The seronegative spondyloarthropathies

Question 1

What clinical features are shared by the seronegative spondyloarthropathies?

Answer 1

• A predilection for axial (spinal and sacroiliac) inflammation
• Asymmetrical peripheral arthritis
• Absence of RF, hence ‘seronegative’
• Inflammation of the enthesis
• A strong association with HLA-B27, but its aetiological relevance is unclear
• Inflammatory bowel disease

Question 2

What is ankylosing spondylitis?

Answer 2

Inflammatory disorder of the spine affecting mainly young adults. More common and more severe in men than women

Question 3

What is the typical presentation of ankylosing spondylitis?

Answer 3

Young man (late teens, early 20s) who presents with increasing pain and prolonged morning stiffness in the lower back and buttocks. Pain and stiffness improves with exercise but not with rest. There is a progressive loss of spinal movement

Question 4

What are the two characteristic spinal abnormalities seen on examination of a patient with ankylosing spondylitis?

Answer 4

1. Loss of lumbar lordosis and increased kyphosis

2. Limitation of lumbar spine mobility in both sagittal and frontal planes

Question 5

How is reduced spinal flexion demonstrated?

Answer 5

The Schober Test:
A mark is made at the 5th lumbar spinous process and 10cm above, with the patient in the erect position. On bending forward, the distance should increase to >15cm in normal individuals

Question 6

What extra-spinal, articular signs are often seen in patients with ankylosing spondylitis?

Answer 6

Achilles tendonitis and plantar fasciitis (enthesitis)
Tenderness around the pelvis and chest wall
Reduction in chest expansion (<2.5cm on deep inspiration measured at 4th intercostal space) due to costovertebral joint involvement

Question 7

What are the non-articular features of ank. spon?

Answer 7

Anterior uveitis
RARE:
Aortic incompetence
Cardiac conduction defects
Apical lung fibrosis

Question 8

Which conditions are classed as seronegative spondyloarthropathies?

Answer 8

ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis (sexually aquired, Reiter’s disease)
Post dysenteric reactive arthritis
Enteropathic arthritis (ulcerative colitis/Crohn’s disease)

Question 9

What is the first test to order for a patient with suspected ankylosing spondylitis?

Answer 9

Pelvic x-ray

Question 10

What are the X-ray signs seen in patients with ankylosing spondylitis?

Answer 10

X-rays may be normal

May show erosion and sclerosis of the margins of the sacroiliac joints, proceeding to anklyosis (immobility and consolidation of the joint).

‘Bamboo spine’ due to entheitis at the insertion of the intervertebral ligmanents healing with new bone formation. This results in bony spurs- syndesmophytes- which, along with the interspinous ligaments, calcify to produce ‘bamboo spine’

Question 11

How is ankylosing spondylitis managed?

Answer 11

Early management is essential to prevent irreversible syndesmophyte formation and progressive calcification.
Treatment:
- Morning exercises to maintain posture and spinal mobility
- Slow release NSAIDs taken at night are particularly effective in relieving night pain and morning stiffness
-If there is peripheral joint involvement, sulfasalazine or methotrexate is added
-With local intra-articular inflammation or enthesitis add intra-articular steroid injection
- TNF-alpha blocking drugs may be used in adults with pain despiten already taking 2 NSAIDs. They can improve both spinal and peripheral joint inflammation

Question 12

What is psoriatic arthritis?

Answer 12

An arthritis occuring in 20% of patients with psoriasis, particularly those with nail disease

Question 13

What are the nail changes seen in psoriatic arthritis? How common are they?

Answer 13

Nail pitting
Onycholysis- separation of the nail from the underlying vascular bed
Yellow-brown discolouration

Seen in 50% of patients with psoriasis

Question 14

What is psoriasis?

Answer 14

A common, chronic, hyperproliferative disorder characterised by the presence of well-demarcated red scaly plaques over extensor surfaces such as the elbows and knees, and in the scalp

Question 15

What is the typical presentation of a patient with psoriatic arthritis?

Answer 15

• Personal or family history of psoriasis
• Joint pain and stiffness
• Peripheral arthritis
• Dactylitis
• History of scalp or nail problems

Question 16

What is dactylitis?

Answer 16

Uniform swelling of an entire digit.

Question 17

How does peripheral arthritis generally present in psoriatic arthritis?

Answer 17

Usually monoarticular. If there are multiple joints involved, the pattern lacks the symmetry of RA

Question 18

What are the four ways in which psoriatic arthritis may present?

