Spondyloarthropathies Flashcards
What are spondyloarthropathies?
Family of inflammatory arthritides characterised by involvement of both the spine and joints, principally in genetically predisposed individuals
What is HLA-B27?
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
What are the subgroups of spondyloarthropathies?
Ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis
What are the characteristics of mechanical pain?
Worsened by activity, typically worst at end of day, better with rest
What are the characteristics of inflammatory pain?
Worse with rest, better with activity, significant early morning stiffness (>30mins)
What is enthesitis?
Inflammation at insertion of tendons into bones
What are the characteristics of inflammatory arthritis?
Digoarticular, asymmetric, predominantly lower limb
What is dactylitis?
“Sausage” digits, inflammation of entire digit
What are the shared features of the spondyloarthropathies?
Sacroiliac and spine involvement, enthesitis, inflammatory arthritis, dactylitis, ocular inflammation, mucocutaneous lesions, no rheumatoid nodules
What are rare features of spondyloarthropathies?
Aortic incompetence or heart block
What is ankylosing spondylitis?
Chronic inflammatory disorder that primarily affects the spine
What is the hallmark of ankylosing spondylitis?
Sacroiliac joint involvement (sacroiliitis)
What is the epidemiology of ankylosing spondylitis?
More common in men, occurs in late adolescence or early childhood
What is the Modified New York Criteria for the Diagnosis of ankylosing spondylitis?
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
What is the ASAS classification criteria for axial spondyloarthritis (SpA)?
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
What is the specificity and sensitivity of the ASAS classification criteria for axial spondyloarthritis?
Sensitivity = 82.9% Specificity = 84.4%
What are the clinical features of ankylosing spondylitis?
Back pain (neck, thoracic, lumbar), enthesitis, peripheral arthritis (shoulder and hip, uncommon)
What are the extra-articular features of ankylosing spondylitis?
Anterior uveitis, involvement of aortic root/valve, fibrosis of upper lung lobes, asymptomatic enteric mucosal inflammation, amyloidosis, neurological involvement
What makes ankylosing spondylitis the “A disease”?
Axial arthritis, Anterior uveitis, Aortic regurgitation, Apical fibrosis, Amyloidosis/Ig A neuropathy, Achilles tendonitis, plantar fasciitis
What are some examinations for a patient with ankylosing spondylitis?
Tragus/occiput to wall, chest expansion, modified Schober test
What is the modified Schober test?
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
What bloods should be done for ankylosing spondylitis?
HLA-B27, inflammatory parameters (ESR, CRP, PV)
What will an x-ray of ankylosing spondylitis show?
Sacroiliitis, syndesmophytes, “Bamboo” spine
What are the features of the spine in a patient with ankylosing spondylitis?
Bone density normal in early disease but reduced in late disease, shiny corners, flowing syndesmophytes, fusion (“bamboo” spine)
What are the features of a spine in a patient with osteoarthritis?
Normal bone density, reduced joint space, subchondral sclerosis and cysts, osteophyte formation associated with neural forminal narrowing
What are the treatments for ankylosing spondylitis?
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
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis = 10-15% of patients have condition without psoriasis
What are the clinical features of psoriatic arthritis?
Sacroiliitis = often asymmetric, may be associated with spondylitis
Nail involvement = pitting, onycholysis
Dactylitis, no rheumatoid nodules
Enthesitis = Achilles tendonitis, plantar fasciitis
What are the clinical subgroups of psoriatic arthritis?
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
What do bloods of patients with psoriatic arthritis show?
Raised inflammatory parameters, negative for rheumatoid factor
What do x-rays of psoriatic arthritis show?
Marginal erosions and whiskering, pencil in a cup deformity, osteolysis, enthesitis
What are some pharmacological treatments for psoriatic arthritis?
NSAIDs, corticosteroids/joint injections, disease modifying drugs (methotrexate, sulfasalazine, leflunomide), secukinumab (anti-IL-17)
When should anti-TNF drugs be given to psoriatic arthritis sufferers?
In severe disease unresponsive to NSAIDs and methotrexate
What are non-pharmacological treatments for psoriatic arthritis?
Physiotherapy, occupational therapy, orthotics, chiropodist
What is reactive arthritis?
Infection-induced systemic illness characterised primarily by an inflammatory synovitis from which viable micro-organisms can’t be cultured
When do symptoms of reactive arthritis appear?
1-4 weeks after infection
What are some common infections that cause reactive arthritis?
Urogential = chlamydia Enterogenic = salmonella, shigella, yersinia
What is the epidemiology of reactive arthritis?
Young adults (20-40), equal sex distribution, HLA-B27 positive
What are the conditions that make up the triad of Reiter’s syndrome of reactive arthritis?
Urethritis, conjunctivitis/uveitis/iritis, arthritis
What are some clinical features of reactive arthritis?
Fever, fatigue, malaise, asymmetrical monoarthritis or oligoarthritis, enthesitis
What are some mucocutaneous lesions present in reactive arthritis?
Keratoderma blenorrhagica (psoriatic-like plaques), circinate balanitis (inflammation of penis), painless oral ulcers, hyperkeratotic nails
What ocular lesions occur in reactive arthritis?
Conjunctivitis, iritis (unilateral or bilateral)
What are some visceral manifestations of reactive arthritis?
Mild renal disease, carditis
What blood tests should be taken for reactive arthritis?
Inflammatory parameters (CRP, ESR, PV), FBC, U & Es, HLA-B27 (rarely necessary)
What cultures should be taken for reactive arthritis?
Urine, blood, stool
What are some investigations that should be done in reactive arthritis?
Joint fluid analysis (rule out infection), x-ray of affected joints, get opinion of ophthalmology, bloods, cultures
Can reactive arthritis resolve on its own?
Yes = 90% of cases resolve spontaneously within 6 months
What are some treatments for reactive arthritis?
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
What is the prognosis of reactive arthritis?
Generally good, recurrences not uncommon, some develop a chronic form
What is enteropathic arthritis associated with?
Inflammatory bowel disease (e.g Crohn’s and UC), symptoms worsen during flare ups of bowel disease
How does enteropathic arthritis present?
Arthritis in several joints, especially the knees, ankles, elbows and wrists, sometimes in spine, hips or shoulders
What are the symptoms of enteropathic arthritis?
Loose watery stool with mucous and blood, weight loss, low grade fever, uveitis, pyoderma gangrenosum, apthous ulcers, enthesitis (Achilles tendonitis, plantar fasciitis, lateral epicondylitis)
What investigations are done for enteropathic arthritis?
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
Why are NSAIDs not used to treat enteropathic arthritis?
They may exacerbate bowel disease
What should be treated to control enteropathic arthritis?
The underlying bowel disease
What are some anti-TNF agents given in enteropathic arthritis?
Infliximab, adalimumab licensed for both Crohn’s disease and inflammatory arthritis
What are some drugs given to treat enteropathic arthritis?
Normal analgesia (paracetamol, cocodamol) Steroids = oral, intra-articular, intramuscular Disease modifying drugs = azathioprine, sulfasalazine, methotrexate
