Spondylarthropathies Flashcards by Aliya Hussain

Defing spondylarthropathies?

Family of inflammatory arthritides characterized by inv. of both the spine and joints, principally in genetically predisposed (HLA-B27 +ve) individuals

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Types of spondylarthropathies?

Ankylosing spondylitis
Enterpathic arthritis
Reactive arthritis (Reiter’s syndrome is part of this)
Psoriatic arthritis

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Usefulness of HLA-B27 screening?

Autosomal dominant inheritance but the background prevalence varies depending on location

It is not a useful screening/diagnostic test, unless the patient has symptoms as well

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Compare the symptoms of mechanical and inflammatory back pain?

Mechanical:
• Worsened by activity and better with rest
• Typically worse at the end of the day

Inflammatory:
• Worsened by rest and better with activity
• Significant early morning stiffness (> 30 mins)

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Rheumatological features that are shared by all spondylarthropathies?

Sacroiliac and spinal inv.

Enthesitis (inflammation at insertion of tendons into bones), e.g: Achilles tendonitis or plantar fasciitis

Inflammatory arthritides that are oligoarticular, asymmetric and mostly affect the lower limb

Dactylitis can occur (inflammation of entire digits) and results in “sausage fingers/toes”

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Extra-articular features shared by the spondylarthropathies?

OCULAR INFLAMMATION (anterior uveitis, conjuntivitis)
Mucocutaneous lesions
Rarely, aortic incompetence or heart block
NO RHEUMATOID NODULES

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What is ankylosing spondylitis?

Chronic systemic inflammatory disorder that primarily affects the spine

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Occurrence of ankylosing spondylitis?

Tends to be late adolescence or early adulthood

It is more common in men (

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Hallmark of ankylosing spondylitis?

Sacroiliac joint involvement (sacroiliitis)

Peripheral arthritis (shoulder and hip) is uncommon

Enthesitis

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What are the features of spondylarthropathies (SpA)?

Inflammatory back pain (neck, thoracic, lumbar, etc)
Peripheral arthritis (shoulders, hips), enthesitis, uveitis, dactylitis
Psoriasis
Crohn’s/colitis
Good response to NSAIDs
FH of SpA
HLA-B27
Elevated CRP

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Define the diagnosis of SpA with the ASAS classification?

Sacroiliitis on imaging AND ≥ 1 SpA feature

HLA-B27 +ve AND ≥ 2 SpA features

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Extra-articular features of ankylosing spondylitis?

Anterior uveitis
CV inv.
Pulmonary inv. (e.g: fibrosis of upper lobes)
Asymptomatic enteric mucosal inflammation
Neurological inv. (rarely, A-A subluxation)
Amyloidosis (deposition of abnormal proteins)

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What are the 7 As of ankylosing spondylitis?

Axial arthritis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis/Ig A neuropathy
Achilles tendonitis
PlAntar fasciitis

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Describe what occurs in a spine with ankylosing spondylitis

Syndesmophytes (fusion of vertebrae) leads to question mark posture

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Examination of a patient with ankylosing spondylitis?

Tragus/occiput to wall (straighten the neck while pressed against a wall)

Chest expansion (to check if fusion of the costovertebral joints had occurred)

Modified Schober test (bend to check lumbar flexure)

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Blood tests for ankylosing spondylitis?

Inflammatory proteins (ESR, PV and CRP) are raised

HLA-B27 (may/may not be +ve)

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X-rays search for what in ankylosing spondylitis?

Sacroiliitis

Syndesmophytes

“Bamboo” spines

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Limitations of X-rays?

Usually show changes after a long period of time, e.g: late changes inc. sacroiliac sclerosis, vertebral fusion and erosions

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Differences between signs seen on a spinal X-ray in ankylosing spondylitis and osteoarthritis

In AS:
• Bone density is normal in early stages but reduced in late disease
• Shiny corners due to initial syndesmophyte formation
• Flowing syndesmophytes
• Fusion forms a “bamboo spine”

In OA:
• Bone density is normal
• Reduced joint space
• Subchondral sclerosis
• Sunchondral cyst formation
• Osteophyte formation assoc. with neural foraminal narrowing

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Advantages of MRI in ankylosing spondylitis?

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Shows early radiological changes, e.g:
• Bone marrow oedema, which indicates inflammation
• Enthesitis

Non-pharmacological treatment of ankylosing spondylitis?

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Physiotherapy & exercise

Occupational therapy

Pharmacological treatment of ankylosing spondylitis?

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NSAIDs
Disease modify drugs are only useful if there is peripheral joint inv.
Anti-TNF treatment, e.g: infliximab, in severe AS
Secukinumbar (anti IL-17) is newly licensed

What is psoriatic arthritis?

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Inflammatory arthritis associated with psoriasis but, sometimes, the arthritis can precede skin signs

Signs of psoriatic arthritis?

