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Spondyloarthropathies

Spondyloarthropathies. Sophie Foot. Aims. To establish a knowledge of- The different classifications of arthritis Ankylosing spondylitis, reactive arthritis, psoriatic arthritis, & juvenile chronic arthritis diagnosis & treatment

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Spondyloarthropathies

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  1. Spondyloarthropathies Sophie Foot

  2. Aims To establish a knowledge of- • The different classifications of arthritis • Ankylosingspondylitis, reactive arthritis, psoriatic arthritis, & juvenile chronic arthritis diagnosis & treatment • To be able to answer AMK style questions surrounding these conditions • GALS screening

  3. What is Arthritis? “inflammation of one or more joints, characterised by warmth, redness of the overlying skin, and diminished range of joint motion” Oxford dictionary

  4. Classifications of arthritis Other- juvenile chronic arthritis & haemorrhagic arthritis (eg in patients with haemophilia)

  5. Spondylarthropathies ‘Characterised by predominant involvement of axial and peripheral joints and entheses (areas where tendons, ligaments or joint capsules attach to bone).’ Sero negative (no IgM RF) They include- • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis (Reiters) • Enteropathicarthritis (associated with IBD) HLA-B27

  6. Ankylosing spondylitis Ankylosing Spondylitis primarily involves the axial skeleton (egsacroiliitis & spondylitis) • Prevalence- 0.15% • Pathophysiology- genetically susceptible individuals develop the disease in response to an infective trigger. • GENETICS- 90% are HLA-B27 positive AMK question- ‘a young man (20-30y/o) presents with a 2 year history of back pain and stiffness which has slowly worsened over the last few months. The stiffness is worse in the morning and improves with exercise. It also wakes him up at night, and improves on getting up. He has no history of trauma.’ ‘There was a history of a painful red eye on 2 occasions for which he had attended eye casualty and received steroid eye drops. He had also had bilateral Achilles tendonitis in the past.’

  7. Extra-articular Complications All the As- • Anterior uveitis • Aortic root dilation and aortic incompetence • AV block • Apical lung fibrosis • Amyloidosis • IgA nephropathy • Achilles tendonitis • And caudaequina • Arthritis- peripheral • In 25% • Pain • Photophobia • Redness • Lacrimation • Blurred vision

  8. On Examination On inspection- POSTURE • Hyperextension of neck • Stooped posture • Loss of lumbar lordosis • Flexion at hips and knees On palpation- • Reduced lateral flexion • Reduced forward flexion- • Schober’s test • Reduced chest expansion • Tenderness over sacro-illiac joints

  9. Differential Diagnosis What other conditions would have similar symptoms? • Mechanical back pain • Inflammatory arthritis- RA, psoriatic, reactive • OA • Infection (eg TB) • Neoplasms • Referred pain • Trauma • Congenital spinal deformity

  10. Investigations Bedside tests- ?ECG, urine dip, spirometry Bloods- FBC, ESR/CRP, LFTs, U&Es, RF & ANA Xray- • Sacroilitis– subchondral erosions, sclerosis & narrowing • Squaring of anterior vertebral bodies • BAMBOO SPINE (uncommon & late) CXR- apical fibrosis

  11. Management Conservative- regular exercise, physio, education, back exercises Medical- • Pain relief (NSAIDS) • Methotrexate for peripheral joint arthritis • Systemic steroids for uveitis, local steroids for plantar fasciitis • Anti-TNF (biological agents) for severe disease Surgical- joint replacement, spine osteotomy for severe deformity

  12. Recap- AnkSpond • How would a patient present with ankspond? • What extra-articular features are there? • What is the O/E test called? And what would you find? • Treatment?

  13. Psoriatic Arthritis What is psoriasis? • Psoriatic arthritis affects 30% of patients with psoriasis • In 60% psoriasis precedes the arthritis • In 15% the sx occur simultaneously • In 25% the arthritis appears first

  14. Typical presentations Often intermittent Sx ‘A 45 y/o female presents to her GP with pain, swelling and stiffness in her R knee and L shoulder. She also complains of swollen fingers. She was diagnosed with psoriasis 2 years previously.’ ‘A 35 y/o man presents to his GP with pain and stiffness in his back. He has no history of trauma. On examination the sacro-illiac area is sore to touch & he has psoriatic nail changes (pitting yellowing, transverse ridges or destruction.’ Extra-articular-similar to AnkSpond- achilles tendonitis, plantar fasciitis, conjunctivitis (20-30%), anterior uveitis, aortitis, secondary amyloidosis

