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2014-02-16 07:39:54
PsA ReA EntA

NRO spondylarthopathies flashcards
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  1. Spondylarthropathies definition
    • Group of related and often overlappinginflammatory joint disorders
    • Enthesitis, synovitis
    • Seronegative for RF
  2. Spondylarthropathies Aetiology (HLA), prevalence
    • True aetiology unknown - ?infection - bacterial trigger in genetically predisposed people
    • HLA-B27, an MHC class 1 antigen
    • HLA-B27 is most prevalence in AS (85-95%_
    • Prevalence: present in 10% of healthy Caucasians
  3. Spondylarthropathies - Pathology
    • Inflammation at the entheses
    • Initially inflammation and erosions, leads to fibrosis and ossification and finally ankylosis of the joints
    • Systemic disease can occur, affecting the heart and lungs
    • In AS, the outer fibres of the vertebral discs become inflammed where they attach to the corners of the vertebral bodies, leading to erosion and squaring of the vertebrae
    • This progress to ossification and syndesmophytes form
    • Get fusion of the SI joints
  4. Types of Spondylarthropathies (5)
    • Ankylosing spondylitis
    • Psoriatic arthropathy
    • Reactive arthritis
    • Reiter's syndrome
    • Enteropathic arthritis
  5. AS: prevalence, M:F ratio, onset
    • Prevalence: 0.5-1% of Caucasians
    • M:F = 3:1
    • Onset: early adulthood, with peak in mid-20s
  6. AS: Musculoskeletal features
    • Axial more than peripheral symptoms, as most are due to spinal and SI disease
    • Presentation: gradual onset of lower back pain and stiffness, symptoms worse in the AM/long rest and improve with exercise
    • Chest pain, reduced expansion - if involvement of thoracic spine and enthesis at costochondral junctions
    • Vertebrae: squaring and syndesmophytes + fibrosis/ossification of ligaments - this leads to a Bamboo spine
    • Bamboo spine: decreased mobility and increased risk of fracture
    • Question mark Posture
    • Peripheral joints: less common, but affect medium/large joints e.g. shoulder, hip or knees, Achilles tendonitis, plantar faschiitis
  7. AS: question mark posture:
    • Cervical hypertension
    • Exaggerated thoracic kyphosis
    • Loss of lumbar lordosis
    • Compensatory flexion at the knee
  8. AS: Extraskeletal features (4 As)
    • Systemic: anorexia, fever, weight loss, fatigue
    • The 4 As:
    • Anterior uveitis: red painful ege, blurred vision (~30% of patients)
    • Aortic regurg/ascending aortitis: (uncommon, late signe)
    • Apical lung fibrosis: (late sign)
    • Amyloidosis: rare
  9. AS: Investigations and possible findings
    • Blood tests:
    • FBC: anaemia of chronic disease
    • ESR/CRP
    • Serology: RF negative
    • HLA-B27 genotyping: expensive and unnecessary for Dx

    • X-rays:
    • AP pelvis: normal to erosions and sclerosis to fusion
    • AP lumbar spine: squaring, syndesmophytes
    • Sites of enthesitis: erosions

    MRI: can see inflammation before changes on XR
  10. AS Management
    • Physiotherapy: most important, long term to maintain normal posture and physical activity
    • NSAIDs
    • DMARDs: sulfasalazine
    • Anti-TNF
    • Surgery: joint replacement, spinal osteotomy, atlantoaxial subluxation
  11. Reactive Arthritis: Definition
    • Aseptic arthritis that develops after an anatomically distant infection, mainly affecting yound adults
    • Triggering infection is usually GI or GU
    • Symptom onset few days to a few weeks post infection
  12. ReA: Musculoskeletal Features
    • Asymmetrical, oligoarticular
    • Large weight bearing joints, fingers and toes
    • Dactylitis: invovlement of entire finger/toe leading to a "sausage finger"
    • Enthesitis is common, can get pain in SI regio
  13. ReA: extraskeletal features
    • Eyes: conjunctivitis (sterile, unilateral or bilateral)
    • Urethritis: frequency, dysuria, sometimes urethral discharge, cervicitis or prostatitis
    • Skin & muscosa lesions: circinate balantitis, keratoderma blenorrhagica¬†
    • Keratoderma blenorrhagica: a sterile pustular rash on palms and soles; looks like pustular psoriasis
    • Reiter's syndrome
  14. Reiter's Syndrome
    • Triad of:
    • arthritis
    • urethritis
    • conjunctivitis
    • in a patient with dysentery
  15. ReA Clinical Course
    • can vary in severity
    • Lasts weeks to months
    • Relapses common - 60% will have 2 or more attacks
    • Permanent joint damage is rare
  16. ReA: Investigations
    • Blood etsts: FBC, ESR, CRP
    • Serology for Abs against: Salmonella, Campylobacter, Chlamydia and Neisseria
    • Joint aspiration: gram stain and culture (to exclude septic arthritis)
    • Cervical swab, MSU, stool sample = bacterial culture
    • X-rays: initially normal, later fluffy periostitis seen in the calcaneous, digits, or pelvis; erosions are rare
  17. ReA Management
    • NSAIDs
    • Local corticosteroid infections
    • DMARDs - may be useful in severe, persistent disease
    • Antibiotics: little influence on disease course
  18. Enteropathic Arthritis: Definition
    • Arthritis occuring in association with IBD
    • in 10-20% of patients with Crohn's disease or UC
  19. EntA: Clinical features
    • Peripheral arthritis: asymmetrical, mono- or oligoarticular; worsens when IBD becomes worse and improves if affected bowel is removed
    • Spondylitis and sacroiliitis: not related to activity of IBD and predates onset of IBD
    • Enthesopathy: can accompany axial or peripheral joint disease
  20. EntA Investigations
    • Axial AP radiograph: typical spinal changes of AS
    • Peripheral: rew radiological changes
  21. EntA: Management
    • Treatment of IBD helps the arthritis
    • Corticosteroids and sulfasalazine
    • NB: NSAIDs aggravate GI symptoms in IBD
  22. Psoriatic Arthopathy Definition
    Inflammatory arthritis associated with psoriasis
  23. PsA: psoriasis prevalence, M:F ratio
    • Psoriasis: 1-3% of the population
    • 10% of those will affected develop PsA
    • M=F
    • Especially common in those with nail involvement
  24. PsA Clinical Features
    • PsA may precede diagnosis of psoriasis and does not correlate with severity of skin lesions
    • Joint pain, stiffness, sometimes swelling
    • dactylitis and enthesitis
    • Uncommon: uveitis, cardiac lesions
  25. PsA 5 Patterns of Joint Disease
    • 1. Distal arthritis involving DIP joints
    • 2. Asymmetrical oligoarthritis
    • 3. Symmetrical polyarthritis indistinguishable from RA
    • 4. Spondylitis
    • 5. Arthritis mutilans - telescoping of the digits
  26. PsA Investigations
    • Bloods: FBC, ESR, CRP, RhF (usually negative)
    • Radiology: changes asymmetrical and affect the small joints of the hands and feet (esp DIP joints)

    • Erosions with proliferation of adjacent bone
    • Reabsorption of terminal phalanges
    • Pencil-in-cup deformities
    • Periostitis
    • Ankylosis
    • New bone formation at entheses
    • Sacroiliitis (up to 30% of pts, usually asymptomatic)
  27. PsA Management
    • Physio
    • NSAIDs
    • DMARDs
    • Anti-TNF
  28. PsA Prognosis
    • Good - joint funtion usually well preserved
    • Some develop a chronic, progressive, deforming arthritis