Seronegative Spondyloarthritis

Question 1

What are the Seronegative Spondyloarthritides?

Answer 1

Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
IBD-related arthropathy

Question 2

What joints are involved in Seronegative Spondyloarthritides?

Answer 2

Spine
Proximal large joints
Joint involvement more limited than in RA

Question 3

What deformities are more commonly seen in Seronegative Spondyloarthritides?

Answer 3

Joint ankylosis
Joint enthesitis
Dactylitis (sausage finger)

Question 4

What is the aetiology of Seronegative Spondyloarthritides?

Answer 4

All HLA B27 +
   -all RF neg
   -generally anti-CCP neg
Male preponderance 3:1
18-30yrs

Question 5

How does Ankylosing Spondylitis present?

Answer 5

Episodic pain/stiffness in lower back/buttocks
-worse in morning, may wake from sleep
-relieved by exercise
-pain alternates b/w buttocks
Asymptomatic b/w episodes

Question 6

What are the signs on examination of Ankylosing Spondylitis?

Answer 6

LOOK - question mark posture (early), paraspinal wasting (later)
FEEL - pain on pressure over SIJs
MOVE - limited lat/forward flexion of lumbar spine
Shober’s +ve

Question 7

What causes a question mark posture in Ankylosing Spondylitis?

Answer 7

Retention of lumbar lordosis during spinal flexion

Question 8

What is Shober’s test?

Answer 8

Line drawn along midline 10cm above & 5cm below L5

Distance b/w two lines should increase >5cm when pt bends forward

Question 9

Which joints are commonly involved in Ankylosing Spondylitis?

Answer 9

Sacroiliac
Hip/shoulder (asymmetrically)
Peripheral joints
Chostocondral joints (chest pain)

Question 10

What are the extra-articular manifestations of Ankylosing Spondylitis?

Answer 10

Ant uveitis (20%)
Pulmonary (apical) fibrosis
AV node block
Aortitis
Amyloidosis

Question 11

What investigations may be appropriate in suspected Ankylosing Spondylitis?

Answer 11

ESR (normal in 50%)
Pelvis XR (bilat sacroilitis)
Spinal XR (bamboo spine)

Question 12

What are the spinal XR findings of Ankylosing Spondylitis?

Answer 12

Vertebral bodies squared
Annulosus fibrosus/interspinous ligaments ossified
-leads to inflexible/rigid spine

Question 13

What is a Syndesmophyte?

Answer 13

Ossified ligament

Question 14

What is the management of Ankylosing Spondylitis?

Answer 14

Full dose NSAIDs (6wks)
Biologics
-started if no improvement on 2 diff NSAIDs

Question 15

What is Psoriatic Arthritis?

Answer 15

Seronegative arthropathy seen in psoriasis

• 8% of psoriasis pts
• equal female/male incidence

Question 16

What are the five subtypes of Psoriatic Arthritis?

Answer 16

Symmetrical polyarthritis (40%)
Asymmetrical oligoarticulararthritis (30%)
DIPJ predominant disease (10%)
Spondylitis
Arthritis mutilans

Question 17

Describe Symmetrical Polyarthritis

Answer 17

Presents similarly to RA
DIPJ involvement
Less severe deformities

Question 18

Describe Asymmetrical Oligoarticulararthritis

Answer 18

<5 joints involved

-often one large joint plus several smaller hand/foot joints

Question 19

Describe DIPJ Predominant Disease

Answer 19

Associated w/ nail changes

• pitting
• onchylolysis
• sausage finger

Question 20

Describe Spondylitis

Answer 20

Affects spine +/- SIJs as per AS

Question 21

Describe Arthritis Mutilans

Answer 21

Severe form (5%)
Marked joint destruction/deformity
   -telescoping of digits

Question 22

What are the radiological signs of Psoriatic Arthritis?

Answer 22

Erosions similar to RA

• minimal osteopenia
• more central erosions (pencil in a cup)

Question 23

What joints are involved in Psoriatic Arthritis?

Answer 23

Sacroiliac (usually unilateral)

Early DIPJ involvement (specific to PA)

Question 24

What are the management options for Psoriatic Arthritis?

Answer 24

If one joint involved
   -full dose NSAIDs +/- steroid injections
If multiple joints involved
   -treat as per RA, better prognosis
   -methotrexate also helps skin
   -DMARDs do not help spinal sx

Question 25

What is Reactive Arthritis (Reiter's Syndrome)?

Answer 25

Acute, asymmetrical lower limb arthritis occurring 4-40 days following an infection (GI/GU) -can then develop into chronic arthritis

Question 26

What are the common causative pathogens causing Reactive Arthritis?

Answer 26

Chlamydia Salmonella Campylobacter

Question 27

How does Reactive Arthritis present?

Answer 27

``` Classical triad (can't see, pee or climb a tree) -conjunctivitis -dysuria -lower-limb oligoarthritis Sacroilitis/spondylitis Enthesitis -associated plantar fasciitis or Achilles tendonitis Skin lesions ```

Question 28

What skin lesions are common in Reactive Arthritis?

Answer 28

Keratoderma blenorrhagica | Balantitis

Question 29

What causes Reactive Arthritis?

Answer 29

Disease process due to antigenic stimulation of inflammatory response

Question 30

What are the management options for Reactive Arthritis?

Answer 30

Full dose NSAIDs +/- steroid injections Sulfasalazine 2nd line -for more extensive disease

Question 31

How common is IBD-related arthropathy?

Answer 31

10-15% of those w/ IBD develop an arthropathy

Question 32

How does IBD-related arthropathy present?

Answer 32

Symmetrical arthritis affecting lower limb joints | -5% have spinal/SIJ involvement

Question 33

What are the management options for IBD-related arthropathy?

Answer 33

Remission of UC = remission of joint disease Arthritis persists in well controlled Chron's MDT management w/ gastroenterologists

Question 34

In what arthritides are Anterior Uveitis common?

Answer 34

HLA B27 + - ankylosing spondylitis - psoriatic arthritis

Question 35

How does Anterior Uveitis present?

Answer 35

Acute pain & photophobia Constricted pupil, poss irregular due to ant/post synechiae Circumcorneal redness

Question 36

How is Anterior Uveitis managed?

Answer 36

Topical steroids | Dilating eye drop

Question 37

In what arthritides are Scleritis/Episcleritis common?

Answer 37

Rheumatoid Arthritis

Question 38

How does Scleritis/Episcleritis present?

Answer 38

Conjunctival congestion - w/ tenderness = episcleritis - w/ extreme pain = scleritis

Question 39

How are Scleritis/Episcleritis managed?

Answer 39

Anti-inflammatory eye drops