Seronegative arthropies

Question 1

What are the disease subgroups of seronegative arthropathies?

Answer 1

′	Ankylosing Spondylitis
′	Reactive Arthritis ( Reiter's Syndrome)
′	Enteropathic Arthritis
′	Psoriatic Arthritis
′	Undifferentiated spondyloarthropathy
′	Juvenile spondyloarthropathy

Question 2

What are the shared features seen in the joints of seronegative arthropathies?

Answer 2

′ Sacroiliac and spinal involvement

′ Enthesitis: Achilles tendinitis, plantar fasciitis…

′ Inflammatory arthritis:
λ Oligoarticular
λ Asymmetric
λ Predominantly lower limb

′ Dactylitis (“sausage” digits)

Question 3

What are the shared extra-articular features of seronegative arthropathies?

Answer 3

′ Ocular inflammation (Anterior uveitis, conjuntivitis)
′ Muco-cutaneous lesions
′ Rare Aortic incompetence or heart block

Question 4

What makes seronegative arthropathies different from rheumatoid arthritis?

Answer 4

′ Different pattern of articular and extra-articular involvement
′ Associated with enthesitis and dactylitis
′ Absent serum Rheumatoid factor
′ Strong association with HLA B27
′ Prognosis is different

Question 5

Ankylosing spondilitis - what is the epidemiology?

Answer 5

′ Late adolescence or early adulthood
′ More common in men 3-5:1
′ Strongest association with HLA B27

Question 6

What are the clinical features of ankylosing spondilitis?

Answer 6

′ Inflammatory low back pain
′ Enthesitis
′ Peripheral arthritis (shoulders,hips) – rare

′ Extra articular features:
λ Anterior uveitis
λ Cardiovascular involvement (aortic valve/root )
λ Pulmonary involvement (fibrosis upper lobes)
λ Asymptomatic enteric mucosal inflammation
λ Neurological involvement (Rarely A-A subluxation)

′ Amyloidosis

′ Eventually fusion of the intervertebral joints of the spine and SI joint

Patients complain of spinal pain and stiffness and they may also develop knee or hip arthritis. Spinal morning stiffness is marked and improves with exercise. Over time there is loss of spinal movement and development of a “question mark” spine, with loss of lumbar lordosis and increased thoracic kyphosis.

Question 7

Why is ankylosing spondilitis known as the ‘A’ disease?

Answer 7

′	Axial Arthritis
′	Anterior Uveitis
′	Aortic Regurgitation
′	Apical fibrosis
′	Amyloidosis/ Ig A Nephropathy
′	Achilles tendinitis
′	Plantar Fasciitis

Question 8

What are the investigations for ankylosing spondilitis?

• blood tests
• immunology
• genetic testing
• x-rays
• MRI

Answer 8

′ Blood tests – FBC, U&Es, inflammatory markers

′ Immunology – none

′ Genetic testing – HLAb27 (90%)

′ X rays
- Bony spurs from the vertebral bodies – syndesmophytes
- These can bridge the intervertebral disc resulting in fusion producing a ‘bamboo spine’
′ MRI – can detect earlier features such as bone marrow oedema and enthesitis of the spinal ligaments. When changes seen it is described as axial SpA

Question 9

What is the clinical test for ankylosing spondilitis?

Answer 9

Schober test:
In this test a mark is made at the level at the level of L5.
The examiner then places one finger 5cm below this mark and another finger at about 10cm above this mark. The patient is then instructed to touch his toes.
If the increase in distance between the two fingers on the patients spine is less than 5cm then this is indicative of a limitation of lumbar flexion.
This test allows serial measurements for patients with progressive disease to be undertaken.

Question 10

How is a diagnosis of ankylosing spondilitis made?

Answer 10

Modified New York Criteria for Diagnosis of Ankylosing Spondylitis:

1. Lower back pain for 3 months
   - Improved with exercise
   - Not relieved by rest
2. Limited lumbar motion – Schober’s test
3. Reduced chest expansion
4. Bilateral, Grade 2 to 4, sacroiliitis on X ray
5. Unilateral, Grade 3 to 4, sacroiliitis on X ray

Definite AS if Criterion 4 or 5, plus 1,2 or 3

Question 11

What is the treatment for ankylosing spondilitis?

