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CC13 - Sponyloarthropathies
Spondyloarthropathies relating to Rheum and Ortho
121
Medical
Undergraduate 1
05/25/2015
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Term
Name 5 spondyloarthropathies.
 Definition
Ankylosing Spondylitis
Psoriatic Arthritis
Reactive Arthritis
Enteropathic Arthritis
Undifferentiated Spondyloarthropathy.
Term
What percentage of those with AS are HLA B27 positive?
 Definition
92%
Term
What percentage of those with psoriatic arthritis are HLA B27 positive?
 Definition
60%
Term
What percentage of those with reactive arthritis are HLA B27 positive?
 Definition
60-80%
Term
What percentage of those with enteropathic arthritis are HLA B27 positive?
 Definition
60%
Term
What percentage of those with undifferentiated spondyloarthropathy are HLA B27 positive?
 Definition
25%
Term
What are SPA characterised by?
 Definition
SPA are characterised by enthesitis, as well as synovitis and occur in patients who are seronegative for RF.
Term
What are all types of SPA genetically associated with?
 Definition
HLA B27
Term
What is the aetiology of SPA?
 Definition
Unknown, infection is thought to be important.
Term
What is IBD?
 Definition
Inflammatory bowel disease.
Term
In SPA, where is the site of the inflammation?
 Definition
The entheses.
Term
In SPA, what follows the initial inflammation and errosions?
 Definition
Fibrosis and Ossification.
Term
In SPA, what can fibrosis and ossification lead to?
 Definition
Ankylosis of the joints.
Term
In AS, where do the outer fibres of the vertebral disks become inflamed?
 Definition
Where they attach to the corners of the vertebral bodies.
Term
What does squaring of the vertebrae occur from?
 Definition
Loss of the anterior contour of the vertebra, resulting from a cycle of destructive osteitis and repair.
Term
What leads to the formation of syndesmorphytes?
 Definition
ossification.
Term
What joints pelvic joints are commonly affected and may become fused in SPA?
 Definition
The sacroilliac joints.
Term
Is synovitis a feature of SPA?
 Definition
Yes,
Term
Are peripheral joints more likely to be affected in enteropathic arthritis and AS, or Psoriatic and reactive arthritis?
 Definition
Psoriatic and reactive arthritis.
Term
What is the prevalence of AS amongst caucasians?
 Definition
0.5-1%
Term
Which gender is more affected by AS?
 Definition
Men
Term
How many times more likely are men to develop AS than women?
 Definition
3x
Term
When does AS most commonly appear?
 Definition
Teenage and early adulthood.
Term
Roughly when is the peak age of onset of AS?
 Definition
Mid 20's
Term
Is presentation of AS over the age of 45 common?
 Definition
No.
Term
What are most symptoms of AS due to?
 Definition
Spinal and sacroilliac disease.
Term
When are symptoms of AS worse?
 Definition
In the mornings and after long periods of rest.
Term
What in AS may involvement of the thoracic spine and enthesitis at the costochondral junctions cause?
 Definition
Chest Pain
Term
In AS, what can disease of the costo-vertebral joints cause?
 Definition
Reduced chest expansion and restricted breathing.
Term
Give four criteria of inflammatory back pain. How many must you meet to be diagnosed?
 Definition
Morning stiffness for at least 30 minutes
Pain that improves with exercise, but not rest
Back pain that awakens the patient during the second half of the night.
Alternating buttock pain.
They must have at least 2.
Term
What often is noticable on examination of the sacroilliac joints in AS?
 Definition
They are tender and pain can be reproduced by applying physical stress to the joint.
Term
What happens to the mobility of the lumbar spine in AS?
 Definition
It is reduced.
Term
What test is used to assess forward flexion of the lumbar spine?
 Definition
The schrober test.
Term
What happens to the normal lumbar lordosis in AS?
 Definition
It is lost.
Term
What happens to the thoracic and cervical spines in AS?
 Definition
They become increasingly kyphotic.
Term
What are the four extraskeletal features of AS?
 Definition
Acute anterior uveitis (iritis)
Aortic Incompetance/ascending aortitis
Aplical lung fibrosis
Amyloidosis
Term
What happens in acute anterior uveitis?
 Definition
The eye becomes red and painful and the vision becomes blurred. Blindness develops if untreated.
Term
What is the normal treatment for iritis?
 Definition
Steroid eye drops.
Term
Who urgeantly needs to assess a patient with iritis?
 Definition
An ophthalmologist.
Term
In AS, what might a FBC reveal?
 Definition
Anaemia of chronic disease.
Term
What will often be raised during acute phases of AS?
 Definition
CRP and ESR
Term
What will serological tests for RF be in AS?
 Definition
Negative.
Term
What is the imaging of choice in AS?
 Definition
MRI
Term
What is the role of X-rays in AS?
