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Rheumatology > Seronegative arthritis & spondyloarthropathies > Flashcards

Seronegative arthritis & spondyloarthropathies Flashcards

1
Q

What are seronegative arthropathies? (5 types)

A

Arthritis in the absence of Rheumatoid factor or other autoantibody/serological abnormalities
Eg: Psoriatic arthritis (PsA), Ankylosing spondylitis (AS), Reactive Arthritis (ReA), Enteropathic Arthritis (IBD) or undifferentiated spondyloparthropathy (SpA)

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2
Q

Ankylosing spondylitis (4)

A

An inflammatory disease of the spine and axial joints – Causes inflammatory back pain with increasing stiffness and kyphosis
Begins in the SI joint progressing upwards
Hips and shoulders can be involved in severe AS and are considered a poor prognostic sign

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3
Q

Epidemiology of AS

A

Typically affects young men (15-30yrs, M:F/3:1)
0.1-1% prevalence
Women may present differently, complaining of neck and breast pain instead of typical inflammatory back pain

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4
Q

New York criteria for diagnosis of AS

A

Limited lumbar movement OR Low back pain improved by exercise not relieved by rest for 3 months OR Reduced chest expansion
AND
Bilateral grade 2-4 sacroilitis on X-ray OR unilateral grade 3-4 sacroilitis on X-ray

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5
Q

Clinical signs of AS

A

Increased thoracic kyphosis and loss of lumbar and cervical lordosis
Progressive ankylosis of the spine leads to immobility (bamboo spine) – ossification of the lateral collateral ligaments and annulus fibrosus (syndesmophytes) – ‘squaring’ of the vertebrae, oestopenia of the bodies

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6
Q

Stages of AS (3,3)

A

Inflammatory –> Can V. painful during flares, hours of morning stiffness, Fatigue (lack of sleep due to pain at night)
Ankylosis –> Increasing stiffness and reduced ROM and increasingly abnormal posture

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7
Q

How to quantify spinal involvement in AS

A 
Measure the occiput to wall distance (increases as posture changes)
Chest expansion (reduced as joint fusion increases)  
-- protuberant abdomen from abdominal breathing
Modified Schober test (lumbar spine flexion)
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8
Q

Laboratory tests for inflammation in AS

A

Inflammation –> FBC (normochromic/cytic anemia), raised CRP/ESR, thrombocytosis
Genetic test for HLA B27 – present in 95% of AS patients but only 6% of normal population

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9
Q

Psoriatic arthritis

A

A seronegative arthritis which usually presents as an inflammatory, peripheral mono- or oligo- arthritis (wrists or knees)
Rarely presents with polyarthritis or spinal disease

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10
Q

Arthritis Mutilans

A

A rare destructive arthropathy which can be seen in RA or PsA
Most commonly causes IP and MCP joint destruction with bone resorption and finger shortening (Opera-glass hands) – this eventually leads to paw like hands with subluxation and loss of function

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11
Q

Psoriatic Oligoarthritis

A

Arthritis effecting up to four joints in the first 6months of the disease classically

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12
Q

Epidemiology of Psoriatic arthritis

A

affects 6-42% of people with Psoriasis - precedes skin changes in 1/3 of cases
Onset at 30-50yrs, M=F for peripheral disease but axial disease is more common in men

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13
Q

Radiology of Psoriatic arthritis

A

classically effects the DIP joints and may cause subchondral bone resorption resulting in ‘pencil in cup’ appearance
Erosive changes seen but without osteopenia

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14
Q

How many ways can Psoriatic arthritis present?

A

Five – DIP involvement, Arthritis mutilans, Asymmetrical polyarthritis, Oligoarthritis, Ankylosing Spondylitis.
May have palmar/plantar vesicles

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15
Q

Progression of Psoriatic Arthritis

A

Oligoarticular in 40-50%, Polyarticular in 30-50% (similar to RA)
Spinal disease is predominant in 5% – usually occur after many years of peripheral arthritis
DIP involvement in 5% and Arthritis mutilans in 5% (mildly erosive in 40-50%)

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16
Q

Poor prognostic factors for Psoriatic arthritis (6)