Answer 18

1. Assymetical involvement of the small joints of the hand including the DIP joint
2. Symmetrical seronegative polyarthritis- resembles RA
3. Arthritis mutilans- a severe form of destruction of the small bones in the hands and feet
4. Sacroiliitis- unilateral and bilateral

Question 19

What is see on an x-ray of hands of a patient with psoriatic arthritis?

Answer 19

Erosion in the DIP joint and perarticular new-bone formation.

May show a pencil in cup deformity in the IPJs- bone erosions creates a pointed appearance and the articulating bone is concave

Question 20

What is the treatment for limited peripheral joint disease psoriatic arthritis?

Answer 20

NSAID + physiotherapy + intra-articular corticosteroid injection as required

Question 21

What is the treatment for progressive peripheral joint disease psoriatic arthritis?

Answer 21

1st line: DMARDs e.g. Methotrexate + NSAID + physiotherapy + intra-articular corticosteroid injection as required

2nd line: switch DMARD to TNF-alpha treatment + NSAID + physio

Question 22

What is reactive arthritis?

Answer 22

A sterile synovitis which occurs following:
- GI infection with Shingella, Salmonella, Yersinia or Campylobacter

-STI due to Chlamydia infection

Question 23

What are the risk factors for reactive arthritis?

Answer 23

• Male gender
• HLA-B27 genotype
• Preceding chlamydial or GI infection

Question 24

Describe the presentation of peripheral arthritis in reactive arthritis

Answer 24

Peripheral arthritis with symptoms beginning 1-4 weeks after the onset of GI/chlamydial infection. Arthritis is commonly an asymmetrical oligoarthritis (although poly- and mono-articular arthritis can occur). There is usually a predilection for larger joints in the lower extremity. The inflammation often leads to painful, swollen, warm, red and still joints with morning stiffness. Dactylitis may be seen.

Question 25

When is a patient defined as having chronic reactive arthritis?

Answer 25

Symptoms present for >6 months

Question 26

Describe the presentation of axial arthritis in reactive arthritis

Answer 26

Spinal inflammation, especially of the sacroiliac joints and lumbosacral spine is a common finding. Symptoms manifest as lower back and/or buttock pain and stiffness, especially during times of inactivity. Symptoms are generally relieved by exercise

Question 27

How is spinal inflammatory arthritis distinguished from mechanical causes of back pain?

Answer 27

Symptoms are relieved by exercise in spinal inflammatory arthritis

Question 28

What systemic symptoms are common in patients with reactive arthritis?

Answer 28

Fever
Fatigue
Weight loss
Entesitis (plantar fasciitis; Achilles tendonitis)
Uveitis (rare)
Skin lesions resembling psoriasis. (rare)
Circinate balanitis (rare)
Karatoderma blenorrhagica (rare)

Question 29

What are the most common sites for joint inflammation in reactive arthritis?

Answer 29

Joints of the lower limb in an asymmetrical pattern- knees, ankles and joints in the feet

Question 30

What is circinate balanitis?

Answer 30

Painless ulcers and plaque like lesions on the shaft or glands of the penis

Question 31

What is keratoderma blennorrhagicum?

Answer 31

Red plaques and pustules that resemble pustular psoriasis found on the palms and soles of the feet

Question 32

What is the triad of Reiter’s syndrome?

Answer 32

Urethritis, reactive arthritis and conjunctivitis

Question 33

What investigations should be carried out in suspected reactive arthritis?

Answer 33

Diagnosis is clinical. ESR and CRP are raised in the acute stages. X-rays may show sacroiliitis

Question 34

How is reactive arthritis managed acutely?

Answer 34

Acute joint inflammation is treated with NSAIDS and local corticosteroid injection. Any persisting infection is treated with antibiotics

Question 35

How is active arthritis managed chronically?

Answer 35

Most patients have a single attack and are treated acutely

Relapsing patients are treated with DMARDS (methotrexate or sulfasalazine) or anti-TNF drugs in severe cases

Question 36

What is enteropathic arthritis?

Answer 36

A large-joint mono- or asymmetrical oligoarthritis occurring in 10-15% of patients with ulcerative colitis or Crohn’s disease. It usually parallels the activity of the inflammatory bowel disease and consequently improves as bowel symptoms improve. In 5% of patients with IBD, an HLA-B27 sacroiliitis or spondylitis occurs which is not related to disease activity

Question 37

What is the shiny corner sign?

Answer 37

A spinal finding in ankylosing spondylitis. It represents small erosions at the superior and inferior endplates (corners on lateral radiograph) of the vertebral bodies, with surrounding reactive sclerosis.