  15. Patterns of presentation • Symmetrical polyarthritis ('rheumatoid' pattern). More common in women. Wrists, hands, feet and ankles affected. Distal interphalangealjoints are involved helping to distinguish it from RA (& absence of skin nodules + negative RF) • Asymmetric oligoarticular/pauciarticular arthritis. Hands and feet are affected initially with enthesopathy causing dactylitis('sausage fingers'). Usually up to five joints are involved. • Spondylitic pattern ± sacroiliitis. This is more common in men. There is morning stiffness and limitation of back movement. There may not be much in the way of symptoms, and it may be noted radiologically. • Lone DIP disease. • Arthritis mutilans. This is a relatively rare variation of DIP disease. Mainly in men with early-onset arthritis. • Juvenile onset

  16. On examination • Psoriatic nail changes • Dactylitis(sausage shaped digits) are characteristic of psoriatic arthritis • Psoriatic skin rash- remember to • check the scalp

  17. Differential Diagnosis • Rheumatoid arthritis (RA). • Reactive arthritis (Reiter's syndrome). • Ankylosing spondylitis. • Enteropathicarthropathy. • Gout (particularly foot monoarthritis). • Septic arthritis. • Juvenile chronic arthritis

  18. Investigations • Bedside- • Bloods- FBC, ESR, CRP, RF • Radiology- • Joint erosions & joint space narrowing • Bony proliferation • Spur formation • Spondylitis • Osteolysis (including ‘pencil in cup’ deformity) • Acro-osteolysis

  19. Treatment All patients suspected of having psoriatic arthritis should be assessed by a rheumatologist • NSAIDS • Intra-articular steroids (oral steroids usually avoided due to rebound exacerbation of rash when withdrawn) • 2nd line- DMARDS- if persistent inflammation (leflunomide, sulfasalazine, methotrexate. Avoid hydroxyquinilone as may cause exfoliative dermatitis) • Biologic agents (anti-TNFs) egetanercept, infliximab if at least 2 DMARDS have failed. Stop tx after 3 months if no success Complications- joint destruction, finger destruction, disability, extra-articular complications such as eye disease and, rarely, aortitis Despite clinical improvement with DMARDs, joint damage has been shown radiologically in up to 47% of people with psoriatic arthritis at a median interval of two years

  20. Recap • What are the different presentations of psoriatic arthritis? • What are the features you look for on the hands? • When would you administer a DMARD?

  21. Reactive arthritis An autoimmune condition that develops in response to an infection • Reiter described the triad of- nongonococcalurethritis, conjunctivitis and arthritis. Two subgroups- • Post-venereal- following Chlamydia trachomatis or HIV • Post-enteric- most commonly following salmonella, campylobacter, shigella, yersinia (the plague) 2-4 weeks after (10% do not have preceding symptomatic infection)

  22. Symptoms Onset is often acute- • malaise, fatigue and fever • Asymmetrical, predominately lower extremity, oligoarthritis (<6 joints) • Low back pain (in 50%) • Complete Reiter’s triad may occur Extra-articular- achilles tendonitis & plantar fascitis • Skin- erythema nodosum, circinatebalanitis Nails- dystrophic changes • Mucous membranes- mouth ulcers EYES- uveitis, episcleritis, keratitis • CVS- aortitis, conduction defects

  23. Differential diagnosis • Ankylosing spondylitis and undifferentiated spondyloarthropathy. • Gonococcal arthritis. • Gout. • Inflammatory bowel disease. • Psoriatic arthritis. • Rheumatic fever. • Rheumatoid arthritis. • Septic arthritis.

  24. Investigations Bed side- Urine dipstick, ECG Bloods- FBC (normocytic normochromic anaemia, leukocytosis) ESR/CRP high, RF, ANA, HLA-B27 (+ve in 65-96% of cases) Joint aspiration- high WCC- polymorphonuclear leukocytes (& rules out septic/crystalline arthritis.) Culture of stools, throat & urogenital tract. Chlamydia serology Xrays- normal in early disease. - long term disease= marginal erosions, adjacent bone proliferation

  25. Management ACUTE PHASE- rest affected joints, aspirate synovial effusions • Physiotherapy • NSAIDS • Steroids • Antibiotics to treat identified organism (doesn’t change course of reactive arthritis) • DMARDS- not much evidence. Sulfasalazine beneficial in some. Prognosis- self-limiting with resolution of symptoms by 3-12 months. 15% develop a long-term, sometimes destructive arthritis

  26. Recap Run through an ISCE framework- A gentleman walks in with ‘aches and pains’. What questions will you ask? And examinations? And investigations? Differentials? And Management? • What infections can lead to reactive arthritis? • What is the prognosis?

