Spondyloarthropathies Flashcards
Ankylosing spondylitis, Enteropathic arthritis, Psoriatic arthritis + Reactive arthritis
What are the spondyloarthropathies?
A group of conditions that affect the spine + peripheral joints + are associated with presence of HLA-B27
- psoriatic arthritis
- ankylosing spondylitis
- Enteropathic arthritis
- reactive arthritis
List the spondylarthropathies
SPEAR
- Spondylarthropathies
- Psoriatic arthritis
- Enteropthic arthritis
- Ankylosing spondylitis
- Reactive arthritis
Common clinic features of spondyloarthropathies
- sacroiliac disease (back/buttock pain)
- inflammatory arthopathy of peripheral joints
- enthesitis (inflammation of tendon insertions)
- extra-articular features
What is ankylosing spondylitis?
- Inflammatory conditions affecting the axial skeleton
- Causes progressive stiffness + pain
- Mainly affects the sacroiliac joints + vertebral column joints > can cause fusion of these joints
Presentation of ankylosing spondylitis
- lower back or buttock pain + stiffness
- > 30 mins morning stiffness
- improve with activity + worsens with rest
- chest pain + SOB
- enthesitis
- dactylitis
- vertebral fracture
What is enthesitis?
Inflammation of tendon insertion points
What is dactylitis?
Inflammation of entire finger
Extra-articular manifestations of ankylosing spondylitis
ALL THE As
- Anterior uveitis
- Aoritc incompetence
- AV block
- Apical lung fibrosis
- Amyloidosis
What is Shober’s test?
- assesses spinal mobility with patient standing straight
- S2 vertebra located
- point marked 10cm above + 5cm below
- patient bends forward as far as possible
- distance between points is measured
- > 20cm is normal
- <20cm indicates restriction in lumbar movement
- helps to support diagnosis of ankylosing spondylitis
What test is used to help to diagnose ankylosing spondylitis?
Shober’s test
What is found on examination of ankylosing spondylitis?
- loss of lumbar lordosis
- exaggerated thoracic kyphosis
- Shober’s test of <20cm
- reduced chest expansion
Investigations of ankylosing spondylitis
- X-ray of spine + sacrum
-
MRI of spine (can show bone marrow oedema before X ray changes)
. - inflammatory markers (CRP+ESR)
- HLA-B27 genetic testing
X ray features of ankylosing spondylitis
- ‘bamboo spine’ due to fusion of sacroiliac + spinal joints
- squaring of vertebral bodies
- subchondral sclerosis + erosions
- ossification of ligaments, discs + joints
- areas of bone growth where ligaments insert (syndesmophytes)
Management of ankylosing spondylitis
- first line: NSAIDs
- second line: anti-TNF meds - e.g. etanercept, infliximab
- third line: mab against IL17 - e.g. secukinumab
- Physiotherapy
- smoking cessation
What % of people with psoriasis will have psoriatic arthritis?
10%
Where does psoriatic arthritis tend of affect?
DIP
Axial skeleton
Signs of psoriatic arthritis
- psoriatic plaques on skin
- nail pitting
- onycholysis
- dactylitis
- enthesitis
What is onycholysis?
Separation of nail from the nail bed
What is used to screen psoriasis patients for psoriatic arthritis?
PEST
Psoriasis Epidemiological Screening Tool
Investigations of psoriatic arthritis
- X ray
- raised CRP
- MRI
X ray features of psoriatic arthritis
- pencil in cup appearance
- periostitis > thickened + irregular bone outline
- ankylosis (fusion of bone at joint)
- osteolysis
- dactylitis > soft tissue swelling
What is the pencil in cup appearance on an X ray associated with?
Psoriatic arthritis
Arthritis mutilans
Management of psoriatic arthritis
- NSAIDs
- steroids
- DMARDs e.g. methotrexate, leflunomide, sulfasalazine
- anti-TNF meds e.g. infliximab, etanercept
What is reactive arthritis?
When does it occur?
Sterile synovitis developing after a distant infection either after gastroenteritis (salmonella/shigella/campylobacter) or following urethritis/cervicitis (chlamydia trachomatis)
Who is reactive arthritis more common in?
Patients with HIV
Presentation of reactive arthritis
+ associated features
- presenting a few days - 2 weeks post infection
- acute single warm swollen painful joint
- acute asymmetrical lower limb arthritis
.
- bilateral conjunctivitis
- uveitis
- urethritis
- circulate balanitis (dermatitis of head of penis)
Classic triad of reactive arthritis
‘Can’t see, pee or climb a tree’
- conjunctivitis/uveitis
- urethritis
- reactive arthritis
Investigations of reactive arthritis
- joint aspiration to rule out septic arthritis + gout
- serology/microbiology
Management of reactive arthritis
- treat infection
- NSAIDs
- steroid joint injections
- most resolve within 2 years, if not > DMARDs
What condition is Enteropathic arthritis associated with?
IBD - Crohn’s + ulcerative colitis
What are the 2 types of peripheral disease in Enteropathic arthritis
- type 1: asymmetric oligoarticular + correlation with IBD flares
- type 2: symmetrical poly articular + less correlation with IBD flares
Management of Enteropathic arthritis
- DMARDs
- TNF inhibitors e.g. infliximab will treat IBD + arthritis
- avoid NSAIDs (may flare IBD)
Associated features of spondyloarthropathies
SPINE ACHE
- Sausage fingers (dactylitis)
- Psoriasis
- Iritis (uveitis)
- NSAID response +
- Enthesitis
- Arthritis
- Crohn’s/UC
- HLA-B27
- Elevated inflammatory markers