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No rheumatoid nodules and rheumatoid factor is negative

5 clinical features of psoriatic arthritis?

1. Sacroiliitis (often asymmetric and can be assoc. with ankylosing spondylitis as well) 2. NAIL inv. 3. Dactylitis 4. Enthesitis 5. Extra-articular features, e.g: uveitis

5 clinical sub-groups of psoriatic arthritis?

1. Confined to DIPs of the hands/feet 2. Symmetric polyarthritis (similar to RA) 3. Spondylitis (spine inv.) with/without peripheral joint inv. 4. Assymetric oligoarthritis with dactylitis 5. Arthritis mutilans

X-ray signs of psoriatic arthritis?

* Marginal erosions and “whiskering” * “Pencil in cup” deformity * Osteolysis (disappearance of bone tissue) * Enthesitis

Non-pharmacological treatment of psoriatic arthritis?

* Physiotherapy * Occupational therapy * Orthotics, chiropodist

Pharmacological treatment of psoriatic arthritis?

* NSAIDs * Corticosteroids/joint injections * Disease Modifying Drugs (methotrexate, sulfasalazine, leflunomide) * Anti-TNF in severe disease unresponsive to NSAIDs and methotrexate * Secukinumab (anti IL-17)

What is reactive arthritis?

Infection-induced systemic illness characterised primarily by an inflammatory synovitis, from which viable micro-organisms cannot be cultured Symptoms occur 1-4 weeks after infection

Most common infection causing spondylarthropathies?

Urogenital, e.g: Chlamydia Enterogenic, e.g: Salmonella, Shigella and Yersinia

Occurrence of reactive arthritis?

Tends to be young adults (20-50 years) with an equal sex distribution People tend to be HLA-B27 +ve

What is Reiter's syndrome?

A form of reactive arthritis which is defined by a triad of features: • Urethritis • Conjunctivitis/uveitis/iritis • Arthritis (tends to affect the knee but can be anywhere)

Clinical features of reactive arthritis?

General symptoms, e.g: fever, fatigue, malaise Asymmetrical mono/oligoarthritis Enthesitis Mucocutaneous lesions, like Occular lesions (uni/bilateral) Visceral manifestations

Examples of mucocutaneous lesions in reactive arthritis?

* Keratoderma blenorrhagica (vesico-pustular waxy lesion with a yellow brown colour, commonly on the palms and soles) * Circinate balanitis (annular dermatitis of the glans penis) * Painless oral ulcers * Hyperkeratotic nails

Examples of occular lesions in reactive arthritis?

Conjunctivitis and iritis

Examples of visceral manifestation of reactive arthritis?

Mild renal disease Carditis

Blood tests in reactive arthritis?

Raised inflammatory markers FBC shows raised WCC HLA-B27 (rarely necessary)

Other tests done in reactive arthritis?

Cultures (blood, urine, stool) Joint fluid analysis (rule out infection) X-ray of affected joints Ophthalmology opinion

Outcome of reactive arthritis?

Most resolve spontaneously within 6 months

Pharmacological treatment of reactive arthritis?

NSAIDs Corticosteroids (intra-articular, if sepsis is ruled out, oral and eye drops) Antibiotics for underlying infection, e.g: respiratory/GI DMARDs if it is resistant/chronic

Non-pharmacological therapy of reactive arthritis?

Physiotherapy Occupational therapy

What is enteropathic arthritis?

Assoc. with IBD, e.g: Crohn’s (usuaully), UC

Presentation of enteropathic arthritis?

Arthritis in several joints, esp. knees, ankles, elbows and wrists; occasionally in the spine, hips of shoulders

When do symptoms of enteropathic arthritis worsen?

During flare-ups of IBD

Clinical symptoms of enteropathic arthritis?

GI: Loose, watery stools with mucous and blood Weight loss adn low grade fever Eye inv. (uveitis) Skin inv. (pyoderma gangrenosum) Enthesitis (achilles tendonitis, plantar fasciitis, lateral epicondylitis) Oral (aphtous ulcers)

Ix for enteropathic arthritis?

Upper and lower GI endoscopy + biopsy (ulceration/colitis) Joint aspirate (no organisms or crystals) Raised inflammatory markers (CRP, PV) X-ray/MRI showing sacroiliitis USS showing synovitis/tenosynovitis

Treatment of enteropathic arthritis?

Treat IBD in order to control arthritis NSAIDs are usually not recommended as they may exacerbate IBD; use normal analgesia instead, e.g: paracteamol, co-codamol Steroids (oral, intra-articular, intramuscular) Disease Modifying Drugs (methotrexate, sulfasalazine), azathioprine) Anti-TNF licensed for both Crohn’s disease and inflammatory arthritis

Spondylarthropathies Flashcards

(48 cards)