Seronegative Arthritis

Question 1

What is it?

Answer 1

• Negative rheumatoid factor
• May be associated with HLA- B27
• Usually an asymmetric arthritis
• Involvement of axial skeleton (spine)
• Enthesitis – inflammation of the area where a tendon or ligament attaches to bone e.g. achiles tendon or around the elbow
• Extra-articular features- uveitis, inflammatory bowel disease

More common in larger joints

Question 2

what is Enthesitis?

Answer 2

inflammation of the area where a tendon or ligament attaches to bone e.g. achiles tendon or around the elbow

Question 3

what are some Different clinical presentations?

Answer 3

• Ankylosing Spondylitis – key one, presents with inflammatory back pain
• Psoriatic arthritis
• Bowel related arthritis (Crohn’s, UC) – inflammatory arthritis
• Reactive arthritis – inflammatory arthritis triggered by various pathogens, usually GI infections
• Others

Question 4

what is Ankylosing Spondylitis?

Answer 4

Ankylosing spondylitis is an inflammatory disease that, over time, can cause some of the small bones in your spine (vertebrae) to fuse. This fusing makes the spine less flexible and can result in a hunched-forward posture

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

Question 5

whoa nd when does Ankylosing Spondylitis occur in?

Answer 5

• Onset in second to third decade of life
• Males > Females (One of the few rheumatological conditions that effects males more than females)
• Prevalence varies in different parts of the world

Question 6

is HLA B27 diagnostic and how common is it?

Answer 6

• NOT diagnostic of AS/SpA
• Positive in 80 to 95% of patients with AS (so can still be negative adn have AS)
• In Europe - Approx 10% population are positive and only a Prevelance of AS 1%
• Risk of AS increased in relatives
• Monozygotic twins 63%
• 1st degree relative 8.2%
• Parent – child 7.8%

Question 7

three different HLA-B27 strucutres

Answer 7

HLA-B27 may be misfolded in some way

Question 8

spinal mobility - how is modified schober test done?

Answer 8

Measurement of how stiff their spine is

Question 9

spinal mobility - how is lateral spinal flexion measures?

Answer 9

Question 10

spinal mobility - how is tragus to wall measured?

Answer 10

Helps to measure the amount of thoracic kyphosis

Question 11

spinal mobility - how is cervical rotation measured?

Answer 11

Gives a score to indicate how severe someone’s spinal restriction is

Question 12

what are the clinical features of AS?

Answer 12

• Inflammatory back pain - a lot of stiffness particularly in the morning and gets better with exercise
• Limitation of movements in antero-posterior as well as lateral planes at lumbar spine
• Limitation of chest expansion
• Bilateral sacroiliitis on X-rays (can take many years to develop on normal x-ray but can be picked up earlier on MRI)

Question 13

what is the grading of radiographic sacroiliitis? (Grading of the x-ray changes) (an inflammation of one or both of your sacroiliac joints — situated where your lower spine and pelvis connect)

Fused spine

On lateral x ray you can see vertebrae are more square in AS

Answer 13

Question 14

In axial spondyloarhtritis, what are the different stages?

Answer 14

Tend to diagnose more in the non-radiographic stage now due to MRI to pick up sacroiliitis

Radiographic means there is x-ray changes

Question 15

what is shown here?

Answer 15

Inflammation around on of the sacroiliac joints on the right hand side of the screen, other one looks okay

Question 16

what is the classification criteria for axial spondyloarthritis?

Answer 16

Question 17

what are some other features that may be seen?

Answer 17

• Peripheral joints - Hips, shoulders, knees
• Achilles tendonitis, dactylitis
• Uveitis
• Cardiac- Aortic incompetence, heart block
• Pulmonary- restrictive disease, apical fibrosis
• GI- IBD
• Osteoporosis and spinal fractures
• Neurological- AAD & cauda equina syndrome
• Renal- secondary amyloidosis (caused by chronic unsuppressed inflammation)

Question 18

what is the Management of AS?

Answer 18

• Physiotherapy - really important to maintain posture and and as much flexibility of the spine as possible
• NSAIDs - may reduce spinal fusion
• DMARDs- Sulfasalazine
• Anti-TNF
• Anti-IL-17
• Treatment of osteoporosis (are at risk of this even though it is a bone forming disease)
• Surgery- joint replacements & spinal surgery

Question 19

Benefit of NSAIDs

People who have a higher intake of NSAID have a lower spinal damage score

Answer 19

Question 20

what is the longterm clinical efficacy of TNF-alpha lbockers in AS?

