Spondyloarthropathies

Question 1

What are spondyloarthropathies?

Answer 1

Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically and predisposed (HLA B-27) individuals

Question 2

What is HLA B-27 associated with?

Answer 2

Ankylosing spondylitis
Reactive arthritis
Crohn’s disease
Uveitis

Question 3

What are the different types of spondyloarthritis disease subgroups?

Answer 3

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis

Question 4

What are the sympotms of mechanical back pain?

Answer 4

Worsened by activity
Typically worst at the end of the day
Better with rest

Question 5

What are the symptoms of inflammatory back pain?

Answer 5

Worse with rest
Better with activity
Significant early morning stiffness that lasts more than 30mins

Question 6

What are some rheumatological features that are present in all spondyloarthropathies?

Answer 6

Sacroiliac and spinal involvement
Enthesitis
Inflammatory arthrtisi
Dactylitis

Question 7

What is enthesitis?

Answer 7

Inflammation at insertion of tendons into bones e.g. achilles tenson causing plantar fasciitis

Question 8

What are the characteristics of inflammatory arthritis?

Answer 8

Oligoarticular
Asymmetric
Predominantly lower limbs

Question 9

What are some extr-articular features that can present in all spondyloarthropathies?

Answer 9

Ocular inflammation (anterior uveitis, conjunctivitis)
Mucotaneous lesions
Rare aortic incompetence or heart block

Question 10

What is ankylosing spondylitis?

Answer 10

Chronic systemic inflammatory disorder that primarly affects the spine

Question 11

What is the hallmark of ankylosing spondylitis?

Answer 11

Sacroiliac joint involvement (sacroiliitis)

Question 12

What is the ASAS classification for ankylosing spondylitis?

Answer 12

In patients with more than 3 months back pain and under 45:
Sacroilits imaging and one spondyloarthritis feature
OR
HLA-B27 positive and 2 spondyloarthritis features

Question 13

What are the spondyloarthritis features in the ASAS classification?

Answer 13

Inflammatory back pain
Arthritis
Enthesitis
Uveitis
Dactylitis
Psoriasis 
Crohn's 
Good response to NSAIDs
Family history of SpA
HLA-B27
Elevated CRP

Question 14

How will sacroiliitis show in images?

Answer 14

Active inflammation on MRI highly suggestive of sacroiliitis associated with SpA

Question 15

What are the clinical features of AS?

Answer 15

Back pain (neck, thoracic, lumbar) 
Enthesitis
Peripheral arthritis (RARE)
Extra articula: anterior uveitis, CV involvement (aortic valve/root), pulmonary fibrosis (upper lobes), asymptomatic enteric mucosal inflammation, neurological involvement (rarely A A subluxation), amyloidosis

Question 16

What is a way to remeber the symptoms of AS?

Answer 16

Remeber as the A disease: 
Axial arthritis
Anterior uveitis 
Aortic regurgitation
Apical fibrosis 
Amyloidosis 
Achilles tendinitis
PlAntar fasciitis

Question 17

What do syndesmophytes cause?

Answer 17

Fusion of vertebrae

Question 18

What examinations can be performed to diagnose AS?

Answer 18

Tragus to wall
Chest expansion
Modified Schober test

Question 19

What bloods can be done to diagnose AS?

Answer 19

Inflammatory parameters (ESR, CRP, PV)
HLA B-27

Question 20

What can be seen on radiological images of AS?

Answer 20

Sacroiliitis
Syndesmophytes
Bamboo spine
Osteopenia 
Shiny corners

Question 21

What can be seen on radiological images of OA?

Answer 21

Normal bone density 
Reduced joint space
Subchondral sclerosis
Subchondral cysts 
Oosteophyte

Question 22

What will an MRI of AS show?

Answer 22

Early radiological changes: bone marrow oedema and enthesitis

Question 23

What is psoriatic arthritis?

Answer 23

Inflammatory arthritis associated with psoriasiss, but 10-15% of patients can have PsA without psoriasis cutaneously

Question 24

How will PsA present?

Answer 24

Sacroiliitis (asymmetric) 
Nail involvement (pitting, onycholysis)
Dactylitis
Enthesitis 
Extra articular features (eye disease)

Question 25

What are the different clinical subgroups of psoriatic arthritis?

Answer 25

``` Confined to DIP joints Symetric polyarthritis Spondylitis Asymmetric oligoarthritis with dactylitis Arthritis mutilans ```

Question 26

What bloods can be done to diagnose PsA?

Answer 26

Inflammatory parameters raised | Negative RF

Question 27

What radiographic findings can be seen in PsA?

Answer 27

Marginal erosions and whiskering Pencil in cup deformity Osteolysis Enthesitis

Question 28

What is reactive arthritis?

Answer 28

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

Question 29

What are the most common infections to cause reactive arthrtitis?

Answer 29

Urogenital: clamydia Enterogenic: salmonella, shigella, yersinia

Question 30

When will reactive arthritis occur after an infection?

Answer 30

1-4 weeks after the infection has cleared up

Question 31

What makes up reiter's syndrome?

Answer 31

Urethritis Conjuctivitis/ uveitis/ iritis Arthritis

Question 32

What are the clinical features of reactive arthritis?

Answer 32

Fever, fatigue, malaise Asymmetrical monoarthritis/ oligoarthritis Enthesitis Mucotaneous lesions: keratoderma blenorrhagica, circinate balnitis, painless oral ulcers, hyperkeratotic nails Ocular lesions - conjuctivitis, iritis Visceral manifestations - mild renal disease, carditis

Question 33

How is reactive arthritis diagnosed via blood tests?

Answer 33

Inflammatory parameters FBC, U&Es HLA B27 Cultures (usually negative)

Question 34

Why is a joint fluid analysis done?

Answer 34

To rule out septic arthritis

Question 35

Why is an x-ray of the affected joints undertaken?

Answer 35

Due to acute nature, need to rult out osteonecrosis or osteomyelitis

Question 36

What is enteropathic arthritis?

Answer 36

Associated with inflammatory bowel disease e.g. crohn's and UC

Question 37

Where will enteropathic arthritis affect?

Answer 37

Several joints, especially knees, ankles, elbows and wrists | Sometimes the spine, hips or shoulders

Question 38

What are the clinical symptoms of enteropathic arthritis?

Answer 38

GI - loose, watery stool with mucous and blood Weight loss, low grade fever Eye involvement (uveitis) Skin involvement (pyoderma gangrenosum) Enthesitis (achilles tendonitis, plantar fasciitis, lateral epicondylitis) Oral - apthous ulcers

Question 39

How is enteropathic arthritis diagnosed?

Answer 39

``` Upper and lower GI endoscopy Joint aspirate - no organisms or crystals Raised inflammatory markers MRI showing sacroiliitis USS showing tenosynovitis ```

Question 40

How is enteropathic arthritis treated?

Answer 40

Treat IBD DONT GIVE NSAID Normal analgesia - paracetamol, cocodamol

Question 41

How are spondyloarthridites treated medically?

Answer 41

``` NSAIDs Corticosteroids Topical steroid eyedrops DMARDs - methotrexate, sulfasalazine, lefunomide Biologics - anti-TNF Secukinumab (anti IL-17) for PsA and AS ```

Question 42

What are the non medical treatments for spondyloarthridites?

Answer 42

Physiotherapy OT Orthotics, chiropodist