Spondyloarthropathies

Question 1

What is a spondyloarthropathy?

Answer 1

Group of related chronic inflammatory conditions, usually affecting the axial skeleton with shared features.
(OHCM)

Question 2

Give 5 things that spondyloarthropathies usually have in common.

Answer 2

Seronegativity (RF -ve)
HLAB27 association
Affect axial skeleton
Assymetric large-joint oligo/monoarthritis
Enthesitis (site of tendon/ligament insertion)
Dactylitis (entire digit inflammation)
Extra-articular manifestations eg iritis, psoriasis, IBD.
(OHCM)

Question 3

What is ankylosing spondyloathritis?

Answer 3

Chronic inflammatory disease of spine and sacroiliac joints. Aetiology unknown but likely genetic/environmental interplay.

Question 4

How is ank spond diagnosed?

Answer 4

Clinical diagnosis supported by imaging.
Tests of spine flexion and sacroiliitis.
Bloods: normocytic anaemia, raised ESR and CRP, HLAB27.

Question 5

Give 5 findings that would be suggestive of ank spond.

Answer 5

Atlanto-axial subluxation
Anterior uveitis
Apical fibrosis
Aortic regurgitation
Amyloidosis (renal)
Achilles tendonitis (enthesitis)

Question 6

Give 3 symptoms of ank spond.

Answer 6

Gradual onset lower back pain
Alternating buttock pain
Spinal morning stiffness relieved by exercise.

Question 7

Describe the epidemiology of ank spond.

Answer 7

90% HLAB27 +ve

M:F 6:1 at 16 years old and 2:1 at 30 years old.

Question 8

What imaging would you do to diagnose ank spond and what would you see on each?

Answer 8

MRI: Active inflammation - bone marrow oedema
X ray: Atlanto-axial subluxation
Both: erosions, sclerosis, ankylosis (bone fusion - bamboo spine)

Question 9

Describe the management of ank spond.

Answer 9

Exercise, physiotherapy
NSAIDs
TNF-a blockers eg adalimumab for severe active AS.
(OHCM)

Question 10

What is psoriatic arthritis?

Answer 10

A long-term inflammatory arthritis that occurs in 10-40% of people affected by the autoimmune disease psoriasis.

Question 11

What is psoriasis and how does it cause arthritis?

Answer 11

1. Inflammation in the dermis - T cells and other WBCs migrate to the epidermis and release cytokines there - this may cause the arthritis.
2. Premature maturation of keratinocytes
3. Excessive epidermal growth (psoriasis)
   [wiki]

Question 12

Give 5 patterns of psoriatic arthritis.

Answer 12

Asymmetrical oligoarthritis (70%)
Symmetrical polyarthritis (25%)
Distal interphalangeal joints (5%)
Spondyloarthritis (spinal, similar to AS)
Arthritis mutilans

Question 13

Give 3 signs of psoriatic arthritis that can be seen on initial examination.

Answer 13

Inflammation - hot, red, painful, swollen joints
Affects DIPJs, PIPJs.
Usually asymmetrical oligoarthritis
Dactylitis (inflammation of entire digit; ‘sausage digit’)
Nail changes (80%)
Acneiform rashes
Palmo-plantar pustulosis

Question 14

What would be seen on X ray for arthritis mutilans?

Answer 14

Erosive changes, causing telescoping of digits in severe cases, called ‘pencil-in-cup’ deformity.

Question 15

Describe the management of psoriatic arthritis.

Answer 15

NSAIDs
DMARDs eg sulfasalazine, methotrexate
Anti-TNFs eg adalimumab

Question 16

What is reactive arthritis?

Answer 16

Arthritis and other manifestations occur as an autoimmune response to infection elsewhere in the body, typically GI or GU, which may resolve before the arthritis starts.

Question 17

Give 3 infections which may cause reactive arthritis.

Answer 17

GI: campylobacter, salmonella, shigella
GU: chlamydia

Question 18

Other than asymmetrical oligoarthritis, give 3 clinical features of reactive arthritis.

Answer 18

Reiter’s triad: urethritis, (asymmetrical oligoarthritis), conjuctivitis. (can’t pee, can’t see, can’t climb a tree).
Others: circinate balanitis (painless penile ulceration)
Enthesitis

Question 19

What investigations would you do for reactive arthritis?

Answer 19

1. History: prev infection/ sexual history.
2. MC&S: Serology for infection, culture stool if diarrhoea
3. Bloods: raised ESR/CRP
4. X ray may show enthesitis with periosteal reaction

Question 20

Describe the management of reactive arthritis.

Answer 20

1. Splint affected joints
2. NSAIDs/ local steroid injections
3. Consider DMARD if symptoms >6 months.
   (Treating original infection makes little difference)

Question 21

What is enteropathic arthitis?

Answer 21

Chronic inflammatory arthritis associated with inflammatory bowel disease.

Question 22

Give 2 skin changes which are characteristic of enteropathic arthritis.

Answer 22

Erythema nodosum

Pyoderma gangrenosum.

Question 23

Describe the management of enteropathic arthritis.

Answer 23

Often improves with treatment of bowel symptoms

Use DMARDs for resistant cases.