What are the two main core clinical issues associated with the spondyloarthropathies?
- Back pain
- Joint pain and swelling
Where does the spondyloarthropathies mainly affect?
Spondyloarthropathies have a degree of genetic involvement. What is the gene responsible for increasing an individual's risk of developing an associated condition?
What are the 4 spondyloarthritis subgroups?
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
How does inflammatory back pain differ from mechanical back pain?
- Onset is usually of age and is insidious
- Pain persists longer than 3 months (chronic)
- Worsens with immobility (at night and early morning)
- Pain/stiffness eases with physical activity and exercise
NSAIDs are very effective
The spondyloarthropathies share many rheumatological features, what are some of these?
- Enthesitis (inflammation at insertion of tendons onto bones)
- Inflammatory arthritis which is oligoarticular, asymmetrical, and predominatly lower limb
- Sacroiliac and spinal involvement
- Dactylitis (inflammation of an entrire digit)
Give an example of enthesitis
- Plantar fasciitis
- Achilles tendinitis
What are the shared extra-articular features of the spondyloarthropathies?
- Ocular inflammation (anterior uveitis, conjunctivitis)
- Mucocutaneous lesions
- Aortic incompetence or heart block (rare)
- No rheumatoid nodules
What is ankylosing spondylitis?
A chronic systemic inflammatory disorder primarily affecting the spine
What is the hallmark of ankylosing spondylitis?
When will ankylosing spondylitis often present?
In which sex is ankylosing spondylitis more common?
What classification criteria is used for axial ankylosing spondyloarthritis?
(assessment of spondyloarthritis international society)
What is the term given to bony outgrowths which cause the fusion of vertebrae in anyklosing spondyloarthritis?
Ankylosing spondylitis is often referred to as "A" disease due to the amount of clinical features which begin with A.
List as many as you can
- Anterior uveitis (also conjunctivitis)
- Aortic valve involvement (leads to aortic regurgitation)
- Apical pulmonary fibrosis
- Asymptomatic enteric mucosal inflammation
- Achilles tendinitis (also plantar fasciitis)
- Atlanto-axial subluxation leading to neurological involvement
Which three useful clinical examinations can be used to diagnose ankylosing spondylitis?
- Occiput/tragus to wall
- Chest expansion
- Schober's test
In ankylosing spondylitis, the fusion of spinal vertebrae creates which appearance on X-ray?
(due to syndesmophytes)
Why are X-rays not so useful in preventing the long term effects of ankylosing spondylitis?
They usually cannot show the early stages/changes of the disease and only the late presentations
How are the best early radiological changes seen in ankylosing spondylitis?
What are the treatment options for ankylosing spondylitis?
- Occupational therapy
- Disease modifying drugs e.g. salazopyrin or methotrexate when there are peripheral joint involvement (rare)
- Anti-TNF treatment (in severe AS)
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis
N.b - not all patients with psoriatic arthritis have psoriasis
Is rheumatoid factor present in psoriatic arthritis?
What are the main clinical features of psoriatic arthritis?
- Sacroiliitis (often asymmetrical and potentially associated with spondylitis)
- Nail involvement (pitting/onycholysis)
- Extra-articular features such as eye disease
How many clinical subgroups of psoriatic arthritis are there?
What are the 5 clinical subgroups of psoriatic arthritis?
- Psoriatic arthritis confined to the distal interphalangeal joints (DIP)
- Symmetric psoriatic polyarthritis
- Psoriatic spondylitis (with or without peripheral joint involvement)
- Asymmetric psoriatic oligoarthritis with dactylitis
- Psoriatic arthritis mutilans
What are the main findings on X-ray for psoriatic arthritis?
- Mariginal erosions
- Pencil in cup deformity
How can psoriatic arthritis be treated?
- Physiotheraphy, occupational therapy, orthotics, podiatry
- Corticosteroid drug injections
- Disease modifying drugs e.g. methotrexate, sulfasalazine, leflunomide
- Anti-TNF (in severe disease and unresponsive to other treatment)
- Secukinumab (anti-IL17)
What is reactive arthritis?
A systemic illness induced by infection and characterised primarility by an inflammatory synovitis
(micro-organisms cannot be cultured)
How long does it take symptoms to come on after infection in recative arthritis?
What are the most common infections to induce reactive arthritis?
Urogenitial - chlamydia
Enterogenic - salmonella, shigella, yersinia
What age group is affected by reactve arthritis?
(equal sex distribution)
What is Reiter's syndrome?
A form of reactive arthritis
Encompasses a triad of conditions:
What are the clinical features of reactive arthritis?
- General malaise, fever and fatigue
- Asymmetrical monoarthritis or oligoarthritis
- Mucocutaneous lesions (oral ulcers, hyperkeratotic nails, keratoderma blennorrhagicum, circinate balanitis)
- Occular lesions (uni or bilateral)
- Visceral manifestations e.g. mild renal disease, carditis
What is keratoderma blennorrhagicum and which condition is it associated with?
Vesico-pustular waxy skin lesions commonly found on the palms and soles but which may spread to the scrotum, scalp and trunk.
The lesions may resemble psoriasis.
Associated with reactive arthritis
What is the most common dermatological manifestation of reactive arthritis?
This is a specific dermatitis of the glans penis
How can reactive arthritis be diagnosed?
- History + Examination
- Bloods - inflammatory markers, FBS, U+Es, HLA B27
- Cultures of blood, urine or stool
- Joint fluid analysis (rules out infection)
- X-ray of affected joints
- Opthamology opinion
How to treat reactive arthritis?
Most cases spontaneously resolve within 6 months
- DMARDs - Salazopyrin
- Physiotherapy and occupational therapy
Enteropathic arthritis is associated with what other chronic condition(s)?
Inflammatory bowel disease
- Crohn's disease
- Ulcerative colitis
Where does arthritis present in patients with enteropathic arthritis?
Knee, ankles, elbows and wrists
Often spine, hip and shoulder involvement occurs
What are the clincal symptoms of enteropathic arthritis?
- Loose watery stool with mucous and blood
- Weight loss
- Low-grade fever
- Pyoderma gangrenosum
- Apthous ulcers
- Arthritis in several joints (polyarthritis)
Which investigations are appropriate for enteropathic arthritis?
Joint aspirate (to rule out infection or crystals)
Raised inflammatory markers
X-ray/MRI to show sacroiliitis
Ultrasound scan (showing synovitis/tenosynovitis)
How is enteropathic arthritis controlled?