Spondyloarthropathies - Psoriatic spondylitis

Question 1

Definition

Answer 1

Autoimmune chronic inflammatory joint disease associated with psoriasis
- can vary in severity
Patients may have a mild stiffness + soreness in joint or the joint can be completely destroyed in a condition called arthritis mutilations
- occurs in 10-20% of patients with psoriasis + usually occurs within 10 years of developing skin changes.

Question 2

Epidemiology

Answer 2

Typically affects people in middle age but can occur at any age
- usually occurs with 10 years of skin changes

Question 3

Risk factors

Answer 3

Psoriasis
Family history of psoriasis or in psoriatic arthritis

Question 4

Aetiology

Answer 4

Strong genetic component with HLA B27 + pathogenesis is not fully understood but activation of CD8+T cells = critical role

Question 5

Types of Psoriatic Arthritis

Answer 5

Symmetric polyarthritis (rheumatoid-like)
- Affects ≥ 5 joints
- Symmetrical distribution
- Resembles rheumatoid arthritis

Asymmetric oligoarthritis
- Affects ≤ 4 joints
- Asymmetrical distribution
- Typically affects the hands and feet

Distal arthritis (DIP joint disease)
- Affects DIP joints of hands and/or feet
- Usually occurs alongside other types

Spondylarthritis (sacroiliitis)
- Primarily involves spine and sacroiliac joints

Arthritis mutilans
- Most severe and least common form
- Deforming and destructive subtype
- Telescoping and flail digits

Question 6

Signs

Answer 6

• Joint tenderness, warmth and reduced range of motion
  Typically affects DIP joints, rather than MCP/PIP joints in rheumatoid arthritis
• Psoriasis: psoriatic lesions, scalp and nail symptoms
• Onycholysis - separation of the nail from the nail bed
• Dactylitis: swelling of an entire digit
• Achilles’ tendon
• Enthesitis: inflammation of the plantar fascia
• TELESCOPIC FINGER = SEVERE = ARTHRITIS MUTALANS = Pencil in cup deformity = osteolysis of bone = progressive shortening of fingers

Question 7

Symptoms

Answer 7

Joint pain + stiffness
- Symptoms worse in the morning + improve on movement is typical of an inflammatory arthropathy
Swollen fingers or toes
Back pain if axial skeleton involved

Question 8

Other symptomatic associations

Answer 8

Eye disease (conjunctivitis + anterior uveitis)
Aortitis (inflammation of the aorta)
Amyloidosis

Question 9

Diagnosis (PODAT) + Diagnostic criteria score

Answer 9

X-ray
- Periostitis = inflammation of periosteum
- Osteolysis
- Dactylitis = inflammation of whole digit
- Ankylosis = bones joining together
- Telescopic fingers
CASPAR criteria state: scores > 2 points
- Psoriatic nail changes (2 points)
- Rheumatoid factor negative (1 point)
- History of dactylitis (1 point)
- Radiological evidence = juxta-articular periostitis (1 point)

Question 10

Treatment

Answer 10

Mild disease:
- FIRST LINE = NSAIDS + physiotherapy
- Intra-articular steroids
Progressive disease:
- DMARDS = METHOTREXATE (FL) or SULFASALAZINE (if MT = CI)
- Biologics agents = TNF-a inhibitors = INFLIXIMAB (following failure of 2 DMARDS)

Question 11

Complications

Answer 11

CVD: IHD, and HTN