Answer 11

′ Home exercises
′ Physiotherapy

′ Occupational therapy

′ NSAID

′ Corticosteroids

′ Anti TNF treatment –
Infliximab (Remicade),
Adalimumab (Humira)

′ Disease modifying drugs for more progressive disease
SZP, MTX (peripheral arthritis)

Question 12

Psoriatic arthritis:

-What are the clinical features of psoriatic arthritis?

Answer 12

′ Inflammatory Arthritis (5 subgroups)
1. Confined to distal interphalangeal joints (DIP) hands/feet
2. Symmetric polyarthritis (similar to RA)
3. Spondylitis with or without peripheral joint involvement
4. Asymmetric oligoarthritis with dactylitis
5. Arthritis mutilans
′ Sacroiliitis:
λ often asymmetric
λ may be associated with spondylitis
′ Nail involvement (Pitting, onycholysis)
′ Dactylitis
′ Enthesitis:
λ Achilles tendinitis
λ Plantar fasciitis
′ Extra articular features (eye disease)

Question 13

What is involved with the diagnosis of psoriatic arthritis?

Answer 13

′	History
′	Examination
′	Bloods:
λ	Inflammatory parameters (raised)
λ	Negative RF
′	X-rays 
λ	 Marginal erosions and “whiskering”
λ	 “Pencil in cup” deformity
λ	 Osteolysis
λ	 Enthesitis

Question 14

What is the medical treatment for psoriatic arthritis?

Answer 14

λ NSAIDs
λ Corticosteroids/joint injections
λ Disease Modifying Drugs (MTX,SZP…)
λ Anti TNF – Etanercept (Enbrel)

Question 15

What is the non-medical treatment for psoriatic arthritis?

Answer 15

λ Physiotherapy
λ Occupational Therapy
Orthotics, Chiropodist

Question 16

What is reactive arthritis also known as?

Answer 16

Reiter’s

Question 17

What is reactive arthritis?

Answer 17

Infection induced systemic illness characterized primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured.

′ Symptoms 1-4 weeks after infection.
′ Equal sex distribution
′ HLA B27 + Infection

It occurs in response to an infection in another part of body (GI/GU commonly)

Question 18

What are the most common infections assoc. with reactive arthritis?

Answer 18

λ Urogenital. Chlamydia

λ Enterogenic. Salmonella, Shigella, Yersinia

Question 19

What are the clinical features of reactive arthritis?

-what is the triad of symptoms seen?

Answer 19

′	General Symptoms (fever, fatigue, malaise)
′	Asymmetrical monoarthritis or oligoarthritis
′	Enthesitis 
′	Mucocutaneous lesions
		- Keratodema Blenorrhagica
		- Circinate balanitis
		- Painless oral ulcers
		- Hyperkeratotic nails

Most patients have a triad of symptoms: urethritis, conjunctivitis and arthritis
= reiter’s syndrome

(Large joints eg the knee become inflamed around 1‐3 weeks following the infection. The infection triggers an autoimmune arthropathy. )

Question 20

What is the diagnosis of reiter’s?

Answer 20

′	History
′	Examination
′	Bloods:
λ	Inflammatory parameters (ESR,CRP,PV)
λ	FBC, U&Es
λ	HLA B27 (rarely necessary)
′	Cultures (blood, urine, stool)
′	Joint fluid analysis (rule out infection)
′	X-ray of affected joints
′	Ophthalmology opinion

Question 21

What is the treatment for reactive arthritis?

• medical
• non-medical

Answer 21

Is aimed at the underlying infectious cause
Symptomatic relief

Medical:
λ	NSAIDs
λ	Corticosteroids 
¥	Intra articular (once sepsis ruled out)
¥	Oral
¥	Eye drops
λ	Antibiotics
λ	DMARDs (SZP) – occasionally if resistant/chronic

Non medical:
λ Physiotherapy
λ Occupational therapy

Question 22

What is the prognosis for reactive arthritis?

Answer 22

′ Generally good
′ Recurrences not uncommon
′ Some develop a chronic form

Question 23

What is enteropathic arthritis?

Answer 23

an inflammatory arthritis involving the peripheral joints and sometimes spine, occurring in patients with inflammatory bowel disease (Crohn’s disease and Ulcerative Colitis). Again it tends to be a large joint asymmetrical oligoarthritis

Question 24

what is the treatment for enteropathic arthritis?

Answer 24

10‐20% of IBD sufferers will experience spine or joint problems. Treatment usually involves finding medication to manage both the underlying condition and the arthritis..