Spondyloarthropathies Flashcards
What HLA group is associated with spondyloarthropathies
HLA B27
Therefore genetically predisposed
What conditions is HLA B27 associated with
Ankylosing spondylitis
Reactive arthritis
Crohn’s disease
Uveitis
Why is HLA screening not always useful
Can be present without causing disease
Only screen if patient has symptoms
Describe mechanical back pain
Worsened by activity
Worse at end of the day
Better with rest
More common
Describe inflammatory back pain
Worse with rest
Better on activity
Significant morning stiffness (>1 hour)
List some features of inflammatory arthritis
Oligoarticular - affects a few joints, typically larger ones like knees, hips etc.
Asymmetric
However psoriatic can be symmetric and in small joints
Predominantly lower limb
Dactylitis - sausage fingers
List some shared rheumatological features of spondyloarthropathies
Involvement of the sacroiliac joints and spine Enthesitis - where tendons attach Tenosynovitis and synovitis Inflammatory arthritis Dactylitis - sausage fingers
List some shared extra-articular features of spondyloarthropathies
Ocular inflammation - e.g. uveitis/iritis
Mucocutaneous lesions - mouth, genitals
Rarely aortic incompetence or heart block
IBS history
What is the hallmark of ankylosing spondylitis
Involvement of the sacro-iliac joint as well as the spine
When should you consider ankylosing spondylitis as a cause of back pain
In patients where pain has lasted more than 3 months
Age of onset less than 45 (typically between 20-40)
What criteria must be met in order to diagnose ankylosing spondylitis
Sacroiliitis on imaging and more than one clinical feature of SpA
OR
HLA-B27 positive and more than 2 clinical features
What are the main clinical features of ankylosing spondylitis
Back pain Enthesitis Peripheral arthritis - rare Uveitis CV or pulmonary involvement Mucosal inflammation Amyloidosis Neurological symptoms
What forms in the spine in ankylosing spondylitis
Syndesmophytes
Fusion of the vertebrae that leads to decreased movement
What is the Schober test
Measure 10cm from dimples of iliac crest and 5cm below
Ask patient to bend over and touch toes
Distance should increase
What is the limitation of the Schober test
Can be limited by pain
Even if back does move its too sore to complete
What is used to diagnose ankylosing spondylitis
History
Exam - occipital to wall, Schober test and chest expansion - reduced
Bloods - HLA B27 and inflammatory markers
X-ray
MRI
How is chest expansion affected in ankylosing spondylitis
May be reduced
Due to fusion of costochondral joints
How might ankylosing spondylitis present on X ray
May be normal in early disease
Bone density reduced (late disease only)
Shiny corners or fuzzy margins- start of fusion
Syndesmophytes
Fusion - bamboo spine due to bridging of sydesmophytes
How can you treat ankylosing spondylitis
Spinal disease: Physio and occupational therapy
NSAIDs
Anti-TNF - e.g. infliximab
Or IL-17 blockers
Peripheral disease
DMARDs - e.g. MTX
IM or IA steroids
Short course of oral steroids
What is psoriatic arthritis
Inflammatory arthritis usually associated with psoriasis
All patients with psoriatic arthritis will have psoriasis - true or false
False
10-15% of patients will present without the skin condition
Often have a family member with psoriasis
What are the clinical features of psoriatic arthritis
Inflammatory arthritis Sacroiliitis - often asymmetrical Nail involvement - pitting or white patches Dactylitis Enthesitis Eye disease - uveitis or iritis
What are the 5 clinical subgroups of psoriatic arthritis
1- confined to DIP joints (hands and feet)
2- symmetrical polyarthritis
3- spondylitis (spine involved)
4- asymmetric oligoarthritis with dactylitis
5- arthritis mutilans - severe damage to the hands and feet
How do you diagnose psoriatic arthritis
History - PMH and FH of psoriasis is key
Examination - nail signs etc
Bloods - raised inflammatory markers
X rays
What X ray signs suggest psoriatic arthritis
Marginal erosions
Enthesitis
