Spondyloarthropathies Flashcards
What are spondyloarthropathies?
Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically and predisposed (HLA B-27) individuals
What is HLA B-27 associated with?
Ankylosing spondylitis
Reactive arthritis
Crohn’s disease
Uveitis
What are the different types of spondyloarthritis disease subgroups?
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
What are the sympotms of mechanical back pain?
Worsened by activity
Typically worst at the end of the day
Better with rest
What are the symptoms of inflammatory back pain?
Worse with rest
Better with activity
Significant early morning stiffness that lasts more than 30mins
What are some rheumatological features that are present in all spondyloarthropathies?
Sacroiliac and spinal involvement
Enthesitis
Inflammatory arthrtisi
Dactylitis
What is enthesitis?
Inflammation at insertion of tendons into bones e.g. achilles tenson causing plantar fasciitis
What are the characteristics of inflammatory arthritis?
Oligoarticular
Asymmetric
Predominantly lower limbs
What are some extr-articular features that can present in all spondyloarthropathies?
Ocular inflammation (anterior uveitis, conjunctivitis)
Mucotaneous lesions
Rare aortic incompetence or heart block
What is ankylosing spondylitis?
Chronic systemic inflammatory disorder that primarly affects the spine
What is the hallmark of ankylosing spondylitis?
Sacroiliac joint involvement (sacroiliitis)
What is the ASAS classification for ankylosing spondylitis?
In patients with more than 3 months back pain and under 45:
Sacroilits imaging and one spondyloarthritis feature
OR
HLA-B27 positive and 2 spondyloarthritis features
What are the spondyloarthritis features in the ASAS classification?
Inflammatory back pain Arthritis Enthesitis Uveitis Dactylitis Psoriasis Crohn's Good response to NSAIDs Family history of SpA HLA-B27 Elevated CRP
How will sacroiliitis show in images?
Active inflammation on MRI highly suggestive of sacroiliitis associated with SpA
What are the clinical features of AS?
Back pain (neck, thoracic, lumbar) Enthesitis Peripheral arthritis (RARE) Extra articula: anterior uveitis, CV involvement (aortic valve/root), pulmonary fibrosis (upper lobes), asymptomatic enteric mucosal inflammation, neurological involvement (rarely A A subluxation), amyloidosis
What is a way to remeber the symptoms of AS?
Remeber as the A disease: Axial arthritis Anterior uveitis Aortic regurgitation Apical fibrosis Amyloidosis Achilles tendinitis PlAntar fasciitis
What do syndesmophytes cause?
Fusion of vertebrae
What examinations can be performed to diagnose AS?
Tragus to wall
Chest expansion
Modified Schober test
What bloods can be done to diagnose AS?
Inflammatory parameters (ESR, CRP, PV) HLA B-27
What can be seen on radiological images of AS?
Sacroiliitis Syndesmophytes Bamboo spine Osteopenia Shiny corners
What can be seen on radiological images of OA?
Normal bone density Reduced joint space Subchondral sclerosis Subchondral cysts Oosteophyte
What will an MRI of AS show?
Early radiological changes: bone marrow oedema and enthesitis
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasiss, but 10-15% of patients can have PsA without psoriasis cutaneously
How will PsA present?
Sacroiliitis (asymmetric) Nail involvement (pitting, onycholysis) Dactylitis Enthesitis Extra articular features (eye disease)
What are the different clinical subgroups of psoriatic arthritis?
Confined to DIP joints Symetric polyarthritis Spondylitis Asymmetric oligoarthritis with dactylitis Arthritis mutilans
What bloods can be done to diagnose PsA?
Inflammatory parameters raised
Negative RF
What radiographic findings can be seen in PsA?
Marginal erosions and whiskering
Pencil in cup deformity
Osteolysis
Enthesitis
What is reactive arthritis?
Infection induced systemic illness characterized primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured
What are the most common infections to cause reactive arthrtitis?
Urogenital: clamydia
Enterogenic: salmonella, shigella, yersinia
When will reactive arthritis occur after an infection?
1-4 weeks after the infection has cleared up
What makes up reiter’s syndrome?
Urethritis
Conjuctivitis/ uveitis/ iritis
Arthritis
What are the clinical features of reactive arthritis?
Fever, fatigue, malaise
Asymmetrical monoarthritis/ oligoarthritis
Enthesitis
Mucotaneous lesions: keratoderma blenorrhagica, circinate balnitis, painless oral ulcers, hyperkeratotic nails
Ocular lesions - conjuctivitis, iritis
Visceral manifestations - mild renal disease, carditis
How is reactive arthritis diagnosed via blood tests?
Inflammatory parameters
FBC, U&Es
HLA B27
Cultures (usually negative)
Why is a joint fluid analysis done?
To rule out septic arthritis
Why is an x-ray of the affected joints undertaken?
Due to acute nature, need to rult out osteonecrosis or osteomyelitis
What is enteropathic arthritis?
Associated with inflammatory bowel disease e.g. crohn’s and UC
Where will enteropathic arthritis affect?
Several joints, especially knees, ankles, elbows and wrists
Sometimes the spine, hips or 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
How is enteropathic arthritis diagnosed?
Upper and lower GI endoscopy Joint aspirate - no organisms or crystals Raised inflammatory markers MRI showing sacroiliitis USS showing tenosynovitis
How is enteropathic arthritis treated?
Treat IBD
DONT GIVE NSAID
Normal analgesia - paracetamol, cocodamol
How are spondyloarthridites treated medically?
NSAIDs Corticosteroids Topical steroid eyedrops DMARDs - methotrexate, sulfasalazine, lefunomide Biologics - anti-TNF Secukinumab (anti IL-17) for PsA and AS
What are the non medical treatments for spondyloarthridites?
Physiotherapy
OT
Orthotics, chiropodist