  27. Enteropathic Arthritis Arthritis that accompanies inflammatory bowel disease. Presentation- an acute, often migratory, oligo-arthritis of the weight bearing joints which follows exacerbations of bowel disease. & Other features associated with bowel disease such as apthous ulceration, uveitis, or erythema nodosum Investigations- raised ESR/CRP, leucocytosis, hypergammaglobulinaemia. Bowel- endoscopy/ barium studies Treatment- treat the underlying bowel disease. NSAIDS and physio to manage arthritis

  28. Juvenile Idiopathic Arthritis 1-2 per 1000 Arthritis occurring in someone <16 y/o lasting >3 months. Morning stiffness and pain Pauciarticular (60%) JIA refers to cases where ≤4 joints are affected. Features of pauciarticularJIA- • joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows • Limp • RA & ANA may be positive - associated with anterior uveitis & rheumatoid nodules Also polyarticular (20%)- large & small joints, symmetrical and systemic onset (fever, rash & arthritis)

  29. JIA Differentials • Infection: septic arthritis, osteomyelitis, tuberculosis, Lyme disease. • Postinfectious, egacute rheumatic fever. • Non-inflamm causes- trauma, slipped epiphysis, osteochondrosis. • Haematological, egleukaemia or haemophilia with recurrent intra-articular bleeds. • Connective tissue disorders- SLE, scleroderma, dermatomyositis. • Malignancy- inc.bone tumours, neuroblastoma. • Ankylosingspondylitis, psoriasis, sarcoidosis, Kawasaki disease. Management- same as RA (NSAIDS, DMARDs, steroids for life threatening complications eg eye involvement)

  30. Complications & Prognosis Complications- osteoporosis, growth restriction, psychosocial Prognosis- • 80% have resolved after 15 years. • 15% go on to develop polyarticular arthritis and severe joint involvement. • Eye involvement is a major problem and 50% will have reduced visual acuity at ten years after presentation and 25% will have developed cataracts or glaucoma. • Polyarticularsero-positive: a more severe course with only 33% independent after 15 years. • About 4% die from infection or amyloidosis.

  31. A few words about DMARDs These include methotrexate, hydroxychloroquine, sulphasalazine, etc. • Methotrexate (1st line for RA)- • Taken once a week • SE- nausea & GI upset, bone marrow supression, alveolitis, hepatotoxicity (Given folic acid to help with these) • Monitor FBC & LFTs weekly for a month then monthly • Teratinogenic (wash out period of 3-6months) • Don’t take trimethoprim Hydroxychloroquine (less SE) Sulphasalazine (daily)- requires FBC & LFT monitoring monthly for 3mths then every 3-6mths

  32. And Biological agents These include anti-TNF agents. For example infliximab, ethercept, adilumimab Licenced for use if failure to respond to a couple of DMARDs. • SE- immunosuppression (no live vaccines), injection site reactions, exacerbation of heart failure, demyelination in MS, not used if hx of Cancer in last 10 yrs, or if preg/breast feeding Should take effect within 2 weeks- withdraw if no response after 3 months

  33. AMK questions A 28-year-old man is diagnosed with having ankylosing spondylitis. He presented with a six month history of back pain. On examination there is reduced lateral flexion of the spine but no evidence of any other complications. Which one of the following is he most likely to offered as first-line treatment? • Exercise regime & NSAIDs • Exercise regime & infliximab • Physiotherapy & sulfasalazine • Physiotherapy & etanercept • Exercise regime & paracetamol

  34. AMK questions Which of the following statements regarding Ankylosing Spondylitis is correct? • Schobers test assesses reduced chest expansion • HLA-B27 is positive in 50% of patients • Achilles tendonitis is a recognised association • It affects men twice as commonly as women • The typical age of presentation is 40-50 years

  35. GALS GAIT- walk a few steps and turn. ARMS- hands-squeeze metacarpals, strength grip, precision grip, prayer sign and reverse, arms over head then up back. LEGS- inspect feet & squeeze metatarsals, flex knee and hip, internal and external rotation of hip. Patellar tap SPINE- inspect (lordosis, kyphosis, scoliosis, muscle bulk, iliac crests, ), ask patient to touch toes & palpate spinus process., & palpate midspinatus. Ear to shoulder. Jaw from side to side.

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