The Spondyloarthropathies Flashcards
Ankylosing Spondylitis
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old
Ankylosing Spondylitis - Ix
Inflammatory markers (ESR, CRP) are typically raised although normal levels do not exclude ankylosing spondylitis.
HLA-B27 is of little use in making the diagnosis as it is positive in:
90% of patients with ankylosing spondylitis
10% of normal patients
Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. Radiographs may be normal early in disease, later changes include:
- sacroilitis: subchondral erosions, sclerosis
NB: Sacroiliitis may present as sclerosis of joint margins which can be asymmetrical at early stage of disease, but is bilateral and symmetrical in late disease.
- squaring of lumbar vertebrae
- ‘bamboo spine’ (late and uncommon)
- syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
A syndesmophyte is a bony growth originating inside a ligament, commonly seen in the ligaments of the spine, specifically the ligaments in the intervertebral joints leading to fusion of vertebrae.
Ankylosing Spondylitis - Mx
Management
The following is partly based on the 2010 EULAR guidelines (please see the link for more details):
encourage regular exercise such as swimming
physiotherapy
NSAIDs are the first-line treatment
the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement
the 2010 EULAR guidelines suggest: ‘Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments’
research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease
NSAIDs are the first-line drug treatment in an ankylosing spondylitis. Regular exercise is also very important. The role of anti-TNF therapies is increasing but they are not currently first-line and the 2008 NICE guidelines specifically advise against using infliximab
Ankylosing Spondylitis - Morning back pain
Note the history of morning pain is typical for an inflammatory arthritis such as ankylosing spondylitis.
Ankylosing Spondylitis - Initial Mx: Example Question
A 23-year-old Sri Lankan male presents with 6 months of gradual onset low back pain, worse before waking. He describes increasing stiffness in his right wrist and left third metacarpal joints. On examination, you note reduced spinal movements in lateral spinal flexion and rotation and a positive Schober’s test. He has not received any previous treatments for his back pain and has no other past medical history. What is the most appropriate initial management?
Start sulphasalazine Start infliximab Start etanercept > Physiotherapy and NSAIDs No treatment
The patient gives a classic description of new onset ankylosing spondylitis. He presents from the typical age group of between 15-25. NSAIDs and physiotherapy should be the first line treatment for all symptomatic AS patients, allowing up to 4 weeks for assessment of effect. Up to 70% of AS patients receive sufficient symptomatic relief with NSAIDs alone, with the most recent EULAR guidelines recommending continuous NSAIDs therapy for those with active persistent symptoms1. There is also evidence that this reduces radiological progression of the disease.
Systemic glucocorticoids have no place for AS management but intra-articular steroid injections may be indicated in peripheral joints or enthesitis. Of traditional DMARDs, sulphasalazine is the only DMARD with evidence of efficacy in peripheral joint involvement but is not effective in those with axial joint involvement2. TNF-alpha inhibitors are recommended on those with AS symptoms insufficiently controlled by NSAIDs alone. There appears to be no difference in efficacy between etanercept, infliximab or adalimumab
Ankylosing Spondylitis - Features
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old.
Features
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
Ankylosing Spondylitis - Clinical Examination
Clinical examination
reduced lateral flexion
reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
reduced chest expansion
Ankylosing Spondylitis - THE As!
Other features - the 'A's Apical fibrosis Anterior uveitis Atlantoaxial Subluxation Aortic regurgitation Achilles tendonitis AV node block AA Amyloidosis Arthritis (peripheral) Arachnoiditis IgA Nephropathy and cauda equina syndrome peripheral arthritis (25%, more common if female)
Arachnoiditis is a pain disorder caused by the inflammation of the arachnoid, one of the membranes that surrounds and protects the nerves of the spinal cord. It is characterized by severe stinging, burning pain, and neurological problems
Ankylosing Spondylitis - Cardiac Cx: Example Question
A 75 year old male presents to A&E with two episodes of loss of consciousness over the last 48 hours. Both episode were witnessed by his wife, onset while sitting in his chair at home, without any witnessed limb jerking, urinary incontinence or tongue biting. He denies any chest pain or shortness of breath normally but reports gradually being able to walk increasingly shorter distances, which he attributed to old age. He has no other significant past medical history, lives with his wife and is a lifelong non-smoker. On examination, he has a significant thoracic kyphosis. On flexion of the lower back, the marked distance increased from 15 cm to 18 cm. He also has a poverty of spinal lateral flexion and bilateral spinal rotation. His cardiovascular examination reveals heart sounds I and II with an early diastolic murmur. Respiratory examination reveals fine inspiratory crackles at both apices. His lying and standing blood pressures are unremarkable. A CT head demonstrated only mild microangiopathic disease. The patient is currently comfortable and alert, requesting to go home. He is attached to cardiac telemetry. What do you expect his ECG to show?
