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Musculoskeletal > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q

What are spondyloarthropathies?

A

Family of inflammatory arthritides characterised by involvement of both the spine and joints, principally in genetically predisposed individuals

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2
Q

What is HLA-B27?

A

Associated with ankylosing spondylitis, reactive arthritis, Crohn’s disease and uveitis, prevalent in 25% of northern hemisphere, not useful screening/diagnostic tool unless patients symptomatic

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3
Q

What are the subgroups of spondyloarthropathies?

A

Ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis

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4
Q

What are the characteristics of mechanical pain?

A

Worsened by activity, typically worst at end of day, better with rest

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5
Q

What are the characteristics of inflammatory pain?

A

Worse with rest, better with activity, significant early morning stiffness (>30mins)

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6
Q

What is enthesitis?

A

Inflammation at insertion of tendons into bones

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7
Q

What are the characteristics of inflammatory arthritis?

A

Digoarticular, asymmetric, predominantly lower limb

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8
Q

What is dactylitis?

A

“Sausage” digits, inflammation of entire digit

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9
Q

What are the shared features of the spondyloarthropathies?

A

Sacroiliac and spine involvement, enthesitis, inflammatory arthritis, dactylitis, ocular inflammation, mucocutaneous lesions, no rheumatoid nodules

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10
Q

What are rare features of spondyloarthropathies?

A

Aortic incompetence or heart block

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11
Q

What is ankylosing spondylitis?

A

Chronic inflammatory disorder that primarily affects the spine

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12
Q

What is the hallmark of ankylosing spondylitis?

A

Sacroiliac joint involvement (sacroiliitis)

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13
Q

What is the epidemiology of ankylosing spondylitis?

A

More common in men, occurs in late adolescence or early childhood

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14
Q

What is the Modified New York Criteria for the Diagnosis of ankylosing spondylitis?

A

1 = limited lumbar motion
2 = lower back pain for 3 months (improved with exercise, not relieved by rest)
3 = reduced chest expansion
4 = Bilateral, Grade 2 to 4, sacroiliitis on x-ray
5 = Unilateral, Grade 3 to 4, sacroiliitis on x-ray
Diagnose if criteria 4 and 5, plus 1, 2 or 3

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15
Q

What is the ASAS classification criteria for axial spondyloarthritis (SpA)?

A

In patients with >= 3 months back pain and age of onset < 45 years
Sacroiliits on imaging and >= 1 SpA feature or HLA-B27 positive and >= 2 other SpA features

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16
Q

What is the specificity and sensitivity of the ASAS classification criteria for axial spondyloarthritis?

A 
Sensitivity = 82.9%
Specificity = 84.4%
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17
Q

What are the clinical features of ankylosing spondylitis?

A

Back pain (neck, thoracic, lumbar), enthesitis, peripheral arthritis (shoulder and hip, uncommon)

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18
Q

What are the extra-articular features of ankylosing spondylitis?

A

Anterior uveitis, involvement of aortic root/valve, fibrosis of upper lung lobes, asymptomatic enteric mucosal inflammation, amyloidosis, neurological involvement

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19
Q

What makes ankylosing spondylitis the “A disease”?

A

Axial arthritis, Anterior uveitis, Aortic regurgitation, Apical fibrosis, Amyloidosis/Ig A neuropathy, Achilles tendonitis, plantar fasciitis

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20
Q

What are some examinations for a patient with ankylosing spondylitis?

A

Tragus/occiput to wall, chest expansion, modified Schober test

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21
Q

What is the modified Schober test?

A

Assesses lumbar flexion = mark made on posterior iliac spine (L5), place one finger 5cm below mark and one finger 10cm above, as patient to bend at waist, if increase in lumbar spine < 5cm the there is limited flexion

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22
Q

What bloods should be done for ankylosing spondylitis?

A

HLA-B27, inflammatory parameters (ESR, CRP, PV)

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23
Q

What will an x-ray of ankylosing spondylitis show?

A

Sacroiliitis, syndesmophytes, “Bamboo” spine

24
Q

What are the features of the spine in a patient with ankylosing spondylitis?

A

Bone density normal in early disease but reduced in late disease, shiny corners, flowing syndesmophytes, fusion (“bamboo” spine)

25
Q

What are the features of a spine in a patient with osteoarthritis?

A

Normal bone density, reduced joint space, subchondral sclerosis and cysts, osteophyte formation associated with neural forminal narrowing

26
Q

What are the treatments for ankylosing spondylitis?

A

Physiotherapy and occupational therapy
NSAIDs
Disease modifying drugs if peripheral joint involvement (SZP, MTX)
Anti TNF treatment = infliximab, certolizumab, adalimumab and etanercept in severe AS

27
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis = 10-15% of patients have condition without psoriasis

28
Q

What are the clinical features of psoriatic arthritis?

A

Sacroiliitis = often asymmetric, may be associated with spondylitis
Nail involvement = pitting, onycholysis
Dactylitis, no rheumatoid nodules
Enthesitis = Achilles tendonitis, plantar fasciitis

29
Q

What are the clinical subgroups of psoriatic arthritis?

