Spondyloarthropathies

Question 1

What are spondyloarthropathies?

Answer 1

Family of inflammatory arthritides characterised by involvement of both the spine and joints, principally in genetically predisposed individuals

Question 2

What is HLA-B27?

Answer 2

Associated with ankylosing spondylitis, reactive arthritis, Crohn’s disease and uveitis, prevalent in 25% of northern hemisphere, not useful screening/diagnostic tool unless patients symptomatic

Question 3

What are the subgroups of spondyloarthropathies?

Answer 3

Ankylosing spondylitis, psoriatic arthritis, reactive arthritis, enteropathic arthritis

Question 4

What are the characteristics of mechanical pain?

Answer 4

Worsened by activity, typically worst at end of day, better with rest

Question 5

What are the characteristics of inflammatory pain?

Answer 5

Worse with rest, better with activity, significant early morning stiffness (>30mins)

Question 6

What is enthesitis?

Answer 6

Inflammation at insertion of tendons into bones

Question 7

What are the characteristics of inflammatory arthritis?

Answer 7

Digoarticular, asymmetric, predominantly lower limb

Question 8

What is dactylitis?

Answer 8

“Sausage” digits, inflammation of entire digit

Question 9

What are the shared features of the spondyloarthropathies?

Answer 9

Sacroiliac and spine involvement, enthesitis, inflammatory arthritis, dactylitis, ocular inflammation, mucocutaneous lesions, no rheumatoid nodules

Question 10

What are rare features of spondyloarthropathies?

Answer 10

Aortic incompetence or heart block

Question 11

What is ankylosing spondylitis?

Answer 11

Chronic inflammatory disorder that primarily affects the spine

Question 12

What is the hallmark of ankylosing spondylitis?

Answer 12

Sacroiliac joint involvement (sacroiliitis)

Question 13

What is the epidemiology of ankylosing spondylitis?

Answer 13

More common in men, occurs in late adolescence or early childhood

Question 14

What is the Modified New York Criteria for the Diagnosis of ankylosing spondylitis?

Answer 14

1 = limited lumbar motion
2 = lower back pain for 3 months (improved with exercise, not relieved by rest)
3 = reduced chest expansion
4 = Bilateral, Grade 2 to 4, sacroiliitis on x-ray
5 = Unilateral, Grade 3 to 4, sacroiliitis on x-ray
Diagnose if criteria 4 and 5, plus 1, 2 or 3

Question 15

What is the ASAS classification criteria for axial spondyloarthritis (SpA)?

Answer 15

In patients with >= 3 months back pain and age of onset < 45 years
Sacroiliits on imaging and >= 1 SpA feature or HLA-B27 positive and >= 2 other SpA features

Question 16

What is the specificity and sensitivity of the ASAS classification criteria for axial spondyloarthritis?

Answer 16

Sensitivity = 82.9%
Specificity = 84.4%

Question 17

What are the clinical features of ankylosing spondylitis?

Answer 17

Back pain (neck, thoracic, lumbar), enthesitis, peripheral arthritis (shoulder and hip, uncommon)

Question 18

What are the extra-articular features of ankylosing spondylitis?

Answer 18

Anterior uveitis, involvement of aortic root/valve, fibrosis of upper lung lobes, asymptomatic enteric mucosal inflammation, amyloidosis, neurological involvement

Question 19

What makes ankylosing spondylitis the “A disease”?

Answer 19

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

Question 20

What are some examinations for a patient with ankylosing spondylitis?

Answer 20

Tragus/occiput to wall, chest expansion, modified Schober test

Question 21

What is the modified Schober test?

Answer 21

Assesses lumbar flexion = mark made on posterior iliac spine (L5), place one finger 5cm below mark and one finger 10cm above, as patient to bend at waist, if increase in lumbar spine < 5cm the there is limited flexion

Question 22

What bloods should be done for ankylosing spondylitis?

Answer 22

HLA-B27, inflammatory parameters (ESR, CRP, PV)

Question 23

What will an x-ray of ankylosing spondylitis show?

Answer 23

Sacroiliitis, syndesmophytes, “Bamboo” spine

Question 24

What are the features of the spine in a patient with ankylosing spondylitis?

Answer 24

Bone density normal in early disease but reduced in late disease, shiny corners, flowing syndesmophytes, fusion (“bamboo” spine)

Question 25

What are the features of a spine in a patient with osteoarthritis?

Answer 25

Normal bone density, reduced joint space, subchondral sclerosis and cysts, osteophyte formation associated with neural forminal narrowing

Question 26

What are the treatments for ankylosing spondylitis?

Answer 26

Physiotherapy and occupational therapy NSAIDs Disease modifying drugs if peripheral joint involvement (SZP, MTX) Anti TNF treatment = infliximab, certolizumab, adalimumab and etanercept in severe AS

Question 27

What is psoriatic arthritis?

Answer 27

Inflammatory arthritis associated with psoriasis = 10-15% of patients have condition without psoriasis

Question 28

What are the clinical features of psoriatic arthritis?

