Spondyloarthropathies Flashcards
Give examples of spondyloarthrites.
Axial spondyloarthritis (AxSpa) such as ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Post-dysenteric reactive arthritis
Enteropathic arthritis
What are the spondyloarthropathies?
A group of related chornic inflammatory conditions.
They usually affect the axial skeleton.
Shared clinical features of spondyloarthropathies.
Seronegativity (RhF -ve)
HLA-B27 associated
Axial arthritis and sacroiliac joints
Assymetrical large-joints oligoarthritis or monoarthritis.
Entehsitis
Dactylitis
Extra-articular manifestations.
What is enthesitis?
Inflammation of the site of insertion of tendon or ligament into bone.
Give examples of enthesites.
Plantar fasciitis
Achilles tendonitis
Costochondritis
Most common spondyloarthropathy.
Axial spondyloarthritis and ankylosing spondylitis.
What is the difference between axial spondyloarthritis and ankylosing spondylitis?
Axial spondyloarthritis is an inflammatory disorder primarily affecting the sacroiliac joints or fibrous and synovial joints of the spine, so is ankylosing spondylitis.
AxSpA can be seen on MRI, so can ankylosing spondylitis.
However Ankylosing spondylitis can also be seen on X-ray.
When the radiographic changes occur in AxSpA it is then termed ankylosing spondylitis.
AS forms part of the spectrum of AxSpA
Epidemiology of ankylosing spondylitis. AS.
Usually in young men where symptoms start to occur in late teens to early thirties.
Male to female 3:1
Women present later and are under-diagnosed.
There is a strong association with HLA-B27.
95% carry HLA-B27 gene.
Clinical presentation of AS.
Bilateral buttock pain, chest wall and thoracic pain
There is an insidious onset of the pain.
It is worse during the night and spinal morning stiffness that is relieved by exercise.
The pain usually improves by the end of the day.
Features on examination of AS.
Often normal
However in late disease there might be loss of lumb lordosis and exaggerated thoracic kyphosis.
Schober’s test
Reduced chest expansion
Explain Schober test.
Mark the skin 10cm above and 5 cm below PSIS.
This gives a 15cm distance between the two marks.
Ask the patient to bend forward with straight legs.
The distance should now be > 20 cm for the spine to be normal.
If it is 20 cm or less there is loss oof lumbar lordosis.
Other features in AS.
Enthesitis - particularly Achilles tendonitis and plantar fasciitis
Acute iritis
Osteoporosis
Acute anterior uveitis
Costochondritis
AV block
Aortic incompetence
Apical lung fibrosis
Amyloidosis
Investigations of AS.
CRP - raised or normal
MRI spine and SI joints (more sensitive than X-ray)
HLA-B27 testin
X-ray and MRI findings in AS.
Bamboo spine is a typical appearance in later stages.
Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Syndesmophytes
Ossification of the ligaments, discs and joints.
Fusion of the facet, sacroiliac and costovertebral joints
Medial and lateral cortical margins of both sacroiliac joints lose their definition due to erosions.
They will eventually become sclerotic.
There is blurring of the upper or low vertebral rims at the thoracolumbar junction due to enthesitis at the insertion of the interverebral ligaments.
Bony spurs may be present
Sacroiliac joints eventually fuse as may the costovertebral joints leading to reduced chest expansion.
Blood findings in AS.
Normocytic anaemia
ESR raised
CRP raised
HLAB27 positive
Back pain criteria for diagnosing axial/ankylosing spondylitis.
Age of onset < 45 years
Insidious onset of pain
Improvement of back pain with exercise
No improvement of back pain with rest
Pain at night with improvement of getting up.
Presence of four of five criteria suggests AS with 80% sensitivity
General management of AS.
Exercise instead of rest to relieve the pain.
Work hard to maintain posture and mobility.
Treatment algorithm for AS.
NSAIDs and analgesics like paracetamol
If there is local intra-articular inflammation or enthesitis give intra-articular corticosteroid injections.
If there is peripheral joint involvement give sulfasalazine.
Treatment algorithm for AS refractory to 2 NSAIDs.
Straight to TNF-alpha blockers
An easy way to remember extra-articular manifestations of AS.
All the As.
Anterior uveitis
Aortic incompetence
AV block
Apical lung fibrosis
Amyloidosis
Clinical features of psoriatic arthritis.
