Spondyloarthropathies

Question 1

What are the spondyloarthropathies?

Answer 1

A group of conditions that affect the spine and peripheral joints and are associated with the presence of HLA-B27.

Question 2

List the four conditions that comprise spondyloarthropathies.

Answer 2

• Ankylosing spondylitis
• Enteropathic arthritis
• Psoriatic arthritis
• Reactive arthritis

Ankylosing spondylitis is the most common among these conditions.

Question 3

What are the common clinical features of spondyloarthropathies?

Answer 3

• Sacroiliac/axial disease (back/buttock pain)
• Inflammatory arthropathy of peripheral joints
• Enthesitis (inflammation at tendon insertion)
• Extra-articular features (skin/gut/eye)

Question 4

What is the typical age group for ankylosing spondylitis?

Answer 4

Usually in young men (teens to mid-thirties)

This age range is significant for the onset of symptoms.

Question 5

What are the common examination findings in ankylosing spondylitis? (3)

Answer 5

• Loss of lumbar lordosis - later
• Exaggerated thoracic kyphosis
• Reduced chest expansion

Schober’s test is used to assess lumbar flexion.

Question 6

What investigations are commonly used for ankylosing spondylitis?

Answer 6

• CRP levels
• MRI of the spine and SI joints (bone marrow oedema)
• X-ray
• HLA B27 genetic testing

MRI is more sensitive than X-ray for detecting changes.

Question 7

What is the primary treatment for ankylosing spondylitis?

Answer 7

• NSAIDs
• Physiotherapy
• TNF inhibitors
• IL-17 inhibitors

These treatments aim to manage symptoms and improve function.

Question 8

What percentage of psoriasis patients develop psoriatic arthritis?

Answer 8

10%

The prevalence is equal in males and females.

Question 9

What are the typical exam findings in psoriatic arthritis?

Answer 9

• Oligo-arthritis
• Dactylitis
• Symmetrical or mono-arthritis

Severe deformities, such as arthritis mutilans, occur in about 5% of cases.

Question 10

What are the key investigation findings in psoriatic arthritis?

Answer 10

• Raised CRP levels
• Central joint erosions seen on ultrasound or MRI

‘Pencil in cup’ appearance on X-ray is a characteristic finding.

Question 11

What is the typical presentation of reactive arthritis?

Answer 11

Sterile synovitis that after a distant infection, typically presenting with acute asymmetrical lower limb arthritis

It occurs a few days to 2 weeks post-infection.

Question 12

What infections are commonly associated with reactive arthritis?

Answer 12

• Salmonella
• Shigella
• Campylobacter (post dysentery)
• Chlamydia trachomatis (post urethritis/cervicitis)

These infections can trigger sterile synovitis.

Question 13

What are the extra-articular features of ankylosing spondylitis?

Answer 13

• Anterior uveitis
• Aortic incompetence
• AV block
• Apical lung fibrosis
• Amyloidosis

These features are important for diagnosis and management.

Question 14

What mnemonic can help remember features of inflammatory back pain?

Answer 14

IPAIN!

I: Insidious onset
P: Pain at night
A: Age at onset < 40
I: Improvement with exercise
N: No improvement with rest.

Question 15

Fill in the blank: In reactive arthritis, the mnemonic for symptoms is ‘Can’t see, can’t ______.’

Answer 15

wee

This refers to conjunctivitis and urethritis.

Question 16

What percentage of individuals with IBD develop enteropathic arthritis?

Answer 16

10-20%

Of these, 2/3 develop peripheral arthritis and 1/3 develop axial disease.

Question 17

What are the two types of peripheral disease in enteropathic arthritis?

Answer 17

• Type 1: Oligoarticular, asymmetric
• Type 2: Polyarticular, symmetrical

Type 1 has more correlation with IBD flares.

Question 18

What is the treatment consideration for NSAIDs in enteropathic arthritis?

Answer 18

NSAIDs may flare IBD

Therefore, DMARDs and TNF inhibitors are often considered.

Question 19

How does ankylosing spondylitis often present

Answer 19

Bilateral buttock pain
Chest wall and thoracic pain

Question 20

What is Schober’s test

Answer 20

• mark skin 10cm above and 5cm below PSIS
• bend forward with straight legs
• distance increase to >20cm is normal

Question 21

What is the treatment of psoriatic arthritis

Answer 21

• NSAIDS
• DMARDs
• TNFi
• IL-17 inhibitor
• IL12/23 inhibitor

Question 22

What are extra-articular features of reactive arthritis

Answer 22

• skin (circinate balanitis,keratoderma blennorrhagica)
• eye (conjunctivitis, uveitis)
• enthesitis

Question 23

What are relevant investigations for reactive arthritis

Answer 23

• serology/microbiology
• inflammatory markers raised
• may need joint aspirate to rule out septic/crystal arthritis

Question 24

What are appropriate treatments for reactive arthritis

Answer 24

• treat infection (this may not improve
  arthritis). NSAIDs and joint injections
• most will resolve within 2 years; those that do not (esp if HLA-B27+) may need DMARDs

Question 25

what is ankylosing spondylitis

Answer 25

inflammatory condition affecting the axial skeleton (mainly the spine and sacroiliac joints), causing progressive stiffness and pain

Question 26

what are the main affected joints of ankylosing spondylitis

Answer 26

• sacroiliac
• vertebral column

can progress to spine and sacroiliac fusion

Question 27

how might ankylosing spondylitis present

Answer 27

Question 28

what is the typical X-ray finding of ankylosing spondylitis and what else might they show

Answer 28

bamboo spine in later stages: fusion of sacroiliac and spinal joints

• Squaring of the vertebral bodies
• Subchondral sclerosis and erosions
• Syndesmophytes (areas of bone growth where the ligaments insert into the bone)
• Ossification of the ligaments, discs and joints (these structures start turning into bone)
• Fusion of the facet, sacroiliac and costovertebral joints