The seronegative spondyloarthropathies Flashcards
What clinical features are shared by the seronegative spondyloarthropathies?
- 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
What is ankylosing spondylitis?
Inflammatory disorder of the spine affecting mainly young adults. More common and more severe in men than women
What is the typical presentation of ankylosing spondylitis?
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
What are the two characteristic spinal abnormalities seen on examination of a patient with ankylosing spondylitis?
- Loss of lumbar lordosis and increased kyphosis
2. Limitation of lumbar spine mobility in both sagittal and frontal planes
How is reduced spinal flexion demonstrated?
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
What extra-spinal, articular signs are often seen in patients with ankylosing spondylitis?
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
What are the non-articular features of ank. spon?
Anterior uveitis RARE: Aortic incompetence Cardiac conduction defects Apical lung fibrosis
Which conditions are classed as seronegative spondyloarthropathies?
ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis (sexually aquired, Reiter’s disease)
Post dysenteric reactive arthritis
Enteropathic arthritis (ulcerative colitis/Crohn’s disease)
What is the first test to order for a patient with suspected ankylosing spondylitis?
Pelvic x-ray
What are the X-ray signs seen in patients with ankylosing spondylitis?
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’
How is ankylosing spondylitis managed?
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
What is psoriatic arthritis?
An arthritis occuring in 20% of patients with psoriasis, particularly those with nail disease
What are the nail changes seen in psoriatic arthritis? How common are they?
Nail pitting
Onycholysis- separation of the nail from the underlying vascular bed
Yellow-brown discolouration
Seen in 50% of patients with psoriasis
What is psoriasis?
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
What is the typical presentation of a patient with psoriatic arthritis?
- Personal or family history of psoriasis
- Joint pain and stiffness
- Peripheral arthritis
- Dactylitis
- History of scalp or nail problems
What is dactylitis?
Uniform swelling of an entire digit.
How does peripheral arthritis generally present in psoriatic arthritis?
Usually monoarticular. If there are multiple joints involved, the pattern lacks the symmetry of RA
What are the four ways in which psoriatic arthritis may present?
- Assymetical involvement of the small joints of the hand including the DIP joint
- Symmetrical seronegative polyarthritis- resembles RA
- Arthritis mutilans- a severe form of destruction of the small bones in the hands and feet
- Sacroiliitis- unilateral and bilateral
What is see on an x-ray of hands of a patient with psoriatic arthritis?
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
What is the treatment for limited peripheral joint disease psoriatic arthritis?
NSAID + physiotherapy + intra-articular corticosteroid injection as required
What is the treatment for progressive peripheral joint disease psoriatic arthritis?
1st line: DMARDs e.g. Methotrexate + NSAID + physiotherapy + intra-articular corticosteroid injection as required
2nd line: switch DMARD to TNF-alpha treatment + NSAID + physio
What is reactive arthritis?
A sterile synovitis which occurs following:
- GI infection with Shingella, Salmonella, Yersinia or Campylobacter
-STI due to Chlamydia infection
What are the risk factors for reactive arthritis?
- Male gender
- HLA-B27 genotype
- Preceding chlamydial or GI infection
Describe the presentation of peripheral arthritis in reactive arthritis
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.