Mono or oligoarthritis.
Polyarthritis in a asymmetrical pattern going symmetrical and can become indistinguishable to RA. This is more common in women and MCPJ are not normally affected.
Spondylitis that is unilateral or bilateral sacroiliitis and early cervical spine involvement.
Distal interphalangeal arthritis
Dactylitis
Arthritis mutilans causing marked periarticular osteolysis and bone shortening.
Onycholysis
Pitting of nails
Enthesitis
Synovitis
Acneiform rashes
Investigations in PA + screening tool
CRP often raised.
X-ray
MRI
Psoriasis Epidemiological Screening Tool (PEST)
NICE recommend patients with psoriasis complete the PEST tool to screen for psoriatic arthritis. This involves several questions asking about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist.
X-ray findings in PA.
Periostitis is inflammation of the periosteum causing a thickened and irregular outline of the bone
Ankylosis is where bones joining together causing joint stiffening
Osteolysis is destruction of bone
Dactylitis is inflammation of the whole digit and appears on the xray as soft tissue swelling
Pencil-in-cup appearance central erosion of the bone
What is dactylitis?
Uniform swelling of a finger
Criteria for diagnosis of psoriatic arthritis.
CASPAR (ClASsification of Psoriatic ARthritis) criteria
Inflammatory articular disease (joint, spine, or entheseal) with ≥3 points from the following 5 categories (current psoriasis score 2 points; all others 1 point):
1 - Evidence of current psoriasis, a personal history of psoriasis, or a family history of psoriasis in a first- or second-degree relative
2 - Psoriatic nail dystrophy
3 - RhF -ve
4 - Current or historical dactylitis
5 - Radiographical evidence of juxta-articular new-bone formation appearing as ill-defined ossification near joint margins (periostitis) on plain films of the hand or foot.
What is arthritis mutilans?
This is the most severe form of psoriatic arthritis.
This occurs in the phalanxes. There is osteolysis (destruction) of the bones around the joints in the digits.
This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.
Treatment of PA.
NSAIDs
DMARDs
TNF inhibitors
IL-17 inhibitors
IL12/23 inhibitors
What is reactive arthritis? ReA
Arthritis and other clinical manifestations occur as an autoimmune response to infection elsewhere in the body, this is typically GI or GU like an STI.
It is a sterile synovitis that develop post dysentery like Salmonella, Shigella or Campylobacter or following urethritis/cervicitis by Chlamydia trachomatis.
Clinical features of ReA.
Acute asymmetrical lower limb arthritis develops few days - 2 weeks post infection
Associations with ReA.
Bilateral conjunctivitis (non-infective)
Anterior uveitis
Circinate balanitis is dermatitis of the head of the penis
Iritis
Keratoderma blennorrhagica
Enthesitis
“can’t see, pee or climb a tree”.
What is Keratoderma blennorrhagica?
What is circinate balanitis?
Investigations of ReA.
Elevated ESR and CRP
Culture stool if diarrhoea
Infectious serology
Sexual health review
Joint aspiration might need to be done to rule of septic/crystal arthritis.
X-ray
What might X-ray show in ReA?
Enthesitis with periosteal reaction
Treatment of ReA.
Treat infection
NSAIDs and joint injections of steroids.
Most will resolve within 2 years but if they don’t the may need DMARDs.
Treatment algorithm of ReA.
What is enteropathic arthritis? EA.
10-20% of those with IBD develop arthritis.
Of these 2/3 are peripheral and 1/3 are axial.
Associated with IBD, GI bypass, coeliac and Whipple’s disease.
Two types of peripheral EA.
Type 1 - oligoarticular, asymmetric and correlated with IBD flares.
Type 2 - Polyarticular symmetrical and less correlation with IBD flares.
Treatment of enteropathic arthritis.
NSAIDs to help with IBD flares.
Consider DMARDs.
TNF inhibitors will treat both the bowel disease and the arthritis.
Treat the IBD and the EA will get better as well.
Features of inflammatory back pain mnemonic.
IPAIN
Insidious onset
Pain at night improving on getting up
Age at onset < 40
Improvement with exercise
No improvement with rest
Handy rhyme for remembering features of ReA.
Can’t see (conjunctivitis/uveitis)
Can’t wee (urethritis)
