Seronegative arthritis & spondyloarthropathies Flashcards Preview

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Flashcards in Seronegative arthritis & spondyloarthropathies Deck (52)

What are seronegative arthropathies? (5 types)

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)


Ankylosing spondylitis (4)

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


Epidemiology of AS

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


New York criteria for diagnosis of AS

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


Clinical signs of AS

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


Stages of AS (3,3)

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


How to quantify spinal involvement in AS

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)


Laboratory tests for inflammation in AS

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


Psoriatic arthritis

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


Arthritis Mutilans

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


Psoriatic Oligoarthritis

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


Epidemiology of Psoriatic arthritis

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


Radiology of Psoriatic arthritis

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


How many ways can Psoriatic arthritis present?

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


Progression of Psoriatic Arthritis

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%)


Poor prognostic factors for Psoriatic arthritis (6)

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


Spinal disease in Psoriatic arthritis

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


Reiter's syndrome (reactive arthritis)

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


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

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


Progression of Reiter's syndrome

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


Epidemology of Reiter's syndrome

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


Keratoderma Blenorrhagicum

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


IBD associated (enteropathic) arthritis

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.



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



Useful analgesia in some cases of mono/oligo arthritis
Also in Enthesitis or spinal disease


Management of psoriatic arthritis

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


Biologics for seronegative spondyloarthropathies

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


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

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


Characteristics of AS back pain

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


Degenerative versus ankylosing spinal changes

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


Treatment of AS (6)

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


Clinical features of Psoriatic arthritis (5)

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


Treatment of Reiter's syndrome (5)

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


Presentation of Sacroilitis

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


Peripheral arthritis in AS

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


Association between spondyloarthropathies and IBD

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


Cardiac complications of AS

Cardiac conduction defects


Prognosis of Reiter's/reactive arthritis

30-70% relapse -- joint, eye, mucocutanous
40% mild spondylitis and 20% chronic peripheral arthritis


Laboratory tests in psoriatic arthritis

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


Prevalence of enteropathic arthritis in IBD

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%)


Extra-articular features of Enteropathic Arthritis (PAIeN)

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


Septic Arthritis

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


Treatment of Enteropathic arthritis

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



Fibrosis and ossification of ligaments and capsule insertions into bone


Reiter's syndrome/disease versus reactive arthritis

Very similar and can be used interchangably
Reiter's is specifically a triad of arthritis, urethritis and conjunctivitis -- often linked to STD


Septic polyarthritis

3 joints - 22% of cases of septic arthritis -- 30% mortality
50% of cases have a background of RA


Treatment of septic arthritis

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


Presentation of Septic Arthritis

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


Diagnosing septic arthritis

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)


Features of Gonococcal septic arthritis

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.


Relationship between psoriatic skin disease and arthritis

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


Antibiotic treatment of septic arthritis

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