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MSK > Spondyloarthropathies > Flashcards

Spondyloarthropathies Flashcards

1
Q

What HLA group is associated with spondyloarthropathies

A

HLA B27

Therefore genetically predisposed

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2
Q

What conditions is HLA B27 associated with

A

Ankylosing spondylitis
Reactive arthritis
Crohn’s disease
Uveitis

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3
Q

Why is HLA screening not always useful

A

Can be present without causing disease

Only screen if patient has symptoms

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4
Q

Describe mechanical back pain

A

Worsened by activity
Worse at end of the day
Better with rest
More common

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5
Q

Describe inflammatory back pain

A

Worse with rest
Better on activity
Significant morning stiffness (>1 hour)

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6
Q

List some features of inflammatory arthritis

A

Oligoarticular - affects a few joints, typically larger ones like knees, hips etc.
Asymmetric
However psoriatic can be symmetric and in small joints
Predominantly lower limb
Dactylitis - sausage fingers

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7
Q

List some shared rheumatological features of spondyloarthropathies

A 
Involvement of the sacroiliac joints and spine 
Enthesitis - where tendons attach
Tenosynovitis and synovitis
Inflammatory arthritis 
Dactylitis - sausage fingers
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8
Q

List some shared extra-articular features of spondyloarthropathies

A

Ocular inflammation - e.g. uveitis/iritis
Mucocutaneous lesions - mouth, genitals
Rarely aortic incompetence or heart block
IBS history

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9
Q

What is the hallmark of ankylosing spondylitis

A

Involvement of the sacro-iliac joint as well as the spine

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10
Q

When should you consider ankylosing spondylitis as a cause of back pain

A

In patients where pain has lasted more than 3 months

Age of onset less than 45 (typically between 20-40)

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11
Q

What criteria must be met in order to diagnose ankylosing spondylitis

A

Sacroiliitis on imaging and more than one clinical feature of SpA
OR
HLA-B27 positive and more than 2 clinical features

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12
Q

What are the main clinical features of ankylosing spondylitis

A 
Back pain 
Enthesitis 
Peripheral arthritis - rare 
Uveitis 
CV or pulmonary involvement 
Mucosal inflammation 
Amyloidosis 
Neurological symptoms
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13
Q

What forms in the spine in ankylosing spondylitis

A

Syndesmophytes

Fusion of the vertebrae that leads to decreased movement

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14
Q

What is the Schober test

A

Measure 10cm from dimples of iliac crest and 5cm below
Ask patient to bend over and touch toes
Distance should increase

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15
Q

What is the limitation of the Schober test

A

Can be limited by pain

Even if back does move its too sore to complete

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16
Q

What is used to diagnose ankylosing spondylitis

A

History
Exam - occipital to wall, Schober test and chest expansion - reduced
Bloods - HLA B27 and inflammatory markers
X-ray
MRI

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17
Q

How is chest expansion affected in ankylosing spondylitis

A

May be reduced

Due to fusion of costochondral joints

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18
Q

How might ankylosing spondylitis present on X ray

A

May be normal in early disease
Bone density reduced (late disease only)
Shiny corners or fuzzy margins- start of fusion
Syndesmophytes
Fusion - bamboo spine due to bridging of sydesmophytes

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19
Q

How can you treat ankylosing spondylitis

A

Spinal disease: Physio and occupational therapy
NSAIDs
Anti-TNF - e.g. infliximab
Or IL-17 blockers

Peripheral disease
DMARDs - e.g. MTX
IM or IA steroids
Short course of oral steroids

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20
Q

What is psoriatic arthritis

A

Inflammatory arthritis usually associated with psoriasis

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21
Q

All patients with psoriatic arthritis will have psoriasis - true or false

A

False
10-15% of patients will present without the skin condition
Often have a family member with psoriasis

22
Q

What are the clinical features of psoriatic arthritis

A 
Inflammatory arthritis 
Sacroiliitis - often asymmetrical 
Nail involvement - pitting or white patches
Dactylitis 
Enthesitis 
Eye disease - uveitis or iritis
23
Q

What are the 5 clinical subgroups of psoriatic arthritis

A

1- confined to DIP joints (hands and feet)
2- symmetrical polyarthritis
3- spondylitis (spine involved)
4- asymmetric oligoarthritis with dactylitis
5- arthritis mutilans - severe damage to the hands and feet

24
Q

How do you diagnose psoriatic arthritis

A

History - PMH and FH of psoriasis is key
Examination - nail signs etc
Bloods - raised inflammatory markers
X rays

