Spondyloarthropathies Flashcards
What are spondyloarthropathies/spondyloathritides?
Group of conditions, associated with HLA-B27, that affect spine & peripheral joints
State 4 spondyloarthropathies- highlight which is most common
- Ankylosing spondylitis
- Enteropathic arthritis
- Psoriatic arthritis
- Reactive arthritis
Spnondyloarthropathies have 4 common clinical features; state these
- Sacroiliac/axial disease (back/buttock pain)
- Inflammatory arthropathy of peripheral joints
- Enthesitis (innflammation at tendon insertions)
- Extra-articular features (skin/gut/eye)
All spondyloathritides are seronegative and some are also not associated HLA B27; true or false?
FALSE:
- All are seronegative
- All associated with HLA B27
What is ankylosis?
What is spondylitis?
- Abnormal stiffening and immobility of joint due to fusion of bones
- Inflammation of joints in back
What is ankylosing spondylitis?
Inflammatory condition mainly affecting spine that causes progressive stiffness and pain
NOTE: no pathophysiology card as pathophysiology not understood. Just know all spondyloarthropathies are associated with HLA-B27
Who does ankylosing spondylitis usually present in?
Usually young men (teens-mid thirties)
State some risk factors for ankylosing spondylitis
- HLA-B27 (around 90% of pts with ankylosing spondylitis have the gene; however, only 2% of people who have the gene will get AS)
- Family history
State some symptoms of ankylosing spondylitis- inlcude joint symptoms and extra-articular manifestations
HINT: for some of extra-articular manifestations think of “all the A’s”
Symptoms develop gradually over > 3 months:
Joint Symptoms
- Lower back pain
- Lower back stiffness
- Sacroiliac pain
- Inflammatory arthropathy therefore worse with rest, improves with movement
- >30 mins morning stifness
- Chest pain related to costovertebral & costosternal joints
- Enthesitis (inflammation of tendon insertions to bone- cause plantar fasciitis, achilles tendonitis)
Extra-articular manifestations
- Weight loss
- Fatigue
- Anaemia
- Anterior uveitis
- Aortitis
- AV blockblock (due to fibrosis of hearts conductive system)
- Apical pulmonary fibrosis
State what might find on clincial examination of someone with ankylosing spondylitis
Clincial examination often normal in early stages but later may find:
- Positive Schober’s test
- Loss of lumbar lordosis
- Exagerated thoracic kyphosis
- Reduced chest expansion
What gastro disease is associated with ankylosing spondyliltis?
IBD
For Schober’s test, describe:
- What it is
- How you do it
- What result indicates
- Test to assess how much mobility there is in the spine
-
Method:
- Pt stand straight with feet hip width apart
- Find L5 vertebrate
- Mark a point 10cm and a point 5cm below
- Ask pt to bend forward as far as they can with legs straight
- Measure the distance between two points
- If the distance between them when bending forwards is <20cm this indicates restriction in lumbar movement and helps support diagnosis of ankylosing spondylitis
*TIP: to locate L5, put your hands on pts waist to find iliac crest, point your thumbs to midline, this should put you in region of L4. Count down one vertebrate.
Dicuss what investigations you would do if you suspect ankylosing sponylitis, include:
- Bedside
- Bloods
- Imaging
Bedside
- Schober’s test (as part of clinical examination)
Bloods
- CRP: raised
- ESR: raised
- HLA-B27 genetic test: found in 90% pts with ankylosing spondylitis
Imaging
- X-ray of spine & sacrum: show changes associated with ankylosing spondylitis
- MRI of spine: can show bone marrow oedema in early stages before there are any x-ray changes
NOTE: you may do other investigations if there any associated conditions (mentioned in symptoms)
What x-ray changes might you see in a pt with ankylosing spondylitis?
“Bamboo spine”
- Squraring of vertebral bodies
- Subchondral sclerosis & erosions
- Syndesmophytes (areas of growth where ligaments insert into bone)
- Ossification of ligaments, discs & joints
- Fusion of facet, sacroiliac & costovertebral joints
Why may a pt with ankylosing spondylitis get bamboo sign on x-ray?