Pencil in a cup deformity - bone looks sharpened
How can you treat psoriatic arthritis
NSAIDs Steroids (inc. joint injection) DMARDs Anti-TNF - severe disease Physio and occupational therapy Orthotics
What is reactive arthritis
Infection induced systemic illness
Typically a infective illness which leads to an inflammatory synovitis
Common after GI or GU infection in UK - campylobacter and chlamydia
Who does reactive arthritis usually affect
Young adults
20-40
Equal sex distribution
What are the clinical features of reactive arthritis
Fever, fatigue, malaise Asymmetrical mono/oligoarthritis Enthesitis Mucocutaneous lesions Ocular lesions Mild renal disease Carditis
Which joints are commonly affected by reactive arthritis
Knees
Can affect any joint
How do you diagnose reactive arthritis
History and Exam Bloods - inflammatory markers, FBC, U&E, HLA B27 Cultures - blood, urine Joint fluid analysis X ray (last 2 mainly to rule out other causes)
How do you treat reactive arthritis
Most resolve itself in 6 months
Can give NSAIDs, corticosteroids, antibiotics for underlying infection
DMARD is resistant/chronic
Physio
What is enteropathic arthritis
Arthritis associated with IBD (Crohn’s and UC)
9-20% of sufferers will get it
Can affect many joints
When does enteropathic arthritis get worse
During flare up of the IBD
What are the clinical symptoms of enteropathic arthritis
GI - loose stool with mucous & blood Weight loss Fever Eye inflammation Skin involvement # Enthesitis Oral ulcers
What investigations might you do for enteropathic arthritis
and what would the findings be
Endoscopy - shows UC or Crohn's Joint aspirate - no organism or crystals (excludes other conditions) Raised inflammatory markers X-ray/MRI - shows sacroiliitis USS - synovitis or tenosynovitis
How do you treat enteropathic arthritis
Treat the underlying bowel disease Normal analgesia - paracetamol Steroids - oral, IA or IM DMARDs Anti-TNF
Why would you not give NSAIDs to treat enteropathic arthritis
May exacerbate the existing inflammatory bowel disease
Psoriatic and other seronegative
arthropathies generally affect the DIPs - true or false
True
This is because of enthesitis at the insertion of the extensor tendon into the terminal phalanx
Not affected in RA
Which age group and sex are most likely to be affected by seronegative
spondyloarthropathies
Young men between 20 and 40 years old are more likely to be affected by seronegative
spondyloarthropathies such as AS.
Family history increases risk of seronegative
spondyloarthropathies - true or false
True
- A first degree relative with AS increases the
risk having the disease by 5-20%
- A 50-fold increase for first degree relatives with
psoriatic arthritis and monozygotic twins have a 50% concordance
rate.
Seronegative
spondyloarthropathies typically affect which joints
Affect sites where tendons insert to bone - DiP, spine etc
Pain radiating down the front or back of legs
usually indicates which type of pain
Mechanical
Neurological
symptoms usually indicate a non-inflammatory cause for back pain - true or false
True
Things such as paraesthesia, bowel or bladder symptoms
Which type of back pain responds to NSAIDs
Inflammatory
Sacro-iliac joint issues can cause pain in the buttock - true or false
True
unilaterally or bilaterally.
List diseases affecting the entheses
seronegative spondyloarthropathies Tennis elbow Golfers elbow Plantar fascitis Achilles tendonitis
What causes the back pain in seronegative spondyloarthropathies
It occurs secondary to enthesitis of
costovertebral and costotransverse ligament attachments
Can also get similar chest pain due to costocondritis
What is the gold standard diagnostic test for seronegative spndyloarthropathies
MRI scans
Particularly of spine and sacroiliac joints
Picks up early changes such as enthesitis
Which blood abnormalities may be seen in seronegative spndyloarthropathies
May have anaemia of chronic disease - FBC
CRP/ESR/PV may be raised
Often normal though so don’t rule out based on low inflammatory markers