A

Younger age of onset
HLA B27 correlates to spondylitic involvement, HLA DR3/4 correlates with erosive disease
Extensive skin involvement or polyarticular involvement
Lack of response to NSAIDs or HIV co-infection

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17
Q

Spinal disease in Psoriatic arthritis

A

Sacroiliac involvement – sacroilitis in 1/3 patients, Usually unilateral and may be asymptomatic
Spinal involvement – Can affect any part of the spine in a random fashion, unlike AS

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18
Q

Reiter’s syndrome (reactive arthritis)

A

A seronegative asymmetrical post-infective arthropathy where there is at least one: Urethritis/cervicitis, Diarrhoea, Uveitis/conjunctivitis, circinate balanitis, oral ulceration (can also occur with HIV infection)
Rheumatic diseases excluded – usually last 3-6months

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19
Q

Bacteria most commonly found to trigger Reiter’s syndrome (1,5,4)

A

Definate:chlamydia trachomatis, salmonella species, shigella flexneri, yersinia enterocolitica/pseudotuberculosis, campylobacter jejuni,
Probable: Neisseria gonorrhoeae, streptococcus pyogenes, Ureaplasma, C Diff
Often can grow organism from synovium

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20
Q

Progression of Reiter’s syndrome

A

Simultaneous with infection or 3-4 weeks after
Self limiting but can be relapsing
Lower limb most commonly effected
40% spondylitis

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21
Q

Epidemology of Reiter’s syndrome

A

M:F/4:1 – 90% of patients are HLA-B27
No.1 cause of inflammatory arthritis in young (20-40)
White>black, M=F if GI related but M>F if urogenital

22
Q

Keratoderma Blenorrhagicum

A

A feature seen in 15% of male patients with reactive arthritis
vesico-pustular waxy, hyperkeratotic lesions with a yellow brown colour commonly on palms and soles but may spread

23
Q

IBD associated (enteropathic) arthritis

A

UC or Crohn’s disease (whipple’s or microscopic colitis). peripheral arthritis which usually self limits in 4-6wks. May effect the SI joints or Enthesitis No relationship between axial disease and IBD activity but peripheral arthritis tends to be related to gut disease activity.

24
Q

Enthesitis

A

Inflammation of tendon or ligament insertions – Achilles is particularly common – can also effect the rotator cuff or plantar fasciitis

25
Q

NSAIDs

A

Useful analgesia in some cases of mono/oligo arthritis

Also in Enthesitis or spinal disease

26
Q

Management of psoriatic arthritis

A

NSAIDs for analgesia
Intra-articular steroid injections
DMARDs (as with RA) to slow disease progression - if synovitis - (Sulfazalazine, methotrexate, leflunomide)
Biologics

27
Q

Biologics for seronegative spondyloarthropathies

A

Biggest advance in years – licensed to treat Psoriatic arthritis and ankylosing spondylitis
Significantly improve both peripheral/axial arthritis, other clinical parameters and slows joint damage

28
Q

Extra-articular features of sponyloarthropathies (AS) (5,3,3)

A

Asymmetric peripheral arthritis Sausage digits
Achilles tenosynovitis Costochondritis
Plantar fasciitis/Mucocutaneous lesions Iritis/anterior uveitis
Cauda equina/atlantoaxial sublux Aortitis/reguritation
Apical pulmonary fibrosis Amyloidosis
Constitutional symptoms
AV block

29
Q

Characteristics of AS back pain

A

Insidious onset before 40yrs for longer than 3months
Associated with early morning stiffness and improves with exercise
May have nocturnal pain

30
Q

Degenerative versus ankylosing spinal changes

A

Degenerative will have joint space narrowing with transverse osteophytes growing away from the vertebra
AS starts with Romanus lesion which grows into a early vertebral syndesmophyte –> eventually grows into a Bridging syndesmophyte

31
Q

Treatment of AS (6)

A

Patient education and Exercise –> physiotherapy or OT
Pain relief with NSAIDs
Intra-articular steroid injections –> Surgical intervention if hip disease
Anti-TNF therapy – DMARDs can be used if there is peripheral arthritis (sulfasalazine mainly) but others are not useful

32
Q

Clinical features of Psoriatic arthritis (5)

