Spondyloarthropathies

Question 1

Question mark spine

Answer 1

Ankylosing spondylitis

Question 2

Hallmarks of spondyloarthropathies

Answer 2

Sacro-iliac and spine involvement
Enthesitis- inflammation at innervation of tendons into bones
Inflammatory arthritis- affecting a few joints, asymmetric, predominantly lower limb
Dactylitis- sausage digits- inflammation of the whole digit

Question 3

What is a spondyloarthropy

Answer 3

Inflammatary arthritic condition that mainly affects the spine, particularly in genetically predisposed individuals (HLA B27)

Question 4

HLA B27

Answer 4

Associated with ankylosing spondylitis, psoriatic arthritis, reactive arthritis, Crohns disease and uveitis.
Genetic autosomal dominant test- doesnt offer diagnosis due to background population can carry the gene without it being pathological.

Question 5

Over time- if ankylosing spondylitis is left, what can happen?

Answer 5

Spinal fusion meaning the patient will have a question mark shaped back. Also hip and knee arthritis can develop. Loss of lumbar lordosis (the normal curvature of the spine) and increased thoracic kyphosis (excessive curvature).

Question 6

Which investigations can be done into ankylsing spondylitis?

Answer 6

Examination is key- tests include
Tragus/occiput to wall
Chest expansion (costovertebral joints may be affected)
Modified Schober test

Blood tests include- inflammatory parameters- ESR, CRP
HMA B27- generally not used but still

X-rays showing sacralitis, syndesmophytes (bony outgrowths in the spine due to erosion) and bamboo spine (vertebral body fusion).

Question 7

Modified Schober test

Answer 7

This involves measuring 5cm below the posterior superior iliac crests and 10cm above, whilst the patient is upright, then asking them to bend forwards and remeasuring the distance. In normal situations it should extend beyond 20cm.

Question 8

Occiput to wall test

Answer 8

Patient puts heels, bum and shoulders against wall and is asked to lean head back. Shows the extension of the neck. Normal people wouldn’t have an issue with this.

Question 9

Xray findings of ankylosing spondyitis

Answer 9

Early signs will not be seen on Xray
Long term disease will show sclerotic sacrum (whitening on X-ray)- may show syndesmophytes
Bone density reduces in late disease
Fusion of the spine.

Question 10

MRI findings of ankylosing spondyitis

Answer 10

May show enthesitis and bone marrow oedema.

Question 11

Treatment of AS

Answer 11

Main treatment is physiotherapy to stop spinal fusion.
Then use NSAIDs e.g. naproxen (in tayside), you have to offer gastroprotection with this.
Use disease modifying drugs if there is also peripheral joint involvement e.g. methotrexate.
Biologics reduce inflammation- anti TNF treatment- infliximab
Or new on the market- Secukinumab (anti IL-17)

Question 12

Psoriatic arthritis

Answer 12

Inflammatory arthritis associated with psoriasis. However sometimes the joint involvement comes first.
Occurs in up to 30% of psoriasis patients.

Question 13

Clinical features of psoriatic arthritis

Answer 13

Usually an asymmetrical oligoarthritis.
May affect the hands in a similar pattern to rheumatoid arthritis.
Sacroilitis
Spondylitis- inflammation of joints of the spine.
Enthesitis- inflammation at insertion of tendon to bone. Commonly achilis tendonitis, plantar fascitis.
Dactylitis- sausage digits
Nail involvement- pitting, oncholysis
Extra articular features- eye disease.

Question 14

Diagnosis of psoriatic arthritis

Answer 14

Exam- look for nail and skin signs.
Bloods- inflammatory markers will be raised. Also it will be negative for rheumatoid factor (this would only be tested in someone who had symmetrical arthritis)
X-rays- will show marginal erosions and whiskering
Pencil in cup deformity

Question 15

Treatment of psoritic arthritis

Answer 15

NSAIDs
Steroid injections/corticosteroids
Disease modifying drugs e.g. methotrexate. If two disease modifying drugs don’t work try biologics.

Non medical treatment- physiotherapy
Occupational therapy
Orthotics, chriopodist.

Question 16

Reactive arthritis

Answer 16

Infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable organisms cannot be cultured.

Question 17

Most common infections causing reactive arthritis

Answer 17

Genitourinary- e.g. chlamydia or GI infections such as campylobacter and salmonella.

Question 18

Pathogenesis (brief) of reactive arthritis

Answer 18

Infection occurs. Then 1-3 weeks later the arthritis ensues. It tends to affect large joints such as the knee. The infection could have been anywhere else in the body, not necessarily at site of arthritic disease.
The patient will be HLA B27 positive

Question 19

Who does reactive arthritis tend to affect?

Answer 19

20-40 year olds.

Question 20

Rieters syndrome

Answer 20

A form of reactive arthritis . They will get all three of urethritis (inflammation of the urethra), conjuntivitis/Uveitis/Iritis, arthritis

Question 21

Clinical features of reactive arthritis

Answer 21

Fever, fatigue and malaise
Asymmetric monoarthritis or oligoarthritis
Enthesitis
Mucocutaneous lesions- e.g. hyperkeratotic nails, onycholysis (lifting of the nail from the nail bed), painless oral ulcers, Keratodema Blenorrhagica (skin lesions commonly found on the soles of hands/feets

If the individual is still recovering from infection they are likely to also be unwell.

Question 22

Diagnosing reactive arthritis

Answer 22

Bloods- inflammatory markers will be raised- ESR, CRP,
FBC and U&E’s.
Cultures of the blood, urine and stool
Joint fluid analysis (just to check for septic arthritis)
X-ray of affected joint.

Question 23

Treatment of reactive arthritis

Answer 23

90% resolve spontaneously within 6 months
NSAIDs
Corticosteroids (once sepsis is ruled out)- oral, intra-articular, eye drops
Antibiotics for underlying infection.
DMARDs- if resistant/chronic

Non medical- physiotherapy and occ therapy.

Question 24

Enteropathic arthritis

Answer 24

Inflammatory arthritis associated with IBD (Crohn’s or Ulcerative colitis)
Patients present with arthritis in several joints including the knees, ankles, elbows, wrists. Sometimes in the spine and elbows.

Question 25

Symptoms of enteropathic arthritis tend to be worse…

Answer 25

In flare ups of the IBD.

Question 26

Symptoms (multisystem) of enteropathic arthritis

Answer 26

GI- loose watery (blood and mucous in) stools
Weight loss
Eye involvement- uveitis
Skin involvement- pyoderma gangernosum
Enthesitis- archilles tendon, plantar fascitis
Oral- apthous ulcers

Question 27

Investigations into enteropathic arthritis

Answer 27

Upper/lower GI endoscopy
Joint aspiration- showing no organisms
Raised inflammatory markers
Xray/MRI showing sacrolitis
Utrasound showing synovitis/tenosynovitis

Question 28

Treatment of enteropathic arthritis

Answer 28

Treat IBD in order to control arthritis
Normal analgesia- e.g. paracetamol and cocodamol (due to NSAIDs exacerbating IBD)
Steroids
Disease modifying drugs e.g. methotrexate
Anti TNF e.g. infliximab