Sinus bradycardia Trigeminy Fast atrial fibrillation with ventricular response greater than 100 Atrial flutter > Bradycardia with 1st degree heart block
The clinical description is of a patient with ankylosing spondylitis, associated with multiple extra-articular features, commonly remembered by MRCP candidates as the As. They classically include atlano axial subluxation, arachnoiditis, apical fibrosis, anterior uveitis, aortitis, aortic regurg, AV block, amyloidosis, IgA nephropathy, Achilles tendonitis and associations with plantar fasciitis and inflammatory bowel disease (the last two are a bit of a stretch!). In this case, the patient is Schobers positive with a murmur of aortic regurgitation from aortitis. The most likely cause of these episodes of syncope are cardiac in origin. AV node block results in first degree heart block on ECG, resulting in symptoms if bradycardia leads to transient cerebral hypoperfusion.
Ankylosing Spondylitis in a female pt - Example Question
A 26-year-old woman presents with a four month history of back pain. The pain is located around the lower lumbar vertebrae and spreads to both buttocks. Ibuprofen and walking seem to improve the pain. A lumbar spine film is requested:
SEE PASSMED
What is the most likely cause of this patients back pain?
Marble bone disease Alkaptonuria > Ankylosing spondylitis Facet-joint dysfunction Rheumatoid arthritis
Ankylosing spondylitis with well formed syndesmophytes are seen on the lumbar spine film.
The first thing to address is the sex of the patient. Of course ankylosing spondylitis is more common in men but the male-to-female ratio is only 3:1. This means it is reasonable to be asked about female patients in questions, particularly if there is accompanying ‘hard evidence’ such as x-rays.
Marble bone disease (osteopetrosis) results in dense, thick bones that are prone to fracture. Syndesmophytes are not a feature.
Facet-joint dysfunction is a common cause of back pain but it would not explain the x-ray findings.
Rheumatoid arthritis of course does not commonly present with back pain. The following x-ray changes are typically seen: loss of joint space juxta-articular osteoporosis soft-tissue swelling periarticular erosions subluxation
Ankylosing Spondylitis - Classical Fx
- Typically a young male who presents with lower back pain and stiffness
- Stiffness is worse in morning
- Stiffness improves with activity
- Peripheral arthritis (25% more common if F)
Psoriatic Arthritis
Psoriatic arthropathy correlates poorly with cutaneous psoriasis and often precedes the development of skin lesions. Around 10-20% percent of patients with skin lesions develop an arthropathy with males and females being equally affected
Psoriatic Arthritis - Types
Types*
rheumatoid-like polyarthritis: (30-40%, most common type)
asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
sacroilitis
DIP joint disease (10%)
arthritis mutilans (severe deformity fingers/hand, ‘telescoping fingers’)
*Until recently it was thought asymmetrical oligoarthritis was the most common type, based on data from the original 1973 Moll and Wright paper. Please see the link for a comparison of more recent studies
Psoriatic Arthritis - Hand XR
SEE PASSMED X-RAY
X-ray showing some of changes in seen in psoriatic arthropathy.
Note that the DIPs are predominately affected, rather than the MCPs and PIPs as would be seen with rheumatoid. Extensive juxta-articular periostitis is seen in the DIPs but the changes have not yet progressed to the classic ‘pencil-in-cup’ changes that are often seen with psoriatic arthritis.
Psoriatic Arthritis - Mx
Management
- treat as rheumatoid arthritis
- but better prognosis