25
Q

What X ray signs suggest psoriatic arthritis

A

Marginal erosions
Enthesitis
Pencil in a cup deformity - bone looks sharpened

26
Q

How can you treat psoriatic arthritis

A 
NSAIDs 
Steroids (inc. joint injection) 
DMARDs 
Anti-TNF - severe disease 
Physio and occupational therapy 
Orthotics
27
Q

What is reactive arthritis

A

Infection induced systemic illness
Typically a infective illness which leads to an inflammatory synovitis
Common after GI or GU infection in UK - campylobacter and chlamydia

28
Q

Who does reactive arthritis usually affect

A

Young adults
20-40
Equal sex distribution

29
Q

What are the clinical features of reactive arthritis

A 
Fever, fatigue, malaise 
Asymmetrical mono/oligoarthritis 
Enthesitis 
Mucocutaneous lesions 
Ocular lesions 
Mild renal disease 
Carditis
30
Q

Which joints are commonly affected by reactive arthritis

A

Knees

Can affect any joint

31
Q

How do you diagnose reactive arthritis

A 
History and Exam 
Bloods - inflammatory markers, FBC, U&E, HLA B27 
Cultures - blood, urine 
Joint fluid analysis 
X ray 
(last 2 mainly to rule out other causes)
32
Q

How do you treat reactive arthritis

A

Most resolve itself in 6 months
Can give NSAIDs, corticosteroids, antibiotics for underlying infection
DMARD is resistant/chronic
Physio

33
Q

What is enteropathic arthritis

A

Arthritis associated with IBD (Crohn’s and UC)
9-20% of sufferers will get it
Can affect many joints

34
Q

When does enteropathic arthritis get worse

A

During flare up of the IBD

35
Q

What are the clinical symptoms of enteropathic arthritis

A 
GI - loose stool with mucous & blood 
Weight loss 
Fever 
Eye inflammation 
Skin involvement #
Enthesitis 
Oral ulcers
36
Q

What investigations might you do for enteropathic arthritis

and what would the findings be

A 
Endoscopy - shows UC or Crohn's 
Joint aspirate - no organism or crystals 
(excludes other conditions) 
Raised inflammatory markers 
X-ray/MRI - shows sacroiliitis 
USS - synovitis or tenosynovitis
37
Q

How do you treat enteropathic arthritis

A 
Treat the underlying bowel disease 
Normal analgesia - paracetamol 
Steroids - oral, IA or IM 
DMARDs 
Anti-TNF
38
Q

Why would you not give NSAIDs to treat enteropathic arthritis

A

May exacerbate the existing inflammatory bowel disease

39
Q

Psoriatic and other seronegative

arthropathies generally affect the DIPs - true or false

A

True
This is because of enthesitis at the insertion of the extensor tendon into the terminal phalanx
Not affected in RA

40
Q

Which age group and sex are most likely to be affected by seronegative
spondyloarthropathies

A

Young men between 20 and 40 years old are more likely to be affected by seronegative
spondyloarthropathies such as AS.

41
Q

Family history increases risk of seronegative

spondyloarthropathies - true or false

A

True
- A first degree relative with AS increases the
risk having the disease by 5-20%
- A 50-fold increase for first degree relatives with
psoriatic arthritis and monozygotic twins have a 50% concordance
rate.

42
Q

Seronegative

spondyloarthropathies typically affect which joints

A

Affect sites where tendons insert to bone - DiP, spine etc

43
Q

Pain radiating down the front or back of legs

usually indicates which type of pain

A

Mechanical

44
Q

Neurological

symptoms usually indicate a non-inflammatory cause for back pain - true or false

A

True

Things such as paraesthesia, bowel or bladder symptoms

45
Q

Which type of back pain responds to NSAIDs

A

Inflammatory

46
Q

Sacro-iliac joint issues can cause pain in the buttock - true or false

A

True

unilaterally or bilaterally.

47
Q

List diseases affecting the entheses

A 
seronegative spondyloarthropathies
Tennis elbow 
Golfers elbow 
Plantar fascitis 
Achilles tendonitis
48
Q

What causes the back pain in seronegative spondyloarthropathies

A

It occurs secondary to enthesitis of
costovertebral and costotransverse ligament attachments
Can also get similar chest pain due to costocondritis

49
Q

What is the gold standard diagnostic test for seronegative spndyloarthropathies

A

MRI scans
Particularly of spine and sacroiliac joints
Picks up early changes such as enthesitis

50
Q

Which blood abnormalities may be seen in seronegative spndyloarthropathies

A

May have anaemia of chronic disease - FBC

CRP/ESR/PV may be raised
Often normal though so don’t rule out based on low inflammatory markers

MSK (21 decks)

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