Seronegative arthritis (spondyloarthirtis)

Question 1

What is it?
what can it be associated with?

involvement of?
more common in?

Answer 1

• Negative rheumatoid factor
• HLA- B27
• axial skeleton (spine)
• larger joints

Question 2

what is Enthesitis

Answer 2

inflation of area where tendon r ligament attaches to bone - around elbow, Achilles

Question 3

Extra-articular features- ? (3)

Answer 3

uveitis, inflammatory bowel disease, psoriasis

Question 4

Clinical presentations

Answer 4

• Ankylosing Spondylitis - back pain
• Psoriatic arthritis
• Bowel related arthritis (Crohn’s, UC)
• Reactive arthritis
  Others

Question 5

Age where sacroiliitis occurs?

Answer 5

late teens

Question 6

Diagnosis of ankylosing spondylitis?

Answer 6

evidence of bilateral sacroiliitis

Question 7

Ankylosing Spondylitis - prototype of?

Predilection for?

who is it more common in?

Answer 7

axial sponyloarthritis

axial skeleton and entheses

MALES

Question 8

HLA b27 is not diagnostic of?

where is it positive in?

Answer 8

AS/SpA

80-95% of patients with AS

Question 9

theories of HLA-B27 that may induce AS (3)

Answer 9

• peptides from foreign antigens presented and trigger inflammatory process
• mis folded - triggering of certain parts of the immune system
• inability to fold into homodimers

Question 10

Clinical aspects of AS - what do we look at (mobility)

Answer 10

spinal mobility - modified schober’s test

10cm mark - patient bends forward - anything less is abnormal

Question 11

Clinical aspects of AS - what do we look at (laterally)

Answer 11

lateral spinal flexion

• best of 2 tries on left and right are recorded
• score is an average of both

Question 12

Clinical aspects of AS - what do we look at (occiput)

Answer 12

• occiput to wall and trigs to wall
• ## measures the amount of thoracic kyphosis

Question 13

Clinical aspects of AS - what do we look at (cervical rotation)

Answer 13

• goniometer on top of the head
• rotate head and records angle between sagital plane and new plane
• average calculated

Question 14

AS- Clinical features (NY criteria) (4)

Answer 14

• Inflammatory back pain
• Limitation of movements in antero-posterior as well as lateral planes at lumbar spine
• Limitation of chest expansion
• Bilateral sacroiliitis on X-rays

Question 15

Grading of sacroiliitis goes from?

Answer 15

0-4

Question 16

a fused spine also known as?
what is it?

in advanced AS the vertebrae are more?

Answer 16

bamboo spine
inflammation nat corner of vertebrae - shiny corners - calcification and ossification

• squaring of the vertebrae

Question 17

Diffuse idiopathic skeletal hyperostosis (foresters disease) (3)

Answer 17

bony projections from vertebra

• unilateral bridging spodylophytes
• extensive calcification of the anterior spinal ligament

Question 18

radiographic means there are?

non radiographic means?

Answer 18

x ray changes

- picked up on MRI

Question 19

classification criteria for SpA

Answer 19

Sacroiliitis on imaging plus >1 SpA feature

or HLA-B27 plus >2 SpA features

Question 20

Name some SpA features

Answer 20

• inflammatory back pain
• arthritis
• Enthesitis
  (heel)
• uveitis
• psoriasis
• crohn’s

Question 21

Other features: systemic

Answer 21

Cardiac- Aortic incompetence, heart block, regurgitation

Pulmonary- restrictive disease, apical fibrosis

Osteoporosis and spinal fractures

Neurological- AAD & cauda equina syndrome

Renal- secondary amyloidosis

Question 22

management of AS (6/7)

Answer 22

• Physiotherapy - posture and spine flexibility
• NSAIDs- anti inflammatory, GI problems

DMARDs- Sulfasalazine

Anti-TNF

Anti-IL-17

• Treatment of osteoporosis
• Surgery- joint replacements and spinal surgery

Question 23

Patients with risk factors for radiographic spinal
progression eg…..?

what do these patients benefit most from?

Answer 23

syndesmophytes (bony changes) , elevated CRP

• NSAID therapy

Question 24

hand features of psoriatic arthritis

Answer 24

distal inter-phalangeal involvement

-lifting of the nail bed, pitting

Question 25

most destructive type of psoriatic arthritis

Answer 25

arthritis mutilans - pencil cup deformity

Question 26

some joints involved in psoriatic arthritis

Answer 26

large joints more common - knees - toes - base of spine - hands - neck

Question 27

Psoriatic arthritis- clinical subtypes (6)

Answer 27

- Arthritis with DIP joint involvement - Symmetric polyarthritis- similar to RA - Asymmetric oligoarticular arthritis (effect less than 5 joints) - Arthritis mutilans - Predominant spondylitis Also characterized by dactylitis (sausage finger) & enthesitis (where tendon joints to bone) Severity of joint disease does not correlate to extent of skin disease. Nail pitting seen

Question 28

Treatment of PA? (lots of examples)

Answer 28

``` Sulfasalazine Methotrexate Leflunomide Cyclosporine Anti-TNF therapy Anti- IL-17 and IL-23 Steroids Physiotherapy and occupational therapy Axial disease treated similar to AS ```

Question 29

Reactive arthritis triggers

Answer 29

- Sterile synovitis after distant infection - Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci - GI infections, throat infections

Question 30

Skin and mucous membrane involvement of reactive arthritis (psoriasis)

Answer 30

- Keratoderma blenorrhagica - Circinate balanitis - chlamydia - Urethritis - chlamydia - Conjunctivitis - Iritis

Question 31

Reiter's syndrome ? (3)

Answer 31

arthritis, urethritis and conjunctivitis

Question 32

Prognostic signs for chronicity?

Answer 32

Prognostic signs for chronicity Hip/heel pain High ESR Family history and HLA-B27 +ve

Question 33

Treatment of reactive arthritis - acute

Answer 33

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

Question 34

Treatment of reactive arthritis - chronic

Answer 34

NSAID | DMARD (e.g. sulphasalazine, methotrexate)

Question 35

Enteropathic arthritis is commonly associated with? it can be both? what is commonly seen in this patient group?

Answer 35

Crohn’s or UC peripheral and/or axial disease Enthesopathy commonly seen

Question 36

Treatment of reactive arthritis? what may alleviate peripheral disease?

Answer 36

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

Question 37

what in the history is key to pick up on?

Answer 37

inflammatory back pain - quality and quantity of early morning stiffness - tends to be more severe in inflammatory not mechanical - improvement of stiffness with activity - physical therapy is just as important as the drug therapy