Answer 28

Sacroiliitis = often asymmetric, may be associated with spondylitis Nail involvement = pitting, onycholysis Dactylitis, no rheumatoid nodules Enthesitis = Achilles tendonitis, plantar fasciitis

Question 29

What are the clinical subgroups of psoriatic arthritis?

Answer 29

Confined to distal interphalangeal joints (DIP = hands/feet) Symmetric polyarthritis Spondylitis (spine involvement) with or without peripheral joint involvement Asymmetrical oligoarthritis with dactylitis Arthritis mutilans

Question 30

What do bloods of patients with psoriatic arthritis show?

Answer 30

Raised inflammatory parameters, negative for rheumatoid factor

Question 31

What do x-rays of psoriatic arthritis show?

Answer 31

Marginal erosions and whiskering, pencil in a cup deformity, osteolysis, enthesitis

Question 32

What are some pharmacological treatments for psoriatic arthritis?

Answer 32

NSAIDs, corticosteroids/joint injections, disease modifying drugs (methotrexate, sulfasalazine, leflunomide), secukinumab (anti-IL-17)

Question 33

When should anti-TNF drugs be given to psoriatic arthritis sufferers?

Answer 33

In severe disease unresponsive to NSAIDs and methotrexate

Question 34

What are non-pharmacological treatments for psoriatic arthritis?

Answer 34

Physiotherapy, occupational therapy, orthotics, chiropodist

Question 35

What is reactive arthritis?

Answer 35

Infection-induced systemic illness characterised primarily by an inflammatory synovitis from which viable micro-organisms can't be cultured

Question 36

When do symptoms of reactive arthritis appear?

Answer 36

1-4 weeks after infection

Question 37

What are some common infections that cause reactive arthritis?

Answer 37

``` Urogential = chlamydia Enterogenic = salmonella, shigella, yersinia ```

Question 38

What is the epidemiology of reactive arthritis?

Answer 38

Young adults (20-40), equal sex distribution, HLA-B27 positive

Question 39

What are the conditions that make up the triad of Reiter's syndrome of reactive arthritis?

Answer 39

Urethritis, conjunctivitis/uveitis/iritis, arthritis

Question 40

What are some clinical features of reactive arthritis?

Answer 40

Fever, fatigue, malaise, asymmetrical monoarthritis or oligoarthritis, enthesitis

Question 41

What are some mucocutaneous lesions present in reactive arthritis?

Answer 41

Keratoderma blenorrhagica (psoriatic-like plaques), circinate balanitis (inflammation of penis), painless oral ulcers, hyperkeratotic nails

Question 42

What ocular lesions occur in reactive arthritis?

Answer 42

Conjunctivitis, iritis (unilateral or bilateral)

Question 43

What are some visceral manifestations of reactive arthritis?

Answer 43

Mild renal disease, carditis

Question 44

What blood tests should be taken for reactive arthritis?

Answer 44

Inflammatory parameters (CRP, ESR, PV), FBC, U & Es, HLA-B27 (rarely necessary)

Question 45

What cultures should be taken for reactive arthritis?

Answer 45

Urine, blood, stool

Question 46

What are some investigations that should be done in reactive arthritis?

Answer 46

Joint fluid analysis (rule out infection), x-ray of affected joints, get opinion of ophthalmology, bloods, cultures

Question 47

Can reactive arthritis resolve on its own?

Answer 47

Yes = 90% of cases resolve spontaneously within 6 months

Question 48

What are some treatments for reactive arthritis?

Answer 48

NSAIDs, corticosteroids (intra-articular once sepsis has been ruled out, oral, eye drops), antibiotics for underlying infection, DMARD (SZP) if resistant or chronic, physiotherapy and occupational therapy

Question 49

What is the prognosis of reactive arthritis?

Answer 49

Generally good, recurrences not uncommon, some develop a chronic form

Question 50

What is enteropathic arthritis associated with?

Answer 50

Inflammatory bowel disease (e.g Crohn's and UC), symptoms worsen during flare ups of bowel disease

Question 51

How does enteropathic arthritis present?

Answer 51

Arthritis in several joints, especially the knees, ankles, elbows and wrists, sometimes in spine, hips or shoulders

Question 52

What are the symptoms of enteropathic arthritis?

Answer 52

Loose watery stool with mucous and blood, weight loss, low grade fever, uveitis, pyoderma gangrenosum, apthous ulcers, enthesitis (Achilles tendonitis, plantar fasciitis, lateral epicondylitis)

Question 53

What investigations are done for enteropathic arthritis?

Answer 53

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

Question 54

Why are NSAIDs not used to treat enteropathic arthritis?

Answer 54

They may exacerbate bowel disease

Question 55

What should be treated to control enteropathic arthritis?

Answer 55

The underlying bowel disease

Question 56

What are some anti-TNF agents given in enteropathic arthritis?

Answer 56

Infliximab, adalimumab licensed for both Crohn's disease and inflammatory arthritis

Question 57

What are some drugs given to treat enteropathic arthritis?

Answer 57

``` Normal analgesia (paracetamol, cocodamol) Steroids = oral, intra-articular, intramuscular Disease modifying drugs = azathioprine, sulfasalazine, methotrexate ```