Spondyloarthropathy Flashcards
what is spondyloarthropathy
family of inflammatory arthritides characterised by involvement of both the spine and joints
what gene predisposes patients to all spondyloarthropathies
HLA B27
what is HLA B27 assocaited with
ankylosing spondylitis, reactive arthritis, crohns disease, uveitis
what are the four subgroups of spondyloarthritic diseases
ankylosing spondylitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis
describe mechanical back pain
worsened by activity, worst at end of the day, better with rest
describe inflammatory back pain
worse with rest, better with activity, significant early morning stiffness (>30 minutes)
what is enthesis
site of insertion of a tendon, ligament or articular capsule into bone
what is enthesopathy
alteration to enthesis
what is enthesitis
inflammation at enthesis
what are the common rheumatoid features of the spondyloarthopathies
sacroiliac and spinal involvement, enthesitis, inflammatory arthritis, dactylitis
what is dactylitis
inflammation of the entire digit
what is the inflammatory arthritis like in the spondyloarthropathies
oligoarticular (just a few joints)
asymmetric
predominantly lower limb
what are the shared extra articular features of the Spondyloarthropathies
occular inflammation (anterior uveitis, conjunctivitis)
mucocutaneous lesions (involvement of oral mucosa and genitals)
rare aortic incompetence or heart block
no rheumatoid nodules
inflammatory bowel disease symptoms
what is ankylosing spondylitis
chronic systemic inflammatory disorder that primary affects the spine
what is the hallmark and other common features of Ankylosing Spondylitis
hallmark- sacroiliac joint involvement (sacroiliitis)
peripheral arthritis uncommon
enthesopathy
who gets Ankylosing Spondylitis
more common in men, late adolescence or early adulthood
what are the main symptoms and signs of Ankylosing Spondylitis
inflammatory back pain arthritis enthesitis anterior uveitis psoriasis crohns/ colitis good response to NSAIDs family history HLA-B27 elevated CRP cardiovascular, neurological and pulmonary involvement amyloidosis
what is seen on imagine in Ankylosing Spondylitis
sacrolitis
active (acute) -inflammation on MRI, bone marrow oedema, enthesitis
x-rays (late disease)- sacroiliac sclerosis, vertebral fusion, erosions
why is Ankylosing Spondylitis called the ‘A’ disease (7)
Axial arthritis Anterior uveitis Aortic regurgitation Apical fibrosis Amyloidosis/ IgA nephropathy Achilles tendinitis plAntar fasciitis
why can movement of spin become limited in Ankylosing Spondylitis
inflammation causes syndesmophytes (fusion of vertebrae)
what posture is seen in Ankylosing Spondylitis
question mark spin; hip flexes, straightening if lumbar spine, thoracic kyphosis
how do you diagnosis Ankylosing Spondylitis
history exam; -tragus/occiput to wall -chest expansion (reduced) -modified schober test
bloods
- inflammatory markers (ESR, CRP, PV) raised
- HLA- B27
x-rays
- sacroilitis
- syndesmophytes
- bamboo spine
what is the occiput to wall test
when shoulder, bum and feet touching wall try to touch head to hall- people with Ankylosing Spondylitis cant
what is the schober test
Distance between ASIS and 10cm above when standing, normal will increase by at least 5cm when bent over,
Ankylosing Spondylitis will be less
what happens to bone density in late Ankylosing Spondylitis
reduced
what does bamboo spine mean
in Ankylosing Spondylitis x ray in late disease will show shiny corners of vertebrae which suggests fusion
what is the treatment for Ankylosing Spondylitis
physiotherapy and occupational therapy
NSAID
DMARD (for peripheral joint involvement, doesnt work on spine)
Anti TNF in severe
what is psoriatic arthritis
inflammatory arthritis associated with psoriasis (10-15% have no psoriasis)
is rheumatoid associated with psoriatic arthritis
psoriatic arthritis has no rheumatoid nodules and is rheumatoid factor negative
what are the clinical features of psoriatic arthritis
inflammatory arthritis sacroiliitis nail involvement (pitting, hyperkeratosis, onycholysis) dactylitis enthesitis extra articular features (eye disease)
what are the five clinical subgroups of psoriatic arthritis
- confined to distal interphalangeal joints (DIP) on hands/feet
- symmetric polyarthritis (similar to RA)
- spondylitis (spine involvement) with/without peripheral joint involvement
- asymmetric oligoarthritis with dactylitis
- arthritis mutilans (fast progression)
how do you diagnose psoriatic arthritis
bloods
-raised inflammatory markers
negative RF
x-rays
- marginal erosions and whiskering
- pencil in cup deformity
- osteolysis
- enthesitis
what is the medical treatment for psoriatic arthritis
NSAIDs corticosteroids/joint injections DMARDs anti TNF secukinumab (anti-IL17)
what is the non medical treatment for psoriatic arthritis
physiotherapy
occupational therapy
orthotics
chiropodist
what is reactive arthritis
infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured
when do you get symptoms in reactive arthritis
1-4 weeks after infection
what are the most common infections causing reactive arthritis
urogenital (chlamydia), enterogenic (salmonella, shigella, yersinia)
who gets reactive arthritis (what gene)
young adults (20-40)
equal sex distribution
HLA-B27 positive
what is reiters syndrome
a form of reactive arthritis triad of; -urethritis -conjunctivitis/ uveitis/iritis -arthritis
what are the general features of reactive arthritis
general symptoms (fever, fatigue, malaise)
asymmetrical monoarthritis or oligoarthritis
enthesitis
mucocutaneous lesions
occular lesions (conjunctivitis, iritis)
visceral manifestations (mild renal disease, carditis)
how do you diagnose reactive arthritis
bloods:
- inflammatory parameters (ESR, CRP, PV)
- FBC, U&ES
- HLA B27 (rarely necessary)
cultures (blood, urine, stool)
joint fluid (to rule out infections or crystal arthropathy)
xray of affected joints
ophthalmology opinion
what is the treatment for reactive arthritis
90% resolve within 6 months
NSAIDs
corticosteroids
antibiotics (for underlying infection)
DMARDs (in chronic)
physiotherapy
occupational therapy
what is enteropathic arthiritis
inflammatory arthritis associated with inflammatory bowel disease
how do patients with enteropathic arthiritis present
arthritis in several joints especially the knees, ankles, elbows, wrists, spine, hips or shoulders
worsening symptoms during flare ups of inflammatory bowel disease
GI-loose watery stool with mucous and blood, apthous ulcers
weight loss, low grade fever, eye involvement, skin involvement, enthesitis
what investigations into enteropathic arthiritis can you do
upper and lower GI endoscopy
joint aspirate
raised inflammatory markers
X-ray/MRI showing sacroilitis
USS showing synovitis/ tenosynovitis
what is the treatment for enteropathic arthiritis
treat IBD
not NSAIDs as may exacerbate IBD
analgesia (e.g. paracetamol, cocodamol)
steroids
DMARDS
Anti tnf
physiotherapy, occupational therapy,orthotics
what is the treatment for ankylosing spondylitis
NSAIDs, physion, exercise
if this doesn’t work anti TNF or anti IL 17
