Spondyloarthropathies - workbook and lecture Flashcards
What are spondyloarthropathies?
- Group of conditions that affect the spine and peripheral joints and are associated with presence of HLA-B27
Examples of spondyloarthropathies
- Ankylosing spondylitis (most common)
- Enteropathic arthirits
- Psoriatic arthirits
- Reactive arthiritis
Common clinical features of spondyloarthropathies
- Sacroiliac/axial disease (back/buttock pain)
- Inflammatory arthropathy of peripheral joints
- Enthesitis (inflammation at tendon insertions)
- Extra-articular features (skin, gut, eye)
Who does ankylosing spondylitis often affect?
Young men - teens-mid thirties
Presentation of AS
- Bilateral buttock pain
- Chest wall and thoracic pain
Examination findings of AS
- Normal
- Later = loss of lumbar lordosis
- Exaggerated thoracic kyphosis
- Schobers test positive
- Reduced chest expansion
What is Schobers test?
- Mark skin 10cm above and 5cm below PSIS (L3/L4)
- Bend forward with straight legs
- Normal is more 20cm distance between 2 original markings
- If less than 5cm increase than +ve
Why do AS patients have reduced chest expansion?
Back pain
Pulmonary fibrosis
Investigation for AS
- CRP raised but often normal
- MRI spine and SI joints (more sensitive than X-ray)
- Rh F -ve
- Can do X-ray - Bamboo sign
Treatment for AS
- NSAIDs
- Physio
- TNF inhibitors eg infliximab
- IL-17 inhibitors
Who does psoriatic arthiritis affect?
Male and female equally
Typical exam findings for psoriatic arthirits
- Oligo arthritis with single digit dactilytis (sausage digit)
- Can be symmetrical like RA or monoarthiritis
- Severe deformites eg arthiritis mutilans
Investigations for Psoriatic arthirits
- CRP often raised
- Central joint erosions seen early on USS or MRI
- Erosions leads to ‘pencil in cup’ deformity seen in x-ray
- Osteopenia - periarticular
Treatment for psoriatic arthiritis
- NSAIDs
- DMARDs - for peripheral disease
- TNF inhibitors
- IL-17 inhibitors
- IL12/23 inhibitors
Can use biologics for axial disease + Rituximab sometimes
What is reactive arthirits?
Sterile arthritis devloping after a distant infection either post dysentry eg salmonella/shigella/campylobacter or urethritis/cervicitis (via Chlamydia trachomatis)
Presentation of reactive arthirits
- Few days-2 weeks post infection
- Acute assymetrical lower limb arthiritis develops
Other features of reactive arthitis
- Skin - circinate balanitis (fluid filled blisters on glans/shaft of penis), keratoderma blennorrhagica
- Eye - cojunctivitis, uveitis
- Enthesitis - inflammation of where tendon meets bone
- Painless oral ulcers
Investigations for reactive arthirits
- Serology/microbiology
- Inflammatory markers raised
- May need joint aspirate to rule out septic/crystal arthirits
- Stool sample - find causative organism?
- Urine culture - same
- Genital swab - same
Treatment for reactive arthirits
- Treat infection - but may not improve arthirits
- NSAIDs
- Joint injectioms
- Most will resolve within 2 years, those that do not (esp if HLA-B27) may need DMARDs
What is Enteropathic arthiritis?
- Arthiritis associated with IBD
- 2/3 develop peripheral and 1/3 axial disease
2 types of peripheral disease of enteropathic arthiritis
- Type 1 - oligoarticular, asymmetric and has correlation with IBD flares
- Type 2 - polyarticular, symmetrical and less correlation with IBD flares
Treatment for enteropathic arthirits
- NSAIDs can flare IBD
- Consider DMARDs
- TNF inhibitors treat IBD and arthirtis
- Other drugs like azathioprine may help symptoms
- Common to be HLA-B27 +ve
5 As of extra-articular features of AS
- Anterior uveitis
- Aortic incompetance - regurge
- AV block
- Apical lung fibrosis
- Amyloidosis
Features of inflammatory back pain
- Insidious onset
- Pain at night - with improvement of getting up
- Age onset less than 40
- Improved with exercise
- No improvement with rest
IPAIN
Handy rhyme for remembering features of reactive arthiritis
Can’t see (conjuctivitis, uveitis) Can’t wee (urethritis)
Can’t stand on one knee (often affects knees and ankles)
X-ray sign for AS
Bamboo spine
* Caused by increased ossification forming syndesmophytes which cause vertebral bodies to fuse at edges
* Also can see squaring of vertebral bodies, less rounded
What are all these spondyloarthropathies?
Serum -ve - no Rh F
What condition is often associated with psoriatic arthiritis?
Psoriasis- raised red plaques with silvery sheen, mainly on extensors
Main peripheral joints affected in psoriatic arthiritis
DIPJ - contrast to AS which is not so much peripheral and RA affects PIPJ
Nail changes in psoriatic arthritis
- Onycholysis
- Leukonychia
- Crumbling nails
- Subungal keratosis
- Splinter haemorrhages
Conjuctivitis vs uveitis
Conjuctivitis will have more inflamed gunk/crusting present
Visual changes in uveitis
What can be +ve in psoriatic arthitis?
Rh F and anti-CCP
How is overall reactive arthirtis diagnosed?
Diagnosis of elimination
Eliminate:
* Septic arthiris - via joint aspirate
* Crystal arthropathy - via joint aspirate
* Psoriatic arthorpathy
* Lymes, TB, Viral (eg Hep), Rheumatic fever
* Disseminated gonococcal infection
Other symptoms to ask about in AS
- Breathless - apical lung fibrosis
- Eye problems - Uveitis
- Enthesitis - achilles?
Other examinations for AS (other than Schobers)
- Stand up straight against wall - loss of neck extension?
- Sacroiliac tenderness on palpation?
- Lumbar spine side flexion test - middle finger tip to floor, side flex, with back against wall
- Tragus wall test - back neck against wall, move tragus to wall
Complications of AS
- Ankylosis or spinal fusion
- Spinal fractures
- Hip involvement
- Anterior uveitis
- Osteoporosis
- Cardiac complications - in general, and aortic valvular disease and arrhytmias
- Pulmonary fibrosis - apical
- Neurological - vertebral fracture, dislocation, cauda equina