- Inflammation can cause ethentesis (inflammation of tendon or ligament insertion into bone)
- Ethentesis leads to bony proliferations between ligaments and vertebrate
- Bony proliferations fuse with vertebrate above
- In later stages get calcification of ligaments leading to bamboo spine appearance
What might an MRI spine show in a pt with ankylosying spondylitis?
Bone marrow oedema
Discuss the management of ankylosing spondylitis, include:
- Conservative management
- Pharmalogical management of acute flare & long term control
Conservative
- Physiotherapy
- Exercise & mobilisation
- Smoking cessation
Acute Flare
- First line= NSAIDs: for pain. If no improvement after 2-4 week of max dose switch to a different NSAID
- Steroids: during flares.- oral, IM or joint injection
Long term control (don’t necessarily need these)
- Anti-TNF medications: e.g. etanercept, adalimumab, infliximab (severe)
- Consider bisphosphonates: incresed risk of osteoporotic vertebral fractures in AS
- Surgery for deformities
State some potential complications of ankylosing spondylitis
- Osteoporosis which increases risk of vertebral fractures
- Cardiac involvement such as arrhythmias
- Iritits (inflammation of iris)
What is pauciarthritis?
Same as oligoarthritis; arthritis which only affects a few joints
What is psoriatic arthritis?
Inflammatory arthritis associated with psorasis which can vary in severity form mild stiffness & soreness to complete joint destruction as in arthritis mutilans
Psoriatic arthropathy is part of seronegative spondyloarthropathys; true or false?
True
Discuss who psoriatic arthritis occurs in
- 10-20% pts with psoriasis
- Usually within 10yrs of developing skin changes
- Typically affects middle aged
State some risk factors for psoriatic arthritis
- Personal or family history of psoriasis
State some conditions associated with psoriatic arthritis-other than psoriasis
- Eye disease (conjunctivits & anterior uveitis)
- Aortitis
- Amyloidosis
State the symptoms of psoriatic arthritis
Presents with pain and stiffness, worse after rest (as it is inflammatory arthritis, in joints; there are several recognised patterns:
- Symmetrical polyarthritis: hands, writsts, ankles, DIP
- Asymmetrical pauciarthritis: affecting fingers, toes and feet. Arthritis only affects a few joints
- Spondylitic pattern: back stiffness, sacroiliitis, atlanto-axial involvement
Other areas can be affected e.g. spine, achilles tendono, plantar fascia
State what you might find on clinical examination of someone with psoriatic arthritis
- Plaques of psoriasis on skin
- Pitting of nails
- Onycholysis (separation of nail from nail bed)
- Dactylitis
- Enthesitis
What screening tool can you use to screen for psoriatic arthritis?
PEST (psoriatic arthritis screening tool): questions asking about joint pain, stiffness, history of arthritis and nail pitting. High score= refer rheumatologist
What investigations would you do if you suspect psoriatic arthritis, include:
- Bedside
- Bloods
- Imaging
*justify each where possible
*Recurrent idea that you are ruling out other causes
Bedside
- If it was hot you do arthrocentesis
Bloods
- CRP: usually raised
- Rheumatoid factor: rule out rheumatoid
- Anti-CCP antibodies: rule out rheumatoid
- Uric acid: check for gout
Imaging
- X-ray: look for ‘pencil-in-cup appearance”
What x-ray changes might you see in psoriatic arthritis?
- “Pencil in cup appearance” (idea that there are central erosions of bone besides joint and this causes appearance of one bone being hollow and looking like a cup whilst the other is narrow and sits in the cup)
- Periostitis: thickened irregular outline of bone
- Ankylosis: fusion of bones
- Osteolysis: destruction of bone
- Dactylitis: inflammation of digit- soft tissue swelling
Discuss the management of psoriatic arthritis
Similar to RA. Crossover between systemic treatments of psoriasis and treatmetn of psoriatic arthritis; coordinated between dermatologist & rheumatologist:
- NSAIDs for pain
- DMARDs (methotrexate, leflunomide, sulfasalazine)
- Anti-TNF (etanercept, infliximab, adalimumab)
- Ustekinumab (monoclonl antibody against IL-12 and IL-23)
*In that order
State some potential complications of psoriatic arthritis
- Arthritis mutilans
- CVD: increased risk angina, hypertension, MI
- Medication related complications
What is arthritis mutilans?
