General features

  • -ve for Rheumatoid Factor
  • Genetic predispostion
  • Initiated by environmental factors
    • eg. infectious trigger
  • Manifestations are
    • immune mediated T cell response

Spondyloarthropaties

  • Definition
    • A group of inflammatory arthropathies that share distinctive clinical, radiological and genetic features
  • The 4 main diseases
    1. Ankylosing Spondylitis
    2. Reiter’s disease (reactive arthritis)
    3. Psoriatic arthritis
    4. Enteropathic arthritis
      • Crohn’s disease
      • Ulcerative colitis
      • Whipple’s disease
  • Diagnosis
    • History
    • physical examination
  • Key features
    • Inflammation of the axial joints
      • sacroiliitis
      • spondylitis
    • Peripheral arthritis
    • Enthesitis
      • inflammation at tendinous or ligamentous attachment
      • Inflammation of the insertion points (entheses) of ligaments, tendons, fascia and fibrous joint capsule
        • leading to fibrosis & ossification of the insertions
        • Rheumatoid Arthritis attacks the synovial membrane
    • HLA-B27 +ve
  • Common link
    • HLA B-27 +ve
    • Basic pathology is enthesitis

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1) Ankylosing spondylitis

  • General
    • Chronic inflammation of the axial joints
      • Sacroiliac joints ascending to cervical spine
    • Starts in the 2nd/3rd decade
    • Insidious/gradual onset
    • Men:women, 5:1
    • 90% are HLA-B27 +ve
  • Classical triad of symptoms
    • inflammatory low back pain
    • immobility
    • morning stiffness
  • Typical presentation
    • young man with
      • low back pain
      • immobility
      • morning stiffness
  • Extraspinal manifestation
    • enthesitis
      • high impact areas
      • around hips, ankle
    • uveitis
      • blurry vision
      • painful red eye
      • excessive lacrimation
        • watery eye
    • peripheral arthritis
  • Complications
    • spinal fusion
      • bamboo spine
    • aortic valve insufficiency
  • Investigation
    • AP Xray
      • bamboo spine
      • sacroiliac joint fusion (pelvis)

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image Bamboo Spine

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2) Reactive arthritis

  • Classic triad
    • arthritis
    • uretritis/vaginitis
    • conjunctivitis
  • Typically an acute arthritis 1-3 weeks after an infective event
    • Urogenital
      • Chlamydia
      • Ureaplasma urealyticum
    • Gastrointestinal/Enteric
      • shigella
      • salmonella typhimurium
      • campylobacter
    • idiopathic
  • Molecular mimicry
    • Unexpected sharing of limited aminoacid sequence
      • between bacterial antigen and self protein
    • Common aminoacid sequence between HLA-B27 molecule and
      • Klebsiella nitrogenase protein
      • arthrogenic Shigella plasmid peptides
  • HIV & Reactive arthritis
    • HLA-B27+ HIV+ patients
      • have a more severe form of reactive arthritis
    • The incidence is decreased by the use of antivirals
    • Not associated with Ankylosing Spondylitis/uveitis
  • Features
    • Arthritis usually
      • asymmetrical
      • oligoarticular
        • few joints involved
    • Circinate balanitis
      • in male patients
      • A form of skin inflammation around the penis
      • The skin around the shaft and tip (glans) penis can become inflamed and scale
    • Self-limiting course
      • less than 6 months
      • Can be chronic and intermittent
    • Decreasing incidence due to increase use of condoms
  • Complications
    • Acute anterior uveitis
      • inflammation of middle layer of the eye
    • Carditis
    • Bony proliferation

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3) Psoriatic Arthritis

  • General
    • Chronic inflammatory arthropathy & psoriasis
      • occurs together
    • Occurs in 5 – 10% of patients with psoriasis
    • Typically distal interphalangeal joint involvement
      • pencil in cup deformity
    • Nail changes are prominent
      • pitting
      • discolouration
      • dystrophy
      • onycholysis
    • Course
      • a chronic destructive arthritis in 30% of patients

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4) Enteropathic arthritis

  • General
    • 5% – 20% of patients with chronic inflammatory bowel disease
    • Risk increases with
      • extent of colonic involvement
      • presence of other extra-intestinal manifestations
  • Peripheral arthritis parallels disease in gut
    • but not the spinal disease
  • Gut disease may be asymptomatic especially ileatis
    • an inflammation of the ileum

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Lyme disease

  • Only chronic inflammatory arthritis with a known aetiology
    • Borrelia burgdorferi
  • Can be cured

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