 Definition
Assessing established disease where substantial mechanical change has occured.
Term
What might show up on x-rays of AS?
 Definition
Squaring of the vertebrae and formation of syndesmophytes.
Term
What appearance does squaring of the vertebrae and formation of syndesmophytes produce on x-ray?
 Definition
Bamboo spine.
Term
What is the aim of physiotherapy in AS?
 Definition
Maintaining normal posture and physical activity.
Term
What is the main initial therapy for AS?
 Definition
NSAIDs
Term
How good is the efficacy for TNF-alpha inhibitors in AS?
 Definition
Very good.
Term
Give three predictors of good response to TNF-alpha inhibitors by AS.
 Definition
Young
Elevated CRP
Shorter disease duration.
Term
Give four criteria of inflammatory back pain. How many must you meet to be diagnosed?
 Definition
Morning stiffness for at least 30 minutes
Pain that improves with exercise, but not rest
Back pain that awakens the patient during the second half of the night.
Alternating buttock pain.
They must have at least 2.
Term
What often is noticable on examination of the sacroilliac joints in AS?
 Definition
They are tender and pain can be reproduced by applying physical stress to the joint.
Term
What happens to the mobility of the lumbar spine in AS?
 Definition
It is reduced.
Term
What test is used to assess forward flexion of the lumbar spine?
 Definition
The schrober test.
Term
What happens to the normal lumbar lordosis in AS?
 Definition
It is lost.
Term
What happens to the thoracic and cervical spines in AS?
 Definition
They become increasingly kyphotic.
Term
What are the four extraskeletal features of AS?
 Definition
Acute anterior uveitis (iritis)
Aortic Incompetance/ascending aortitis
Aplical lung fibrosis
Amyloidosis
Term
What happens in acute anterior uveitis?
 Definition
The eye becomes red and painful and the vision becomes blurred. Blindness develops if untreated.
Term
What is the normal treatment for iritis?
 Definition
Steroid eye drops.
Term
Who urgeantly needs to assess a patient with iritis?
 Definition
An ophthalmologist.
Term
In AS, what might a FBC reveal?
 Definition
Anaemia of chronic disease.
Term
What will often be raised during acute phases of AS?
 Definition
CRP and ESR
Term
What will serological tests for RF be in AS?
 Definition
Negative.
Term
What is the imaging of choice in AS?
 Definition
MRI
Term
What is the role of X-rays in AS?
 Definition
Assessing established disease where substantial mechanical change has occured.
Term
What might show up on x-rays of AS?
 Definition
Squaring of the vertebrae and formation of syndesmophytes.
Term
What appearance does squaring of the vertebrae and formation of syndesmophytes produce on x-ray?
 Definition
Bamboo spine.
Term
What is the aim of physiotherapy in AS?
 Definition
Maintaining normal posture and physical activity.
Term
What is the main initial therapy for AS?
 Definition
NSAIDs
Term
How good is the efficacy for TNF-alpha inhibitors in AS?
 Definition
Very good.
Term
Give three predictors of good response to TNF-alpha inhibitors by AS.
 Definition
Young
Elevated CRP
Shorter disease duration.
Term
What percentage of the population has psoriasis?
 Definition
1-3%
Term
WHat percentage of those with psoriasis have psoriatic arthritis?
 Definition
10%
Term
What are psoriasis patients with nail involvement more likely to have?
 Definition
Psoriatic arthritis.
Term
Which gender is affected most by psoriatic arthritis?
 Definition
Neither, they affect the genders equally.
Term
Does the severity of psoriatic arthritis correlate with the severity of skin lesions in psoriatic arthritis?
 Definition
No.
Term
Can you get psoriatic arthritis before psoriasis?
 Definition
Yes.
Term
What are the following patterns of joint disease indicative of?
Distal arthritis involving the DIP joints
Asymmetrical oligoarthritis
Symmetrical polyarthritis indistinguishable from RA
Spondylitis
Arthritis Mutilans.
 Definition
Psoriatic Arthritis
Term
Give 5 patterns of joint disease found in psoriatic arthritis.
 Definition
Distal arthritis involving the DIP joints
Asymmetrical oligoarthritis
Symmetrical polyarthritis indistinguishable from RA
Spondylitis
Arthritis Mutilans.
Term
In psoriatic arthritis, what might be associated with involvement with the DIP joints?
 Definition
Nail pitting or onycholysis.
Term
In psoriatic arthritis, what might be associated with nail pitting or onycholysis?
 Definition
Involvement of the DIP joints.
Term
In psoriatic arthritis, is arthritis mutilans common?
 Definition
No.
Term
In psoriatic arthritis, what causes telescoping of the digits?
 Definition
Resorption of bone at the metacarpals and phalanges.
Term
In psoriatic arthritis, what does resorption of bone at the metacarpals and phalanges cause?
