Spondyloarthropathies

Question 1

What gene is Ankylosing Spondylitis associated with?

Answer 1

HLA-B27

Question 2

What is the pathophysiology of Ankylosing Spondylitis?

Answer 2

Chronic, inflammatory disease
Bony outgrowths due to enthesitis
Leads to fusion of the spine

Question 3

What are the Sx of Ankylosing Spondylitis?

Answer 3

Lower back pain: Gradual onset
Worse am & night
Radiates to Sacroiliac joint, hips & buttocks
Morning stiffness: Relieved by exercise
Enthesitis: Achilles tendon, Plantar fasciitis
↓ Spinal movement: Progressive
Deformity of spine: Kyphosis, neck hyperextension
QUESTION MARK DEFORMITY

Question 4

What are the extra-articular Sx of Ankylosing Spondylitis?

Answer 4

Apical fibrosis
Anterior uveitis
Aortic regurg
Achilles tendon rupture
AV node block
Amyloidosis
CaudA Equina syndrome

Question 5

How is Ankylosing Spondylitis investigated?

Answer 5

REFERAL to Rheumatology
Diagnosis = CLINICAL but supported by imaging
Xray: Sacroiliitis, narrow joint spaces, vertebral, syndesmophytes COMMON = T11-L1, BAMBOO SPINE
Bloods: FBC (norm anaemia), ↑↑ESR/CRP, HLA B27 +ve (90%)

Question 6

What are vertebral Syndesmophytes?

Answer 6

Bony outgrowths due to enthesitis at ligament & vertebra

Fuse w/vertebral body above = ANKYLOSING

Question 7

How is Ankylosing Spondylitis managed?

Answer 7

Conservative: Exercise, NSAIDs +/- Paracetamol
IA steroid injections
Meds: TNF-a inhibitors- Adalimumab/Etanercept
Surgery: Hip replacement

Question 8

What are the poor prognostic indicators for Ankylosing Spondylitis?

Answer 8

ESR >30
Onset <16yo
Early hip involvement
Poor response to NSAIDs

Question 9

What are the complications of Ankylosing Spondylitis?

Answer 9

Anterior uveitis: U/L PAINFUL + RED eye can lead to permanent loss of vision
Osteoporotic spine #

Question 10

What is a reactive arthritis?

Answer 10

Inflammatory arthritis that occurs after exposure to certain GI/GU infections
Mainly affects synovial membrane, tendons & fascia
Usually lower limbs

Question 11

What are the causes of reactive arthritis?

Answer 11

STI: Chlamydia, Gonorrhoea, Trachomatis
Dysenteric: Shigella, Salmonella, Campylobacter

Question 12

How does reactive arthritis present?

Answer 12

Reiter’s: Arthritis + Conjunctivitis + Urethritis
Constitutional: Fever, fatigue, malaise
Circinate balanitis
Keratoderma blenorrhagica: Brown, raised plaques on palms/soles

Question 13

How is reactive arthritis investigated?

Answer 13

Bloods: ↑ESR, ↑CRP
STI Screen: MSU (men) VVS & ECS swabs (women) +/- pharyngeal/rectal swabs w/NAAT for chlamydia
Stool Culture: If diarrhoea

Question 14

How is reactive arthritis treated?

Answer 14

Self-Limiting
Splint
NSAIDs, IA injection
Sx >6m = Sulfasalazine/Methotrexate

Question 15

What is the prognosis for reactive arthritis?

Answer 15

Very good
Resolves 3-12months
Recurrence likely if HLA-B27 +ve

Question 16

What are the Sx of psoriatic arthritis?

Answer 16

Nail changes: Onycholysis, Subungal hyperkeratosis, ridging, pitting
Weight bearing joints: usually 2-5joints affected
Skin lesions/plaques
Dactylitis

Question 17

How is Psoriatic arthritis investigated?

Answer 17

Bloods: ESR/CRP, RF, Lipids, Glucose, Uric acid
Xray: DIP erosions, periarticular new-bone formation, ‘pencil in cup’ deformity
Synovial aspiration

Question 18

How is psoriatic arthritis managed?

Answer 18

Limited: NSAIDs (Naproxen) + Physio +/- IA injection
Progressive: Limited Tx PLUS
1) DMARD: Methotrexate/ Hydroxychloroquine
2) Anti-TNF-a: Infliximab