Seronegative Spondyloarthropathy

Question 1

What is seronegative spondyloarthropathy?

Answer 1

Group of inflammatory rheumatic diseases without the presence of rheumatoid factor
Tends to affect spine and proximal large joints

Question 2

What is Ankylosing Spondylitis (AS)?

Answer 2

Stiffness and inflammation of vertebra
Inflammation of ligaments around the vertebra which heals by dense ossification and fibrosis of the ligaments
Spine eventually becomes fused, inflexible and rigid

Question 3

What are the symptoms of AS?

Answer 3

Episodic pain and stiffness in back/buttocks-worse in the morning and relieved by exercise

Asymptomatic between episodes

Pain can alternate between sides of buttocks

Question 4

What are signs of AS?

Answer 4

Question mark posture due to lumbar lordosis

Shobers test

• draw line across midline 10cm above and 5cm below L5
• distance should increase >5cm when patient bends forwards

SI stress test
-bring knee to contralateral shoulder- pain in SI area

Paraspinal muscle wasting- late sign

Question 5

What are extra-articular manifestations of SA?

Answer 5

Anterior uveitis
Pulmonary fibrosis
AV node block
Amyloidosis
Aortitis- inflammation of aortic root

Question 6

What investigations are needed for AS?

Answer 6

Bloods
-ESR=normal

XR

• pelvic= narrowing of SI joint line and fusion
• Spinal= squaring of vertebral bodies and bamboo spine appearance

Question 7

How is AS diagnosed?

Answer 7

Based on the following

• Low back pain >3months improved by exercise and not relieved by rest
• limited lumbar spine movement
• limited chest expansion
• sacroiliitis on XR

Definite- Radiological criteria PLUS one clinical

Probably- 3 clinical OR one radiological

Question 8

What is the management of AS?

Answer 8

Conservative

• patient education= no cure, symptomatic relief
• mobilise, exercise
• support groups
• stop smoking

Medical

• NSAIDs for 6wks
• if no improvement on 2 different NSAIDs and high DAS score then biologics e.g. etanercept

Question 9

What is Psoriatic Arthritis (PA)?

Answer 9

Seronegative arthritis associated with psoriasis

Question 10

What are symptoms of PA?

Answer 10

Early DIPJ involvement- dactylitis, nail changes and oncholysis
Psoriatic plaques
SI involvement is unilateral

5 subtypes recognised

Question 11

What are the 5 subtypes of PA?

Answer 11

1) Symmetrical polyarthritis
- presentation similar to RA
- more DIPJ involvement and less severe deformities

2) Asymmetrical oligoarticular
- <5joints
- often one large joint an dsmaller joints

3) DIPJ prominant disease
- significant nail changes e.g. pitting
- can lead to sausage finger(dactylitis)

4) Spondylitis
- similar to SA

5) Arthritis Mutilans
- severe form
- joint destruction and deformity

Question 12

What are extra-articular symptoms of PA?

Answer 12

Anterior uveitis

• acute pain and photophobia
• constricted pupil
• ciliary flushing

Question 13

What investigations are needed for PA?

Answer 13

XR
-erosions similar to RA
Pencil in cup appearance
-Arthritis mutilans can cause telescoping of fingers- soft tissue accumulation at base

Question 14

What is the management of PA?

Answer 14

If one joint affected
-full dose NSAIDs +/-steroid injections

If multiple

• treat as RA
• Methotrexate good as helps psoriasis
• DMARDs do not help spinal symptoms

Question 15

What is Reactive Arthritis?

Answer 15

Acute asymmetrical lower limb arthritis occurring 4-40 day post infection normally GI/GU

Question 16

What are common causative organisms of Reactive Arthritis?

Answer 16

Chlamydia
Salmonella
Campylobacter

Question 17

What are symptoms of Reactive Arthritis?

Answer 17

Classic Triad

1) Bilateral conjunctivitis
2) Dysuria
3) Lower limb oligoarthritis- warm swollen painful joint

Enthesitis is common

Skin lesions

• keratoderma blennorrhagica
• balanitis in uncircumcised male

Question 18

What investigations are needed in Reactive Arthritis?

Answer 18

Joint aspiration- rule out SA and crystal associated

Stool/throat/urogenital culture- identify causative organism

Uric acid levels- gout

XR for erosive changes

Question 19

What is the management of Reactive Arthritis?

Answer 19

Full dose NSAIDs +/- steroid injections into affected joints

Systemic if multiple joints

2nd line or recurrent then DMARDS such as sulfasalazine
Normally resolves within 6 months

Question 20

What is IBD related arthropathy?

Answer 20

Occurs in 10-15% with IBD

Usually symmetrical arthritis affecting lower limbs

5% have spinal disease

Remission of UC leads to remission of joint disease but Crohns persists even if well controlled

MDT management with gastro adn rheumatology input