Ankylosing spondylitis

Question 1

Where does ankylosing spondylitis affect?

Answer 1

Spine and sacro-iliac joints.

Can lead to fusion of these joints.

Question 2

Which sex is more commonly affected?

Answer 2

Males

Question 3

At what age is this usually diagnosed

?

Answer 3

20-40

Question 4

What are the usual symptoms?

Answer 4

Spinal pain
Stiffness - especially in the morning which improves with exercise
Knee or hip arthritis

Question 5

What spinal changes can occur over time?

Answer 5

Loss of lumbar lordosis
Increased thoracic kyphosis
“question mark spine”
Hunching over and loss of neck

Question 6

How is lumbar spine flexion measured?

Answer 6

Schobers test.
10cm mark above posterior superior iliac crests and 5 cm below.
This space should increase to 20cm on flexion.

Question 7

What might you seen on x-ray?

Answer 7

Sclerosis
Fusion of SI joints
Syndesmophytes- bony spurs from the vertebral bodies

Question 8

Which immunological marker is positive in patients with spondyloarthropathies?

Answer 8

HLA- B27

Question 9

What is the recommended treatment for AS?

Answer 9

Physiotherapy, exercise, NSAIDs and anti-TNF inhibitors.

No role for DMARDs

Question 10

What are spondyloarthropathies?

Answer 10

Group of inflammatory arthritides which affect the spine and joints.

Question 11

What is mechanical pain?

Answer 11

Worsened on activity, worst at end of day, better with rest.

Question 12

What is enthesitis?

Answer 12

Inflammation at insertion of tendons into bones

Question 13

What is dactylitis?

Answer 13

Inflammation of entire digits- swollen, erythematous

Question 14

What extra-articular features do all spondyloarthopathies have?

Answer 14

Ocular inflammation

Mucocutaneous lesions

Question 15

Why is ankylosing spondylitis known as the A disease?

Answer 15

Axial arthritis
Anterior uveitis
Amyloidosis
Achilles tendinitis
Apical fibrosis
Aortic regurgitation

Question 16

How common is psoriatic arthritis in patients with psoriasis?

Answer 16

Around 30%

Question 17

What is the pattern of this arthritis?

Answer 17

Asymmetrical oligoarthritis (1-4 joints).
Also affect the hands in a RA pattern.
Dactylitis
Enthesitis

Question 18

What nail changes commonly occur?

Answer 18

Pitting and onycholysis

Question 19

What treatment is recommended?

Answer 19

NSAIDs
Steroids
DMARDs- usually methotrexate

Question 20

What would you see on X-ray?

Answer 20

Marginal erosions and whiskering
Pencil in cup deformity
Osteolysis
Enthesitis

Question 21

What is Reiter’s syndrome?

Answer 21

TRIAD

Reactive arthritis PLUS urethritis and conjunctivitis or similar

Question 22

What is reactive arthritis?

Answer 22

Occurs in response to an infection in another part of the body- mostly GU or GI infections.

Question 23

What is usually responsible for reactive arthritis?

Answer 23

Chlamydia, salmonella, shigella

Question 24

What age group is most likely to develop reactive arthritis?

Answer 24

20-40 yr olds

M:F equal

Question 25

What are the clinical features of reactive arthritis?

Answer 25

``` Constitutional symptoms Asymmetrical monoarthritis Enthesitis Conjunctivitis Mild renal disease Oral ulcers Hyperkeratotic nails Keratodema blenorrhagica ```

Question 26

What is keratodema blenorrhagica?

Answer 26

Scaly patches/pustules, especially on the soles of feet and on hands

Question 27

What treatment would you give for reactive arthritis?

Answer 27

90% resolve within 6/12 NSAIDs Steroids- intra-articular, oral and eye drops Abx

Question 28

What is the arthritis called in patients who have an IBD?

Answer 28

Enteropathic arthritis

Question 29

How common is enteropathic arthritis?

Answer 29

10-20% of IBD sufferers also have this | Also common to have sacroilitis

Question 30

What is the presenting symptoms of enteropathic arthritis?

Answer 30

``` Oligoarthritis. Knees, ankles, elbows and wrists. Diarrhoea with mucous and blood Weight loss and fever Pyoderma gangrenosum Apthous ulcers ```

Question 31

What investigations would you do for enteropathic arthritis?

Answer 31

Upper and lower GI scope with biopsy | X-ray to show sacroilitis

Question 32

What is the treatment of enteropathic arthritis?

Answer 32

IBD must be managed and this will manage the arthritis. | Not NSAIDs.