Spondyloarthropathies Flashcards
What are spondyloarthropathies?
Inflammatory conditions with axial and/ or peripheral arthritis
Negative rheumatoid factor
Usually asymmetric arthritis
Enthesitis can be a feature
Can be associated with HLA-B27
What are some extra-articular features of spondyloarthropathies?
Uveitis, inflammatory bowel disease and psoriasis
What are some different clinical presentations?
Axial spondyloarthropathy - radiographic and non-radiographic (seen on MRI only)
Psoriatic arthritis
Enteropathic related arthritis
Reactive arthritis
Undifferentiated SqA
What is axial spondyloarthropathy?
Chronic inflammatory rheumatoid disorder with a predilection for axial skeleton and entheses
When is the onset for axial spondyloarthropathy?
Onset below 45 years and often younger
Classic is late teen early 20s/30s
Prevalence varies around the world
What are the symptoms of SpA?
Lower back pain before 35 years
Waking up in night with pain
Buttock pain
Improvement with movement and NSAIDs
Current of past or present inflammatory arthritis - IBD, psoriasis and enthesitis
Describe HLA-B27 and spondyloarthropathies (SpA)
Not diagnostic of SpA
Positive in 80/95% of patients with radiographic SpA and less in non-radiographic (60%)
Risk of AS increases in relatives
What are the stages of axial SpA?
Non-radiographic (back pain and sacroiliitis on MRI)
Then radiographic stage - radiographic sacroiliitis and syndesmophytes
Sometimes stay non-radiographic
What is the ASAS classification for axial SpA?
In patients with more than 3 months of back pain and age of onset less than 45
Sacroiliitis on imaging plus more than 1 feature or HLA-B27 plus more than 2 features
What are the SpA features in ASAS classification?
Inflammatory back pain, arthritis, enthesitis (heel), uveitis, dactylitis, psoriasis, Chron’s disease, good response to NSAIDs, HLA-B27 and elevated CRP
What are characteristics that differentiate between radiographic and non-radiographic?
Radiographic - More men (3:1)
Non-radiographic - equal sex, more likely to be HLA-B27 negative and presentation less classical
What is suggestive of sacroiliitis on MRI?
Bilateral changes of both sides of the joint are more suggestive
What are some other systemic features of spondyloarthropathies (SpA)?
Peripheral joints - hips, shoulder and knees
Achillies tendonitis
Uveitis
Cardiac - aortic incompetence and heart block
Pulmonary - apical fibrosis
Osteoporosis and spinal fractures
Cauda equina syndrome
Secondary amyloidosis - renal
IBD
What are some clinical subtypes of psoriatic arthritis?
Arthritis with DIP joint involvement
Symmetric polyarthritis
Asymmetric oligoarticular arthritis (4 joints or less)
Arthritis mutilans (melting of joints)
Predominant spondylitis
What are some important factors of psoriatic arthritis?
Also characterised by dactylitis and enthesitis
Severity of joint disease does not correlate to extent of skin disease
Nail pitting seen
What are some joints commonly affected by psoriasis arthritis?
Neck, shoulder, elbows, wrists, all joints of knuckles fingers and thumbs, ankles, knees, back of spine and all joints of toes
What is the treatment for psoriatic arthritis?
Sulfasalazine, Methotrexate, leflunomide, Cyclosporine, Anti-TNF therapy, Anti-IL-17 and IL-23, steroids, physiotherapy, and axial disease treated similar to AS
What is Reactive arthritis?
Sterile synovitis after distant infection
Disease may be systemic
Usually mono or oligoarthritic
Infections of throat, urogenital and GI
Dactylitis and enthesitis seen
What infections can cause reactive arthritis?
Salmonella, shigella, yersinia, campylobacter, chlamydia, trachomatis or pneumoniae, borrelia, neisseria and streptococci
What are some classic features of reactive arthritis - skin and mucous membrane?
Keratoderma blenorrhagica - classic feature rash
Scleritis and conjunctivitis
Urethritis
Iritis
Circinate balanitis
What is Reiter’s syndrome?
Triad of arthritis, urethritis and conjunctivitis
What are some prognostic signs of chronic reactive arthritis?
Hip/ heel pain
High ESR
Family history and HLA-B27 positive
What is the acute treatment of reactive arthritis?
NSAIDs
Joint injection
Antibiotics in chlamydia infection
What is the chronic treatment for reactive arthritis?
NSAIDs and DMARD - sulphasalazine and methotrexate
What is enteropathic arthritis?
Commonly associated with IBD - Chron’s or UC
Can be peripheral and/ or axial disease
Enthesopathy commonly seen
When is eneropathic arthritis rarely seen?
Whipple’s disease, infectious enteritis and Coeliac disease
What is the treatment for spondyloarthropathies?
Physio
NSAIDs - can reduce spinal fusion
Steroids - short term or rescue
DMARDs
Biologic drugs
For enteropathic related arthritis - bowel resection may help
What biologics can be used in spondyloarthropathies?
Anti-TNF, Anti-IL-17, Anti-IL12/23 and JAK inhibitors
Many licensed for skin, bowel and joint disease
What can help differentiate inflammatory back pain?
Quality and quantity of morning stiffness
Stiffness improves with movement