Answer 20

Percentage improvement

Question 21

Psoriatic arthritis

Question 22

what is Psoriatic arthritis?

Answer 22

Psoriatic arthritis is a form of arthritis that affects some people who have psoriasis — a condition that features red patches of skin topped with silvery scales. Most people develop psoriasis first and are later diagnosed with psoriatic arthritis, but the joint problems can sometimes begin before skin patches appear

(nail changes seen in photograph)

Question 23

what joints are commonly affected by psoriatic arthritis?

Answer 23

Large joints more common than small joints

Question 24

what are the lcinical subtypes of Psoriatic arthritis?

Answer 24

• Arthritis with DIP joint involvement
• Symmetric polyarthritis- similar to RA
• Asymmetric oligoarticular arthritis
• Arthritis mutilans
• Predominant spondylitis

Also characterized by dactylitis (swelling of digit) & enthesitis (inflammation of ligament or tendons as they attach to bone)

Severity of joint disease does not correlate to extent of skin disease. Nail pitting seen

Question 25

what is the treatment of psoriatic arhtiritis?

Answer 25

* Sulfasalazine * Methotrexate * Leflunomide * Cyclosporine * Anti-TNF therapy * Anti- IL-17 and IL-23 * Steroids * Physiotherapy and occupational therapy * Axial disease treated similar to AS Treatments is with DMARDS If don’t respond well enough to DMARDS then they can get biologics like anti TF an anti-IL

Question 26

what causes reactive arhiritis?

Answer 26

* Sterile synovitis after distant infection * Infections include- Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci * Infections- throat, urogenital & GI joint pain and swelling triggered by an infection in another part of your body — most often your intestines, genitals or urinary tract. Reactive arthritis usually targets your knees and the joints of your ankles and feet. Inflammation also can affect your eyes, skin and urethra

Question 27

what else may also be seen in reactive arthritis?

Answer 27

* Disease may be systemic * Usually mono or oligoarthritis * Dactylitis or enthesitis also seen

Question 28

What Skin and mucous membrane involvement may there be in reactive arthritis?

Answer 28

* Keratoderma blenorrhagica * Circinate balanitis * Urethritis * Conjunctivitis * Iritis

Question 29

whata re osme other kinds of reactive arhtritis?

Answer 29

* Recurrent attacks common in chlamydia-induced arthritis * Reiter’s syndrome – arthritis, urethritis and conjunctivitis

Question 30

In reactive arthritis, what are some signs for chronicity?

Answer 30

Hip/heel pain High ESR Family history and HLA-B27 +ve

Question 31

what is the acute and chronic treatment of reactive arthritis?

Answer 31

• Acute - NSAID - Joint injection (if infection excluded) - antibiotics in chlamydia infection (contacts as well) • Chronic - NSAID - DMARD (e.g. sulphasalazine, methotrexate) Initially symptomatic Continue with anti-inflammatory drugs but then move onto the disease modifying drugs and maybe use biologics if necessary

Question 32

what is Enteropathic arthritis?

Answer 32

Enteropathic arthritis is an inflammatory condition affecting the spine and other joints that commonly occurs in the inflammatory bowel diseases – Crohn's disease and ulcerative colitis * Commonly associated with inflammatory bowel disease (Crohn’s or UC) * Rarely seen with infectious enteritis, Whipple’s disease and Coeliac disease

Question 33

how can Enteropathic arthritis present?

Answer 33

* Can present with both peripheral and/or axial disease * Enthesopathy commonly seen (a disorder involving the attachment of a tendon or ligament to a bone. This site of attachment is known as the enthesis (pl. entheses). If the condition is known to be inflammatory, it can more precisely be called an enthesitis)

Question 34

what is the treatment of enteropathic arthritis?

Answer 34

* NSAIDs difficult to use * Sulfasalazine * Steroids * Methotrexate * Anti-TNF * Bowel resection may alleviate peripheral disease

Question 35

Summary: * HLA B27 is not __________ of AS/SpA * Inflammatory ____ pain history is the key: - quality and quantity of early ________ stiffness - improvement of stiffness with \_\_\_\_\_\_ •\_\_\_\_\_\_\_\_ therapy as important as drug therapy

Answer 35

diagnostic back morning activity Physical