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
