Sero-Negative arthritis

Question 1

What are the Seronegative spondyloarthropathies

Answer 1

Seronegative spondyloarthropathies are a family of joint disorders that classically include ankylosing spondylitis (AS), psoriatic arthritis (PsA), inflammatory bowel disease (IBD) associated arthritis, reactive arthritis (formerly Reiter syndrome; ReA), and undifferentiated SpA.

Question 2

What are classic features of the Seronegative spondyloarthropathies

Answer 2

Negative rheumatoid factor

May be associated with HLA- B27

Usually an asymmetric arthritis

Involvement of axial skeleton (spine) – sacroiliitus

Enthesitis

Extra-articular features- uveitis, inflammatory bowel disease, Psoriasis

Question 3

What is Enthesitis

Answer 3

Enthesitis is inflammation of the entheses, the sites where tendons or ligaments insert into the bone.

Question 4

What is common in all the Seronegative spondyloarthropathies

Answer 4

Sacroiliitus

Question 5

What at the common seronegative arthritis’

Answer 5

Ankylosing spondylitis (AS),

Psoriatic arthritis (PsA),

Inflammatory bowel disease (IBD) associated arthritis,

Reactive arthritis (formerly Reiter syndrome; ReA),

Undifferentiated SpA.

Question 6

What is Ankylosing Spondylitis

Answer 6

Chronic inflammatory rheumatic disorder with a predilection for axial skeleton and entheses

Question 7

What is Epidemiology

of Ankylosing Spondylitis

Answer 7

Onset in second to third decade of life

Males 3X more likely that Females

Prevalence varies in different parts of the world

Question 8

What are the genetics of Ankylosing Spondylitis

Answer 8

HLA B27 is positive in 80-95% of patients with AS

BUT
It is not diagnostic of AS/Spa

Risk of AS increases in relatives

Question 9

What are the common presenting symptoms of Ankylosing Spondylitis

Answer 9

Inflammatory back pain
- Stiffness in morning that gets better during day

Sacroiliac pain (buttock region)

Limitation of movements in antero-posterior as well as lateral planes at lumbar spine

Limitation of chest expansion

Question 10

What examinations can be done to test for Ankylosing Spondylitis

Answer 10

Schober’s Test

Question 11

What is the Schober’s Test

Answer 11

Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points.

If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

Question 12

What investigations can be used for Ankylosing Spondylitis

Answer 12

MRI

Xray

Question 13

What radiographic investigation would you do first for Ankylosing Spondylitis

Answer 13

MRI is used to pick up sacroiliitis initially. (picks up bone marrow oedema)

Changes take a while to be seen on an X-ray

Question 14

What are the changes seen on an MRI of Ankylosing Spondylitis called

Answer 14

Non-radiographic stage changes

Question 15

What are the changes seen on an X-ray of Ankylosing Spondylitis called

Answer 15

Radiographic stage changes

Question 16

What Radiographic stage changes could be seen in Ankylosing Spondylitis

Answer 16

Squaring of the vertebral bodies

Subchondral sclerosis and erosions

Ossification of the ligaments, discs and joints.

Fusion of the facet, sacroiliac and costovertebral joints

Question 17

What is the typical description of the xray appearance of the spine in later stage ankylosing spondylitis.

Answer 17

Bamboo spine

Question 18

What is the diagnostic criteria for ankylosing spondylitis

Answer 18

Sacroiliitis on imaging and one SpA feature

OR

HLA-B27 and >2 SpA feature

Question 19

What are diagnostic SpA features

Answer 19

Inflammatory back pain 
arthritis 
enthesitis 
Uveitis 
dactylritis 
Psoriaisas 
Crohns 
Good response to NSAIDS 
Family Hx
Elevated CRP

Question 20

What is first line treatment of ankylosing spondylitis

Answer 20

Physiotherapy

Question 21

What are the treatment options for ankylosing spondylitis

Answer 21

Physiotherapy 
NSAIDS 
DMARDs- Sulfasalazine
Anti-TNF
Anti-IL-17 
Treatment of osteoporosis
Surgery

Question 22

What is Psoriatic Arthritis

Answer 22

Psoriatic arthritis is a type of arthritis that affects some people with the skin condition psoriasis. It typically causes affected joints to become swollen, stiff and painful.

Question 23

What is the prognosis of Psoriatic Arthritis

Answer 23

Can be bad but if its treated early, it’s progression can be slowed down and permanent joint damage can be prevented or minimised

Question 24

What are the important sub-groups of Psoriatic Arthritis

Answer 24

Symmetric polyarthritis

Asymmetric oligoarticular arthritis

Spondylitic pattern

Arthritis mutilans

Question 25

What is the epidemiology of Psoriatic Arthritis

Answer 25

It occurs in 10-20% of patients with psoriasis and usually occurs within 10 years of developing the skin changes. It typically affects people in middle age but can occur at any age.

Question 26

Describe Symmetric polyarthritis

Answer 26

presents similarly to rheumatoid arthritis and is more common in women. The hands, wrists, ankles and DIP joints are affected. The MCP joints are less commonly affected (unlike rheumatoid).

Question 27

Describe ASymmetric oligoarticular polyarthritis

Answer 27

Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints.

Question 28

Describe Spondylitic pattern

Answer 28

Spondylitic pattern is more common in men. It presents with: Back stiffness Sacroiliitis Atlanto-axial joint involvement

Question 29

What are signs of Psoriatic arthritis

Answer 29

``` Plaques of psoriasis on the skin Pitting of the nails Onycholysis Dactylitis Enthesitis ```

Question 30

What is Onycholysis

Answer 30

Separation of the nail from the nail bed

Question 31

What is Dactylitis

Answer 31

Inflammation of the full finger

Question 32

What is Enthesitis

Answer 32

Inflammation of the entheses, which are the points of insertion of tendons into bone

Question 33

What is management for Psoriatic arthritis

Answer 33

``` DMADS Anti-TNF therapy Anti- IL-17 and IL-23 Steroids Physiotherapy and occupational therapy ```

Question 34

Name some DMADS that can be used for Psoriatic arthritis

Answer 34

methotrexate leflunomide sulfasalazine

Question 35

Name some Anti-TNFs that can be used for Psoriatic arthritis

Answer 35

Etanercept Infliximab Adalimumab

Question 36

What is Reactive arthritis

Answer 36

Reactive arthritis is where synovitis occurs in the joints as a reaction to a recent infective trigger

Question 37

What did Reactive arthritis used to be known as

Answer 37

Reiter Syndrome

Question 38

What is a typical presentation of Reactive arthritis

Answer 38

Acute monoarthritis, affecting a single joint in the lower limb (most often the knee) presenting with a warm, swollen and painful joint.

Question 39

What infections typically causes Reactive arthritis

Answer 39

Gastroenteritis | STI

Question 40

What STI most commonly causes Reactive arthritis

Answer 40

Chylamydia

Question 41

Whats the prognosis of Reactive arthritis

Answer 41

Usually resolve within 6 months but sometimes need medications

Question 42

What are common associated symptoms of Reactive arthritis

Answer 42

Bilateral conjunctivitis (non-infective) Anterior uveitis Circinate balanitis dermatitis of the head of the penis

Question 43

What is Circinate balanitis

Answer 43

Circinate balanitis is dermatitis of the head of the penis

Question 44

What is treatment for acute Reactive arthritis

Answer 44

NSAID Joint injection (if infection excluded) Antibiotics in chlamydia infection (contacts as well)

Question 45

What is treatment for chronic Reactive arthritis

Answer 45

NSAID DMARD (e.g. sulphasalazine, methotrexate)