A 
Nail changes -- Pitting or onycholysis
Sausage digits
Sacroilitis (may also have AS like spinal changes)
Enthesopathy
Psoriatic skin disease
33
Q

Treatment of Reiter’s syndrome (5)

A

screen for STDs –> refer to GUM clinic
NSAIDs or antibiotics
Intra-articular steroids for mono- or oligo arthritis
In severe, intractable disease –> use methotrexate, azathioprine or sulfazalazine

34
Q

Presentation of Sacroilitis

A

Low back pain or bilateral buttock pain – may radiate down one or both legs - worse after prolonged immobility
Will show juxta-articular osteoporosis and sclerosis
Eventually the joint is obliterated
Test for with Pelvic compression or Patrick’s test

35
Q

Peripheral arthritis in AS

A

Variable and with a better prognosis than RA
Rarely erosive
Occurs in 30% of patients – most commonly lower limb

36
Q

Association between spondyloarthropathies and IBD

A

AS may also have clinical or subclinical GI complications or primary IBD – cross over with Enteropathic arthritis
Similar risk factors and genetics

37
Q

Cardiac complications of AS

A

Aortitis
Cardiac conduction defects
Pericarditis

38
Q

Prognosis of Reiter’s/reactive arthritis

A

30-70% relapse – joint, eye, mucocutanous

40% mild spondylitis and 20% chronic peripheral arthritis

39
Q

Laboratory tests in psoriatic arthritis

A

No serological marker - RF negative and 5% ANA positive (same as general population)
ESR/CRP elevated

40
Q

Prevalence of enteropathic arthritis in IBD

A

occurs in 7-21% of cases – 3:1/M:F
Peripheral arthritis - UC (10%), Crohn’s (20%)
Sacroilitis - UC (15%), Crohn’s (15%)
Spondylitis - UC (5%), Crohn’s (5%)

41
Q

Extra-articular features of Enteropathic Arthritis (PAIeN)

A

Pyoderma gangrenosum
Aphthous stomatitis
Inflammatory eye diseases
Erythema nodosum (Crohn’s)

42
Q

Septic Arthritis

A

Occurs due to acute primary infection. Risk factors- pre existing joint disease, DM, Immunosuppresion, renal compromise, trauma/surgery, IVDU. 10% mortality (medical emergency)
Usually caused by staph or strep

43
Q

Treatment of Enteropathic arthritis

A 
Physiotherapy and NSAIDs
Sulfasalazine for peripheral arthritis (poss SI joint)
Azathioprine has weak evidence
Bowel resection (UC only)
Anti-TNF drugs
44
Q

Enthesopathy

A

Fibrosis and ossification of ligaments and capsule insertions into bone

45
Q

Reiter’s syndrome/disease versus reactive arthritis

A

Very similar and can be used interchangably

Reiter’s is specifically a triad of arthritis, urethritis and conjunctivitis – often linked to STD

46
Q

Septic polyarthritis

A

3 joints - 22% of cases of septic arthritis – 30% mortality

50% of cases have a background of RA

47
Q

Treatment of septic arthritis

A

Antibiotics for at least 2weeks IV and the 4wks of oral Abx

48
Q

Presentation of Septic Arthritis

A

extreme pain with swelling, increased temp and systemic illness. 1/3 of cases present as polyarthritis

49
Q

Diagnosing septic arthritis

A

joint aspiration is the central feature but cultures are negative in 75% of gonococcal arthritis (20% - mainly younger, fitter people) and blood cultures are less sensitive (50% for non-gonococcal and ~0% for gonococcal)

50
Q

Features of Gonococcal septic arthritis

A

Occurs in younger, healther people and it tends to present with a migratory pattern of arthritis. tenosynovitis and skin lesions are a frequent feature. The initial infection can often be asymptomatic.

51
Q

Relationship between psoriatic skin disease and arthritis

A

The activity of the two is unrelated and one may flare without the other. Enteropathic arthropathy is more closely related.

52
Q

Antibiotic treatment of septic arthritis

A

Normal: flucloxicillin (clindamycin if pen allergic)
MRSA: vancomycin
Gonococcal: cefotaxime

Rheumatology (15 decks)

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