A

Confined to distal interphalangeal joints (DIP = hands/feet)
Symmetric polyarthritis
Spondylitis (spine involvement) with or without peripheral joint involvement
Asymmetrical oligoarthritis with dactylitis
Arthritis mutilans

30
Q

What do bloods of patients with psoriatic arthritis show?

A

Raised inflammatory parameters, negative for rheumatoid factor

31
Q

What do x-rays of psoriatic arthritis show?

A

Marginal erosions and whiskering, pencil in a cup deformity, osteolysis, enthesitis

32
Q

What are some pharmacological treatments for psoriatic arthritis?

A

NSAIDs, corticosteroids/joint injections, disease modifying drugs (methotrexate, sulfasalazine, leflunomide), secukinumab (anti-IL-17)

33
Q

When should anti-TNF drugs be given to psoriatic arthritis sufferers?

A

In severe disease unresponsive to NSAIDs and methotrexate

34
Q

What are non-pharmacological treatments for psoriatic arthritis?

A

Physiotherapy, occupational therapy, orthotics, chiropodist

35
Q

What is reactive arthritis?

A

Infection-induced systemic illness characterised primarily by an inflammatory synovitis from which viable micro-organisms can’t be cultured

36
Q

When do symptoms of reactive arthritis appear?

A

1-4 weeks after infection

37
Q

What are some common infections that cause reactive arthritis?

A 
Urogential = chlamydia
Enterogenic = salmonella, shigella, yersinia
38
Q

What is the epidemiology of reactive arthritis?

A

Young adults (20-40), equal sex distribution, HLA-B27 positive

39
Q

What are the conditions that make up the triad of Reiter’s syndrome of reactive arthritis?

A

Urethritis, conjunctivitis/uveitis/iritis, arthritis

40
Q

What are some clinical features of reactive arthritis?

A

Fever, fatigue, malaise, asymmetrical monoarthritis or oligoarthritis, enthesitis

41
Q

What are some mucocutaneous lesions present in reactive arthritis?

A

Keratoderma blenorrhagica (psoriatic-like plaques), circinate balanitis (inflammation of penis), painless oral ulcers, hyperkeratotic nails

42
Q

What ocular lesions occur in reactive arthritis?

A

Conjunctivitis, iritis (unilateral or bilateral)

43
Q

What are some visceral manifestations of reactive arthritis?

A

Mild renal disease, carditis

44
Q

What blood tests should be taken for reactive arthritis?

A

Inflammatory parameters (CRP, ESR, PV), FBC, U & Es, HLA-B27 (rarely necessary)

45
Q

What cultures should be taken for reactive arthritis?

A

Urine, blood, stool

46
Q

What are some investigations that should be done in reactive arthritis?

A

Joint fluid analysis (rule out infection), x-ray of affected joints, get opinion of ophthalmology, bloods, cultures

47
Q

Can reactive arthritis resolve on its own?

A

Yes = 90% of cases resolve spontaneously within 6 months

48
Q

What are some treatments for reactive arthritis?

A

NSAIDs, corticosteroids (intra-articular once sepsis has been ruled out, oral, eye drops), antibiotics for underlying infection, DMARD (SZP) if resistant or chronic, physiotherapy and occupational therapy

49
Q

What is the prognosis of reactive arthritis?

A

Generally good, recurrences not uncommon, some develop a chronic form

50
Q

What is enteropathic arthritis associated with?

A

Inflammatory bowel disease (e.g Crohn’s and UC), symptoms worsen during flare ups of bowel disease

51
Q

How does enteropathic arthritis present?

A

Arthritis in several joints, especially the knees, ankles, elbows and wrists, sometimes in spine, hips or shoulders

52
Q

What are the symptoms of enteropathic arthritis?

A

Loose watery stool with mucous and blood, weight loss, low grade fever, uveitis, pyoderma gangrenosum, apthous ulcers, enthesitis (Achilles tendonitis, plantar fasciitis, lateral epicondylitis)

53
Q

What investigations are done for enteropathic arthritis?

A

Upper and lower GI endoscopy with biopsy showing ulceration/colitis
Joint aspirate (no organisms or crystals)
Raised inflammatory markers (CRP, PV)
X-ray/MRI showing sacroiliitis, USS showing synovitis/tenosynovitis

54
Q

Why are NSAIDs not used to treat enteropathic arthritis?

A

They may exacerbate bowel disease

55
Q

What should be treated to control enteropathic arthritis?

A

The underlying bowel disease

56
Q

What are some anti-TNF agents given in enteropathic arthritis?

A

Infliximab, adalimumab licensed for both Crohn’s disease and inflammatory arthritis

57
Q

What are some drugs given to treat enteropathic arthritis?

A 
Normal analgesia (paracetamol, cocodamol)
Steroids = oral, intra-articular, intramuscular
Disease modifying drugs = azathioprine, sulfasalazine, methotrexate

Musculoskeletal (57 decks)

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