Spondyloarthropathies - workbook and lecture Flashcards
(37 cards)
1
Q
What are spondyloarthropathies?
A
- Group of conditions that affect the spine and peripheral joints and are associated with presence of HLA-B27
2
Q
Examples of spondyloarthropathies
A
- Ankylosing spondylitis (most common)
- Enteropathic arthirits
- Psoriatic arthirits
- Reactive arthiritis
3
Q
Common clinical features of spondyloarthropathies
A
- Sacroiliac/axial disease (back/buttock pain)
- Inflammatory arthropathy of peripheral joints
- Enthesitis (inflammation at tendon insertions)
- Extra-articular features (skin, gut, eye)
4
Q
Who does ankylosing spondylitis often affect?
A
Young men - teens-mid thirties
5
Q
Presentation of AS
A
- Bilateral buttock pain
- Chest wall and thoracic pain
6
Q
Examination findings of AS
A
- Normal
- Later = loss of lumbar lordosis
- Exaggerated thoracic kyphosis
- Schobers test positive
- Reduced chest expansion
7
Q
What is Schobers test?
A
- Mark skin 10cm above and 5cm below PSIS (L3/L4)
- Bend forward with straight legs
- Normal is more 20cm distance between 2 original markings
- If less than 5cm increase than +ve
8
Q
Why do AS patients have reduced chest expansion?
A
Back pain
Pulmonary fibrosis
9
Q
Investigation for AS
A
- CRP raised but often normal
- MRI spine and SI joints (more sensitive than X-ray)
- Rh F -ve
- Can do X-ray - Bamboo sign
10
Q
Treatment for AS
A
- NSAIDs
- Physio
- TNF inhibitors eg infliximab
- IL-17 inhibitors
11
Q
Who does psoriatic arthiritis affect?
A
Male and female equally
12
Q
Typical exam findings for psoriatic arthirits
A
- Oligo arthritis with single digit dactilytis (sausage digit)
- Can be symmetrical like RA or monoarthiritis
- Severe deformites eg arthiritis mutilans
13
Q
Investigations for Psoriatic arthirits
A
- CRP often raised
- Central joint erosions seen early on USS or MRI
- Erosions leads to ‘pencil in cup’ deformity seen in x-ray
- Osteopenia - periarticular
14
Q
Treatment for psoriatic arthiritis
A
- NSAIDs
- DMARDs - for peripheral disease
- TNF inhibitors
- IL-17 inhibitors
- IL12/23 inhibitors
Can use biologics for axial disease + Rituximab sometimes
15
Q
What is reactive arthirits?
A
Sterile arthritis devloping after a distant infection either post dysentry eg salmonella/shigella/campylobacter or urethritis/cervicitis (via Chlamydia trachomatis)
16
Q
Presentation of reactive arthirits
A
- Few days-2 weeks post infection
- Acute assymetrical lower limb arthiritis develops
17
Q
Other features of reactive arthitis
A
- Skin - circinate balanitis (fluid filled blisters on glans/shaft of penis), keratoderma blennorrhagica
- Eye - cojunctivitis, uveitis
- Enthesitis - inflammation of where tendon meets bone
- Painless oral ulcers
18
Q
Investigations for reactive arthirits
A
- Serology/microbiology
- Inflammatory markers raised
- May need joint aspirate to rule out septic/crystal arthirits
- Stool sample - find causative organism?
- Urine culture - same
- Genital swab - same
19
Q
Treatment for reactive arthirits
A
- Treat infection - but may not improve arthirits
- NSAIDs
- Joint injectioms
- Most will resolve within 2 years, those that do not (esp if HLA-B27) may need DMARDs
20
Q
What is Enteropathic arthiritis?
A
- Arthiritis associated with IBD
- 2/3 develop peripheral and 1/3 axial disease
21
Q
2 types of peripheral disease of enteropathic arthiritis
A
- Type 1 - oligoarticular, asymmetric and has correlation with IBD flares
- Type 2 - polyarticular, symmetrical and less correlation with IBD flares
22
Q
Treatment for enteropathic arthirits
A
- NSAIDs can flare IBD
- Consider DMARDs
- TNF inhibitors treat IBD and arthirtis
- Other drugs like azathioprine may help symptoms
- Common to be HLA-B27 +ve
23
Q
5 As of extra-articular features of AS
A
- Anterior uveitis
- Aortic incompetance - regurge
- AV block
- Apical lung fibrosis
- Amyloidosis
24
Q
Features of inflammatory back pain
A
- Insidious onset
- Pain at night - with improvement of getting up
- Age onset less than 40
- Improved with exercise
- No improvement with rest
IPAIN
25
Handy rhyme for remembering features of reactive arthiritis
Can't see (conjuctivitis, uveitis) Can't wee (urethritis)
Can't stand on one knee (often affects knees and ankles)
26
X-ray sign for AS
Bamboo spine
* Caused by increased ossification forming syndesmophytes which cause vertebral bodies to fuse at edges
* Also can see squaring of vertebral bodies, less rounded
27
What are all these spondyloarthropathies?
Serum -ve - no Rh F
28
What condition is often associated with psoriatic arthiritis?
Psoriasis- raised red plaques with silvery sheen, mainly on extensors
29
Main peripheral joints affected in psoriatic arthiritis
DIPJ - contrast to AS which is not so much peripheral and RA affects PIPJ
30
Nail changes in psoriatic arthritis
* Onycholysis
* Leukonychia
* Crumbling nails
* Subungal keratosis
* Splinter haemorrhages
31
Conjuctivitis vs uveitis
Conjuctivitis will have more inflamed gunk/crusting present
Visual changes in uveitis
32
What can be +ve in psoriatic arthitis?
Rh F and anti-CCP
33
How is overall reactive arthirtis diagnosed?
Diagnosis of elimination
Eliminate:
* Septic arthiris - via joint aspirate
* Crystal arthropathy - via joint aspirate
* Psoriatic arthorpathy
* Lymes, TB, Viral (eg Hep), Rheumatic fever
* Disseminated gonococcal infection
34
Other symptoms to ask about in AS
* Breathless - apical lung fibrosis
* Eye problems - Uveitis
* Enthesitis - achilles?
35
Other examinations for AS (other than Schobers)
* Stand up straight against wall - loss of neck extension?
* Sacroiliac tenderness on palpation?
* Lumbar spine side flexion test - middle finger tip to floor, side flex, with back against wall
* Tragus wall test - back neck against wall, move tragus to wall
36
Complications of AS
* Ankylosis or spinal fusion
* Spinal fractures
* Hip involvement
* Anterior uveitis
* Osteoporosis
* Cardiac complications - in general, and aortic valvular disease and arrhytmias
* Pulmonary fibrosis - apical
* Neurological - vertebral fracture, dislocation, cauda equina
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