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Yr3 Medicine- Rheumatology > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q

What are spondyloarthropathies/spondyloathritides?

A

Group of conditions, associated with HLA-B27, that affect spine & peripheral joints

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2
Q

State 4 spondyloarthropathies- highlight which is most common

A
  • Ankylosing spondylitis
  • Enteropathic arthritis
  • Psoriatic arthritis
  • Reactive arthritis
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3
Q

Spnondyloarthropathies have 4 common clinical features; state these

A
  • Sacroiliac/axial disease (back/buttock pain)
  • Inflammatory arthropathy of peripheral joints
  • Enthesitis (innflammation at tendon insertions)
  • Extra-articular features (skin/gut/eye)
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4
Q

All spondyloathritides are seronegative and some are also not associated HLA B27; true or false?

A

FALSE:

  • All are seronegative
  • All associated with HLA B27
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5
Q

What is ankylosis?

What is spondylitis?

A
  • Abnormal stiffening and immobility of joint due to fusion of bones
  • Inflammation of joints in back
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6
Q

What is ankylosing spondylitis?

A

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

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7
Q

Who does ankylosing spondylitis usually present in?

A

Usually young men (teens-mid thirties)

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8
Q

State some risk factors for ankylosing spondylitis

A
  • 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
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9
Q

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”

A

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
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10
Q

State what might find on clincial examination of someone with ankylosing spondylitis

A

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
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11
Q

What gastro disease is associated with ankylosing spondyliltis?

A

IBD

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12
Q

For Schober’s test, describe:

  • What it is
  • How you do it
  • What result indicates
A
  • 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.

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13
Q

Dicuss what investigations you would do if you suspect ankylosing sponylitis, include:

  • Bedside
  • Bloods
  • Imaging
A

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)

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14
Q

What x-ray changes might you see in a pt with ankylosing spondylitis?

A

“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
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15
Q

Why may a pt with ankylosing spondylitis get bamboo sign on x-ray?

A
  • 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
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16
Q

What might an MRI spine show in a pt with ankylosying spondylitis?

A

Bone marrow oedema

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17
Q

Discuss the management of ankylosing spondylitis, include:

  • Conservative management
  • Pharmalogical management of acute flare & long term control
A

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
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18
Q

State some potential complications of ankylosing spondylitis

A
  • Osteoporosis which increases risk of vertebral fractures
  • Cardiac involvement such as arrhythmias
  • Iritits (inflammation of iris)
19
Q

What is pauciarthritis?

A

Same as oligoarthritis; arthritis which only affects a few joints

20
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psorasis which can vary in severity form mild stiffness & soreness to complete joint destruction as in arthritis mutilans

21
Q

Psoriatic arthropathy is part of seronegative spondyloarthropathys; true or false?

A

True

22
Q

Discuss who psoriatic arthritis occurs in

A
  • 10-20% pts with psoriasis
  • Usually within 10yrs of developing skin changes
  • Typically affects middle aged
23
Q

State some risk factors for psoriatic arthritis

A
  • Personal or family history of psoriasis
24
Q

State some conditions associated with psoriatic arthritis-other than psoriasis

A
  • Eye disease (conjunctivits & anterior uveitis)
  • Aortitis
  • Amyloidosis
25
Q

State the symptoms of psoriatic arthritis

A

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

26
Q

State what you might find on clinical examination of someone with psoriatic arthritis

A
  • Plaques of psoriasis on skin
  • Pitting of nails
  • Onycholysis (separation of nail from nail bed)
  • Dactylitis
  • Enthesitis
27
Q

What screening tool can you use to screen for psoriatic arthritis?

A

PEST (psoriatic arthritis screening tool): questions asking about joint pain, stiffness, history of arthritis and nail pitting. High score= refer rheumatologist

28
Q

What investigations would you do if you suspect psoriatic arthritis, include:

  • Bedside
  • Bloods
  • Imaging

*justify each where possible

A

*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”
29
Q

What x-ray changes might you see in psoriatic arthritis?

A
  • “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
30
Q

Discuss the management of psoriatic arthritis

A

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

31
Q

State some potential complications of psoriatic arthritis

A
  • Arthritis mutilans
  • CVD: increased risk angina, hypertension, MI
  • Medication related complications
32
Q

What is arthritis mutilans?

A
  • 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”
33
Q

What is reactive arthritis?

What did it used to be known as?

A
  • Synovitis in joint as a reaction to a recent infective trigger
  • Reiter syndrome
34
Q

State some risk factors for reactive arthritis

A
  • HLA B27 gene
  • Recent infection (most commonly gastroenteritis, STI or UTI)
35
Q

Reactive arthritis is most commonly seen after what 3 infections?

How many days/week/months following infection does reactive athritis symptoms occur?

A
  • Gastroenteritis, STI or UTI
  • Few days to 2 weeks post infection symptoms start
36
Q

State symptoms & signs of reactive arthritis

A

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”

37
Q

Discuss what investigations you would want if you suspect reactive arthritis, include:

  • Bedside
  • Bloods
  • Imaging

*Justify each where appropriate

A

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
38
Q

Discuss the management of reactive arthritis

A
  • 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

39
Q

State some potential complications of reactive arthritis

A
  • Secondary osteoathritis (develops in 50% of pts with recurrent reactive arthritis)
40
Q

What is enteropathic arthritis?

A

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.

41
Q

State some symptoms & signs of enteropathic arthritis

A
  • Arthritic symptoms
    • Joint pain
    • Joint stiffness
    • Joint swelling
  • IBD symptoms
42
Q

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
A

Type 1

  • Oligoarticular
  • Asymmetric
  • Correlation with IBD flares

Type 2

  • Polyarticular
  • Symmetrical
  • Less correlation with IBD flares
43
Q

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

A
  • 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..
44
Q

Discuss the management of enteropathic arthritis

A
  • Control flare of IBD
  • Consider DMARDs
  • TNF inhhibitors will work well for both athritis & bowel disease
  • Avoid NSAIDs as they worsen IBD

Yr3 Medicine- Rheumatology (18 decks)

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