Spondyloarthropathies Flashcards by Kieran Ruthven

Define the term spondyloarthropathy

“A family of inflammatory arthritides characterised by the involvement of both the spine and joints, principally in genetically predisposed (HLA-B27 positive) individuals”

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HLA-B27 is exclusively assoicated with AS. True/false?

False - also with reactive arthritis, Crohn’s, uveitis

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Screening patients for HLA-B27 is a useful public health tool. True/false?

False - unless patient has symptoms

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Name the 4 spondyloarthritides

1) AS 2) Psoriatic arthritis 3) Reactive Arthritis / Reiter’s Syndrome 4) Enteropathic Arthritis

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Mechanical pain is worsened/relieved by activity and typically worst at beginning/end of day?

Worse with activity, typically worst at end of day.

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Inflammatory pain is worsened/relieved by activity and tends to present with what symptom?

Relieved by activity. Significant early morning stiffness.

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Ankylosing spondylitis primarily affects what?

Spine

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The hallmark of AS is…

Sacroiliac joint involvement (sacroilitis)

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AS is more common in men/women?

Men (5:1)

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AS is diagnosed upon which crtiera?

ASAS (includes clinical features, imaging and B27 testing)

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What are the “A” of AS? (7)

1) Axial arthritis 2) Anterior uveitis 3) Aortic regurgitation 4) Apical fibrosis 5) Amyloidosis 6) Achilles tendonitis 7) plAntar fasciitis

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The fusion of spine in AS is achieved with what structures?

Syndesmophytes

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”? spine” is a classical deformity for which condition?

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Which clinical exam can be used to help rule out AS?

Schober’s Test

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How do you differentiate AS from OA on imaging?

AS has normal bone density and reduced in late disease (OA is always normal density). AS also has shiny corners and flowing syndesmophytes (OA does not). Finally, “bamboo” spine is classical for AS.

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Treatment region of AS includes (6)

-Physiotherapy -OT -NSAIDs -DMARDs -AntiTNF (inflixmab) -Secukinumab (anti-IL17)

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An anti-IL17 drug used to treat AS is called…

Secukinamub

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Anti-TNF drug examples (2)

-Infliximab -Adaluminab

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Do psoriatic arthritis patients always have psoriasis?

No - 10-15% will not have psoriasis.

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Pencil in cup deformity is buzzword for what?

Psoriatic arthritis

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Treatment regimen for psoriatic arthritis includes (5)

1) NSAIDs 2) Corticosteroid injections 3) DMARDs 4) Anti-TNF (severe) 5) Secukinumab (severe)

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Viable organisms can be cultured from joint aspirates in reactive arthritis. True/false?

False

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Reactive arthritis follows what and when?

Infection, typically 1-4 weeks post-infection

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The most common route of infection in reactive arthritis is…

Urogenital (chlamydia), followed by enterogenic (salmonella). Think young people put things in their mouths (so STIs and food poisoning)

Reactive arthritis is common in which age range & in which sex?

20-40s. Equal sex distribution

Reiter's Syndrome is which triad

Urethritis Conjunctivitis Arthritis (Can't See, Can't Pee, Can't Bend the Knee)

Reactive arthritis is typically a mono/poly arthritis that is symmetrical/asymmetrical.

Monoarthritis Asymmetrical

Mucutaneous lesions indicative of Reiter's Syndrome include (4)

1) Keratodema blenorrhagica 2) Circinate balanitis 3) Painless oral ulcers 4) Hyperkeratotic nails

Which % of reactive arthritis cases resolve spontaneously within 6 months?

90%

Treatment for reactive arthritis (4)

1) NSAIDs 2) Corticosteroids 3) Antibiotics if underlying infection 4) DMARDs if resistant

NSAIDs are advised in enteropathic arthritis. True/false?

False - they may exacerbate bowel disease

Inflammatory markers are raised/lowered in enteropathic arthritis. (PV and CRP)

Raised

Shared extra-articular features of spondyloarthropathy include (4)

1) Ocular inflammation 2) Mucutaneous lesions 3) Rare: aortic incompetence 4) No rheumatoid nodules

By ASAS classification, patients must have sacroilitis on imaging + how many SpA features before AS can be diagnosed?

By ASAS classification, patients must have HLA-B27+ and how many other features of SpA before AS can be diagnosed?

Etanrecept is what kind of drug?

Anti-TNF

Rheumatoid factor is positive/negative in psoriatic arthritis.

Negative

Urogenital infective causes of reactive arthritis (1)

Chlamydia

Enterogenic infective causes of reactive arthritis (3)

-Salmonella -Shigella -Yerisinia

Corticosteroids can be used almost immediately in reactive arthritis. True/false?

False - must rule out sepsis

What are the shared rheumatological features of SpAs? (4)

1) Sacroiliac involvement 2) Enthesitis (inflammation at insertion tendons, esp. plantar fasciitis, Achillies tendonitis) 3) Inflammatory arthritis (often oligoarticular, asymetric, lower-limb mostly) 4) Dactylytis

ASAS classification for SpAs looks at patients with \>3 months of backpain before 45 years old. What are the 2 main criteria for diagnosing SpA?

1) Sacroilitis on imaging PLUS 1 (or more) SpA feature OR 2) HLA-B27 positive PLUS 2 (or more) SpA feature

Which imaging modality is useful for detecting early inflammation in SpAs?

MRI

How many vertebrae are normally present?

What are the clinical exams for AS diagnosis? (3)

1) Tragus/ occiput to wall 2) Chest expansion 3) Modified Schober's Test

What are the X-ray signs for AS? (3)

1) Sacroilitis 2) Syndesmophytes 3) Bamboo spine (fusion)

Rheumatoid Factor status in psoriatic arthritis

Negative (and no nodules)

What are the 5 subgroups of psoriatic arthritis?

1) Confined to DIPs of the hands and feet 2) Symmetric polyarthritis (very similar to RA) 3) Spondylitis (pure, or with or without peripheral joints involved) 4) Asymmetric oligoarthritis with dactylitis 5) Arthritis mutilans (severe)

What is the "unique" clinical feature(s) to reactive arthritis?

Mild renal impairment, carditis

How is reactive arthritis diagnosed?

History + cultures of joint aspirate negative + inflammatory markers + ophthalmology opinion

How is reactive arthritis treated? How many cases spontaneously resolve?

90% of cases spontaneously resolv within 6 months. Medical treatments: 1) NSAIDs 2) Corticosteroids (IA after sepsis ruled out) 3) Antibiotics for underlying infection 4) DMARDs (SZP if resistant / chronic) Non-medical: physio, OT

Reactive arthritis is exclusively a 1-time thing, T/F?

False - it can reoccur or become chronic

Enteropathic arthritis is associated with what condition(s)

IBD (CD and UC)

What % of patients with IBD develop enteropathic arthritis?

9-20%

What % of Crohn's patients have sacroilitis?

20%

How can enteropathic arthritis be diagnosed clinically?

The symptoms are worse during flare-ups of IBD

How is enteropathic arthritis treated? (3)

1) Treat underlying IBD 2) Analgesia (NOT NSAIDs) 3) DMARDs 4) Anti-TNF

What sign is this? What disease is it typical of?

Keratoderma blennorhagicum. Reactive Arthritis

Young cricketer with severe lumbar pain, likely diagnosis?

Spondolyitis