Spondyloarthropathies Flashcards
What is spondyloarthopathy?
family of inflammatory arthritis characterised by involvement of both the spine and joints, principally in genetically predisposed (HLA b27 positive) individuals
What is HLA b27 associated with (not useful unless patients also have symptoms)
ankylosing spondylitis, reactive arthiritis, Crohn’s disease, uveitis
What are the Spondyloarthritis Disease Subgroups
Ankylosing Spondylitis
Psoriatic Arthritis
Reactive Arthritis
Enteropathic Arthritis
What is the difference between mechanical and inflammatory back pain?
Mechanical-worsened by activity, typically worst at the end of the day, better with rest
Inflammatory- worse with rest, better with activity, significant early morning stiffness (>30 mins)
What are the shared rheumatological features
of the Spondyloarthropathies
Sacroiliac and spinal involvement
Enthesitis-inflammation at insertion of tendons into bones e.g. Achilles tendinitis, plantar fasciitis
Inflammatory arthiritis- Oligoarticular,asymmetric,predominantly lower limb
Dactylitis - inflammation of entire digit
What are the shared extra-articular features
of the Spondyloarthropathies
Ocular inflammation (anterior uveitis, conjunctivitis)
Mucocutaneous lesions
Rare Aortic incompetence or heart block
no rheumatoid nodules
What is ankylosing spondylitis?
Chronic systemic inflammatory disorder that primarily affects the spine
- peripheral arthritis uncommon
- sacroiliac joint involvement
- late adolescence or early adulthood
- more common in men
Why is MRI such a good test to use
MRI can pick up inflammation much earlier- can see the bone marrow oedema
What is the ASAS classification criteria for Axial Spondyloarthritis (SpA)
In patients with > 3 months back pain and age of onset <45 years
Sacroillitis on imaging and >=1 SpA feature
OR
HLA-B27 positive and >=2 other SpA features
What are the clinical features of ankylosing spondylitis
Back pain ( neck, thoracic, lumbar)
enthesitis
Peripheral arthritis (shoulder, hips)-rare
Extra articular features
Anterior uveitis
Cardiovascular involvement (aortic valve/root )
Pulmonary involvement (fibrosis upper lobes)
Asymptomatic enteric mucosal inflammation
Neurological involvement (Rarely A-A subluxation)
Amyloidosis
What is a helpful way to remember features of ankylosing spondylitis
“A” disease
Axial Arthritis Anterior Uveitis Aortic Regurgitation Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis Plantar Fasciitis
With ankylosing spondylitis what shows on examination?
Tragus/occiput to wall
Chest expansion
Modified Schober test
With ankylosing spondylitis what shows in the bloods
HLA B27 Inflammatory parameters (ESR,CRP,PV)
With ankylosing spondylitis what is shown on X-ray
Sacroillitis
Syndesmophytes
“Bamboo” spine
With ankylosing spondylitis what changes magic the seen on x-ray
Changes over a long period of time
e.g. sacroiliac sclerosis/ vertebral fusion/erosions
What is the difference between the spine in AS and OA
AS beone density-normal in early disease, reduced in late shiny comers Flowing syndesmophwytes Fusion (Bamboo spine)
OA Normal bone density reduced joint space subchondral sclerosis Subcondral scyst formation osteophyte formation associated with neural foramina narrowing
What treatment can be used in ankylosing spondylitis
physiotherapy occupational therapy NSAID disease modifying drugs e.g. SPZ, MTX Anti TNF treatment- Infliximab , Certolizumab, Adalimumab and Etanercept in severe AS Secukinumab
What is Psoriatic Arthritis
Inflammatory arthritis associated with psoriasis but 10-15% of patients have PsA without psoriasis
No rheumatoid nodules
Rheumatoid factor negative
What are the clinical features of psoriatic arthritis
inflammatory arthritis
Sactoilliitis
- often asymmetrical, may be associated with spondylitis
Nail involvement (pitting,onycholysis)
Dactylitis
Enthesitis - Achilles tendinitis, plantar fasciitis
Extra articular features (eye disease)
What are the clinical subgroups of psoriatic arthritis
- Confined to DIP hands/feet
- Symmetrical polyarthritis (similar to RA)
- Spondylitis (spine involvement) with or without peripheral joint involvement
- Asymmetric oligoarthiritis with dactylitis
- Arthritis mutilans
Aside from History and Examination what helps with diagnosis?
Bloods- inflammatory parameters(raised) and negative RF
X-rays - marginal erosions and “whispering” , “pencil in cup” deformity, osteolysis and enthesitis
What is enthesitis?
inflammation of the entheses, the sites where tendons or ligaments insert into the bone
Treatment of psoriatic arthritis?
Medical-NSAIDs, corticosteroids/joint injections. DMARDs, Anti TNF if unresponsive to NSAIDs and methotrexate, Secukinumab (anti-IL17)
Non medical- physiotherapy, OT, orthotics , Chiropodist
What is reactive arthritis?
Infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured
In young adults (20-40) and equal sex distribution
Reactive arthritis- How common after infection does symptoms appear and what are the common infections?
Symptoms 1-4 weeks after infection
More common infections
-Urogenital e.g. Chlamydia
-Enterogenic e.g. salmonella, Shigella, Yersinia
Reactive arthritis is HLA B27 positive
true
What is Reiter’s syndrome?
A form of Reactive arthiritis triad of -Urethritis -Conjunctivitis/Uveitis/Iritis -Arthiritis
What are the clinical features of reactive arthritis?
General features ( fatigue, fever,malaise)
Aysmmetrical monoarthiritis or oligoarthiritis
Enthesitis
Mucocutaneous lesions
- Keratodema Blenorrhagica
- Circinate balanitis
- painless oral ulcer
- Hyperkeratotic nails
Ocular lesions (unilateral or bilateral) -Conjunctivitis or iritis
Visceral manifestations
- mild renal disease
- carditis
What is used to rule out infection in arthiritis?
joint fluid analysis
Why may you not treat reactive arthritis?
90% resolve spontaneously within 6 months
What medical/ non-medical treatment could be used in reactive arthritis?
Medical- NSAIDs ( Corticosteroids, antibiotics for underlying infection and DMARDs if resistant/chronic)
Non-medical –> Physiotherapy and OT
What is the prognosis of reactive arthritis?
generally good, recurrences not uncommon, some develop a chronic form
What is Enteropathic Arthritis associated with?
IBD e.g. Crohn’s, UC
What do patients with Enteropathic Arthritis present with?
Arthritis in several joints, especially the knees, ankles, elbows and wrists, and sometimes in the spine, hips and shoulders
What are the clinical symptoms of Enteropathic arthritis?
GI-loose, watery stool with mucous and blood)
- Weight loss, low grade fever
- Eye involvement (uveitis)
- Skin involvement (pyoderma gangrenosum)
- Enthesitis ( Achilles tendonitis, plantar fasciitis, lateral epicondylitis)
- Oral-apthous ulcers
Investigations for enteropathic arthritis?
- Upper and lower GI endoscopy with biopsy showing ulceration/colitis
- Joint asperate- no organisms or crystals
- Raised inflammatory markers-CRP,PV
- X ray/MRI showing sacroiliitis
- USS showing synovitis/tenosynovitis
Treatment of enteropathic arthritis?
Treat IBD in order to control arthritis NOT NSAIDs as can exacerbate IBD Normal analgesia e.g. paracetamol, Cocodamol Steroids (oral,IA,IM) DMARDs Anti-TNF
