylitis
  • Arthritis mutilans
26
Q

What are the main articular symptoms of psoriatic arthritis?

A

Stiffening of joints
Dactylitis
Enthesitis (Achilles and plantar)

27
Q

What are some extra-articular features of psoriatic arthritis?

A

Uveitis
Nail involvement (Pitting, onycholysis)

28
Q

What joints are mostly affected in distal interphalangeal psoriatic arthritis?

A

DIP joints

29
Q

What joints are mostly affected in symmetric polyarthritis, psoriatic arthritis?

A

This is similar to RA, with joints including PIP, wrists, elbow and shoulders most common
More than 4 joints are usually affected

30
Q

What joins are affected in spondylitis psoriatic arthritis?

A

Axial skeleton, most often causing back stiffness and pain

31
Q

What joints are affected in asymmetric oligoarthritis psoriatic arthritis?

A

This affects 1-4 joints, asymmetrically

32
Q

How does arthritis mutilans present?

A

This affects the phalanges, causing osteolysis of bone around the joints, causing telescoping digits as the skin folds

33
Q

How is psoriatic arthritis diagnosed?

A

History, examination, bloods and imaging

34
Q

What will blood testing show in psoriatic arthritis?

A

Raised inflammatory markers
Negative rheumatoid factor

35
Q

What will be shown on X-ray in psoriatic arthritis?

A

Marginal erosions
Whiskering
Pencil and cup deformity (Arthritis mutilans)
Osteolysis
Enthesitis

36
Q

What medications are used in the treatment of psoriatic arthritis?

A

1st - NSAIDs - Ibuprofen, Naproxen
2nd - Anti-TNF - Infliximab, Entanercept
3rd - Anti-IL7 - Secukinumab, Ixekizumab
3rd - JAK inhibitor - Upadacitinab

37
Q

What are some non-pharmacological treatment options in psoriatic arthritis?

A

Physiotherapy
Exercise therapy
Orthotics
Smoking cessation

38
Q

What is reactive arthritis?

A

Reactive arthritis is an infection-induced systemic illness, characterised primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured

39
Q

What are the most common infections leading to reactive arthritis?

A
  • Urogenital - e.g. Chlamydia
  • Enterogenic - e.g. Salmonella, Shigella, Yersinia
40
Q

Who is most at risk of reactive arthritis?

A

Ages 20-40
Equal sex distribution
HLA-B27 positive

41
Q

Describe the pathophysiology of reactive arthritis

A

A genitourinary or gastrointestinal infection occurs, which, after 1 to 4 weeks, can trigger an autoimmune arthropathy, most commonly affecting the large joints such as the knee

42
Q

What is Reiter’s syndrome?

A

Reiter’s syndrome is a form of reactive arthritis, characterised by a triad of symptoms:

  • Urethritis
  • Conjunctivitis/Uveitis/Iritis
  • Arthritis

“Can’t see, pee or climb a tree”

43
Q

How will reactive arthritis usually present?

A

Fever
Fatigue
Malaise
Asymmetrical mono- or oligo- arthritis (Red, hot swollen joints)
Enthesitis

44
Q

What are some mucocutaneous lesions that can occur in reactive arthritis?

A

Keratodema blennorrhagicum (Skin lesions on feet and palms)
Circinate balantis (Dermatitis of penile head)
Painless oral ulcers
Hyperkeratotic nails

45
Q

What are some ocular lesions that can occur in reactive arthritis?

A

Conjunctivitis
Iritis

46
Q

What are some visceral manifestations that can occur in reactive arthritis?

A

Mild renal disease
Carditis

47
Q

What tests are require din diagnosis of reactive arthritis?

A

History
Examination
Bloods
Cultures
X-ray

48
Q

What will blood testing show in reactive arthritis?

A

Raised ESR, CRP and PV

49
Q

What cultures are required in reactive arthritis?

A

Blood
Urine
Stool
Joint fluid

50
Q

How should patients presenting with an acute, hot swollen joint be treated?

A

They should be given antibiotics
Joints should aspirated and cultured to rule out septic arthritis

51
Q

How should reactive arthritis be treated once septic arthritis is ruled out?

A

Treatment of underlying condition
Intra-articular or intra-muscular steroid injections
Most (90%) are self-limiting

52
Q

How should chronic progressive, erosive reactive arthritis be treated?

A

DMARDs and Anti-TNF

53
Q

What is enteropathic arthritis?

A

This is a form of inflammatory arthritis, involving the peripheral joints and occasionally the spine, occurring in patients with inflammatory bowel disease

This is a seropositive arthritis

54
Q

How do symptoms of IBD correlate with enteropathic arthritis?

A

Symptoms of enteropathic arthritis will usually worsen during flare-ups of IBD

55
Q

How will patients with enteropathic arthritis present?

A

Patients usually present with arthritis in several joints, especially the knees, ankles, elbows and wrists with occasional spine, hip and shoulder involvement

There will often be enthesitis such as Achilles tendonitis, plantar fasciitis and lateral epicondylitis

56
Q

What are some extra-articular features of enteropathic arthritis?

A
  • Loose, watery stools with mucus and blood
  • Weight loss
  • Apthous ulceration
  • Pyoderma gangrenosum
  • Low grade fever
  • Uveitis
57
Q

What investigations are required to diagnose enteropathic arthritis?

A

Upper and lower GI endoscopy
Joint aspiration
Bloods
X-ray
MRI
USS

58
Q

What will X-ray and MRI show in enteropathic arthritis?

A

Sacroiliitis

59
Q

What will USS show in enteropathic arthritis?

A

Synovitis and tenosynovitis

60
Q

How is enteropathic arthritis treated?

A

Management of enteropathic arthritis usually involves finding medication that treats both the underlying IBD and the arthritis

Management of the arthritis is similar to other seropositive arthritides, physiotherapy, NSAIDs, DMARDs and anti-TNF agents

Musculoskeletal (123 decks)

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