 Definition
Telescoping of the digits.
Term
Give three areas that should be checked for psoriasis in a patient with no diagnosis of psoriasis, but who has psoriatic arthritis.
 Definition
Scalp, navel, natal cleft.
Term
What tends to produce milder symptoms, AS or psoriatic spondylitis?
 Definition
Psoriatic spondylitis.
Term
Is RF normally present in psoriatic arthritis?
 Definition
No.
Term
Are the radiological changes in psoriatic arthritis symmetrical?
 Definition
No.
Term
Give 7 radiological changes in psoriatic arthritis.
 Definition
Erosions with proliferation of adjacent bone.
Resorption of the terminal phalanges
Pencil in cup deformities.
Periostitis.
Ankylosis
New bone formation at entheses
Sacroiliitis, usually asymetrical.
Term
Give 4 treatments of peripheral joint disease in psoriatic arthritis.
 Definition
NSAIDS, methotrexate, leflunomide,sulfasalazine.
Term
How is axial disease in psoriatic arthritis treated?
 Definition
With physiotherapy, NSAIDs and biologic therapy.
Term
What is the prognosis for those with psoriatic arthritis, usually?
 Definition
Good.
Term
What is septic arthritis?
 Definition
An aseptic arthritis that develops after an anatomically distinct infection.
Term
What age group does reactive arthritis normally develop in?
 Definition
Young adults.
Term
Give two locations where the triggering infection for reactive arthritis is usually found.
 Definition
The gastrointestinal an genitourinary tracts.
Term
When do the symptoms of reactive arthritis start, relative to the infection?
 Definition
a few days to a few weeks after the infection.
Term
What is the normal pattern of reactive arthritis?
 Definition
Asymmetrical and oligoarticular.
Term
What three groups of joints does reactive arthritis tend to affect?
 Definition
Large weight bearing joints, fingers and toes.
Term
What region of the pelvis do some patients with reactive arthritis sometimes experience pain?
 Definition
The sacroilic region.
Term
Describe the conjunctivitis sometimes found in reactive arthritis.
 Definition
Sterile, and can be unilateral or bilateral.
Term
What does Reiter's syndrome describe?
 Definition
The triad of arthritis, urethritis and conjunctivitis in a patient following a bacterial infection.
Term
Describe the urethritis sometimes found in reactive arthritis.
 Definition
Sterile inflammation of the urogenital tracts, potentially causing symptoms of frequency, dysuria and sometimes urethral discharge.
Term
Can prostatitis or cervicitis occur in the urethritis of Reiter's syndrome?
 Definition
Yes
Term
Describe the prognosis of reactive arthritis.
 Definition
Symptoms can vary in severity, lasting weeks or months, but the vast majority are self limiting. At least 60% have a relapse at least once, and permenant joint damage can occur, if rarely.
Term
What can serological tests be used for in reactive arthritis?
 Definition
Identification of the organism responsible for the infection.
Term
In any reactive arthritis, what must be done to the synovial fluid?
 Definition
It must be sampled, examined, and sent for a gram stain and culture.
Term
In reactive arthritis, how must you exclude GI and GU infection?
 Definition
A cervical/penile swab, midstream urine, and stool sample should all be obtained for bacterial culture.
Term
Initially, what are the radiological signs of reactive arthritis?
 Definition
There are usually none.
Term
What might be seen on the calcaneous, digits or pelvis late on in reactive arthritis in an x-ray?
 Definition
Fluffy periostitis.
Term
Where might you see fluffy periostitis late on in reactive arthritis in an x-ray?
 Definition
The calcaneous, digits or pelvis.
Term
Give three common aspects of treatment for reactive arthritis.
 Definition
Treat the underlying infection with antibiotics.
NSAIDs
Corticosteroid joint injections.
Term
Can DMARDs be used in reactive arthritis?
 Definition
Yes, but rarely.
Term
What is enteropathic arthritis?
 Definition
Arthritis occuring in association with IBD.
Term
What is the term for arthritis occuring in association with IBD?
 Definition
Enteropathic arthritis.
Term
What percentage of patients with Crohn disease or ulcerative colitis have enteropathic arthritis?
 Definition
10-20%
Term
Give the four key patterns of enteropathic arthritis.
 Definition
Peripheral arthritis
Spondylitis
Sacroilitis
Enthesopathy.
Term
What is the severity of the peripheral arthritis in enteropathic arthritis associated with?
 Definition
The severity of the bowel disease.
Term
Give three locations you might find inflammation in enteropathic arthritis.
 Definition
The entheses
The peripheral joints
The axis.
Term
What will show up on most x-rays in enteropathic arthritis?
 Definition
Nothing, they will be normal.
Term
What do NSAIDS often do in IBD?
 Definition
Aggravate it.
Term
Is anti-tnf therapy licensed for IBD?
 Definition
Yes.
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