- Most severe form of psoriatic arthritis
- Occurs in phalanxes
- Osteolysis of bones around joints in digits leading to shortening of digit
- Skin then folds as digits shortens giving appearance of a “telescopic finger”
What is reactive arthritis?
What did it used to be known as?
- Synovitis in joint as a reaction to a recent infective trigger
- Reiter syndrome
State some risk factors for reactive arthritis
- HLA B27 gene
- Recent infection (most commonly gastroenteritis, STI or UTI)
Reactive arthritis is most commonly seen after what 3 infections?
How many days/week/months following infection does reactive athritis symptoms occur?
- Gastroenteritis, STI or UTI
- Few days to 2 weeks post infection symptoms start
State symptoms & signs of reactive arthritis
Often affects single joint, commonly the knee:
- Pain
- Swollen joint
- Warm
Other associated features:
- Bilateral non-infective conjunctivitis
- Anterior uveitis
- Circinate balanitis
*HINT: think “can’t see, can’t pee, can’t climb a tree”
Discuss what investigations you would want if you suspect reactive arthritis, include:
- Bedside
- Bloods
- Imaging
*Justify each where appropriate
Bedside
- Athrocentesis: rule out septic arthritis, gout & pseudogout
- Stool culture
- Urogenital culture
Bloods
- FBC: infection?
- U&Es: urate nephropathy in gout
- CRP: infection/inflammation
- Uric acid level: looking for evidence of gout
- HLA B27 genetic testing
Imaging
- X-ray of joint
Discuss the management of reactive arthritis
- As with any hot joint, need to exlcude septic arthritis as a possiblity; start antibiotics until septic arthritis is excluded
- Treat underlying infection if still present
Once septic arthritis excluded, management:
- NSAIDs
- Steroid injection into affected joints
- Systemic steroids may be required- particularly where multiple joints are affected
- Recurrent cases may require DMARDs or anti-TNF medications
*NOTE: most resolve in 6 months & don’t reoccur
State some potential complications of reactive arthritis
- Secondary osteoathritis (develops in 50% of pts with recurrent reactive arthritis)
What is enteropathic arthritis?
Chronic inflammatory arthritis associated with IBD (10-20% of pts with IBD develop athropathy). Most commonly it is peripheral arthritis but pts can develop axial/spinal disease.
State some symptoms & signs of enteropathic arthritis
- Arthritic symptoms
- Joint pain
- Joint stiffness
- Joint swelling
- IBD symptoms
We have already said that about 10% of pts with IBD will develop enteropathic arthritis; 2/3 of these will develop peripheral arthritis and 1/3 develop axial/spinal arthritis. Of the peripheral arthritis, there are two types, describe each type including:
- How many joints affected
- Symmetrical or asymmetrical
- Correlation with IBD flares
Type 1
- Oligoarticular
- Asymmetric
- Correlation with IBD flares
Type 2
- Polyarticular
- Symmetrical
- Less correlation with IBD flares
Summarise what investigations you would consider in enteropathic arthritis (don’t need to do usual bedside, bloods, imaging). Think about the principles of what you need to investigate
- Investigations to rule out other causes of arthritis e.g. if hot rule out SA, rule out others e.g. rheumatoid, gout, pseudogout
- Investigations of joint e.g. x-ray
- Investigations to see if IBD is flaring e.g. stool culture, faecal calprotectin, CRP, colonscopy etc..
Discuss the management of enteropathic arthritis
- Control flare of IBD
- Consider DMARDs
- TNF inhhibitors will work well for both athritis & bowel disease
- Avoid NSAIDs as they worsen IBD
