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A group of inflammatory joint diseases called seronegative spondyloarthropathies, which include Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis, and Enteropathic Arthritis. These conditions share clinical features such as a predilection for axial inflammation, asymmetrical peripheral arthritis, absence of rheumatoid factor, inflammation of the enthesis, and a strong association with HLA-B27. information on the clinical features, symptoms, diagnosis, and treatment of each condition.
Typology: Summaries
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435 medicine teamwork [ Important | Notes | Extra | Editing file ]
Done By: Rawan Aldhuwayhi Revised By:Luluh Alzeghayer References: Kumar + step up +master the board +slides
Seronegative Spondyloarthropathies (SPA)
General Characteristic of SPA: What is it:
their clinical features and a shared immunogenetic association with the HLA-B27 antigen, They include:
than that seen in RA and its distribution is different)
****Enthesitis peripheral arthritis (MCQ!!!!)*
the calcaneus.
into the calcaneus
often affects only one to three joints.
very suggestive of SpA, but its absence would not be helpful in excluding this possibility. ENTHESIS: point at which ligaments and tendons (both ▶ NOTE:^ stabilize joints) insert into bone Despite the association with HLA-B27, this is never the “best initial” or “most accurate” test for SPA. since 8% of the general population is positive. What I want u to know r those 3: Ankylosing spondylitis Psoriatic arthritis Reactive arthritis
1 ) 🔰 Best Initial Test is an x-ray of the sacroiliac (SI) joint. 2 ) ESR and CRP are often raised. 3 ) 📍 The Most Accurate Test is an MRI. MRI detects abnormalities years before the x-ray becomes abnormal.MRI shows sacroiliitis before it is seen on plain X-ray. 4 ) HLA-B27 testing is not usually performed.bc it’s not a confirmatory diagnostic test since 8% of the general population is positive.
Patients with early disease can have normal X-rays, and if clinical suspicion is high, MRI should be performed مهم مهم تعرفونه ان: الي لشي ا MRI is very good in early diagnosis ↓ ↓ The EARLIEST radiological appearances in the spine X ray are ( BLURRING) of the upper or lower vertebral rims at the thoracolumbar junction (best seen on a lateral X-ray) ,caused by an enthesitis at the insertion of the intervertebral ligaments ↓ ↓ This heals with new bone formation resulting in bony spurs (SYNDESMOPHYTES) ‘syndesmophytes is a bony growth originating inside a ligament’ ↓ ↓ In advanced disease: Progressive calcification of the interspinous ligaments and syndesmophytes eventually produce the ( BAMBOO SPINE)
irreversible syndesmophyte formation and progressive calcification. With effective treatment most patients are able to lead a normal active life and remain at work.
1 ) FIRST LINE OF TREATMENT: NSAIDs(taken at night are particularly effective in relieving night pain and morning stiffness) 2 ) If NSAID failed give→TNF-α-blockers(are highly effective in active inflammatory disease and improve both spinal and peripheral joint inflammation) 3 ) If anti TNF α failed give→ IL 17 inhibtor (secukinumab) newly approved medication بس ماودي اعلمكم اشياء وتضيع عليكم البيسك MRI appearances in sacroiliitis. in early ankylosing spondylitis. Bone marrow oedema (circles) is present around both sacroiliac joints, which show irregularities due to erosions (arrows) Fine symmetrical marginal syndesmophytes typical of ankylosing spondylitis (arrow). يتمنت هذي اهم جزئية ابغاكم تعرفونهاالئر NSAID is first line of treatment if failedanti TNF α مابيكم تعرفونها انواعها وشي فقري معلومه مره مره مره مهمه ان كل الدراسات اثبتت ان الكورتيكوستئر ويد مالها فايده اذا عطيته بالفم النها ماتوصل للعمود ال *وكمان في ▶ NOTE: Methotrexate & sulfasalazine:helps the peripheral arthritis but NOT SPINAL DISEASE
Psoriatic Arthritis
precede the skin disease.
There are several types:
Asymmetrical involvement of the small joints of the hand, including the distal interphalangeal joints
dystrophy(pitting&onycholysis(تقش االظافر Symmetrical seronegative polyarthritis resembling Rheumatoid Arthritis Arthritis mutilans a severe form with destruction of the small bones in the hands and feet (’telescopic’ fingers) هي تك هاند الي اي روماتويد هاند والسور بير اسهل طريقه تفرقير DIP not involved in RA Sacroiliitis unilateral or bilateral.
1 ) 🔰 Best Initial Test is an x-ray of the joint showing a ‘pencil in cup’ deformity in the IPJs (bone erosions creates a pointed appearance and the articulating bone is concave). 2 ) Routine blood tests are unhelpful in the diagnosis. The E SR is often normal. ‘pencil in cup’ deformity
‘Sausage’ middle finger of a patient with psoriatic arthritis ▶ some notes regarding dectylitis: o Dectorylitis also can be found in reactive arthritis(Occasionally) o unlike synovitis, in which swelling is confined to the joints, with dactylitis:the entire digit is swollen. o dactylitis is not specific for spa and may also be seen:(tuberculosis ,syphilis,sarcoidosis,sickle cell disease,tophaceous gout) Typical distal interphalangeal joint pattern with accompanying nail dystrophy (pitting & onycholysis). Oncycholysis:is separation of a fingernail from its nail bed The Clinical features of psoriatic arthritic is almost similar to AS BUT the hand involvement is more aggressive , ممم ظهر اول اذا التحدب بالظهر طلع قبل الصدفيه فهذا الي طيب كيف نفرق بينهم بالتشخيص!! شوف مير نمممممنني ني ن اما اذا التغئر ات بالجلد والصدفيه طلعت قبل تحدب واالم الظهر فهذا, AS Psoriatic arthritis
Enteropathic Arthritis
patients with ulcerative colitis or Crohn’s disease.
symptoms improve.
occasionally required. Summary Seronegative Spondyloarthropathies This title describes a group of conditions that share certain clinical features:
Ankylosing spondylitis Psoriatic Arthritis Reactive arthritis Enteric Arthritis S & S The cardinal feature is low back pain and early morning stiffness with radiation to the buttocks or posterior thighs. Symptoms are exacerbated by inactivity and relieved by movement. Characteristic findings are: Dactylitis(Sausage digits)&Nail dystrophy
presents with an acute arthritis shortly (within 4 weeks) after an enteric or sexually acquired infection, which may have been mild or asymptomatic. The joints of the LOWER LIMBS are particularly affected in an ASYMMETRICAL pattern; the knees, ankles and feet are the most common sites.
(urethritis, Asymmetrical reactive arthritis and conjunctivitis).*but most patients do not have the classic findings of Reiter’s syndrome Enteropathic arthritis is a large- joint mono- or Asymmetrical oligoarthritis occurring in 10–15% of patients with ulcerative colitis or Crohn’s disease. D X 🔰 Best Initial Test is an x-ray of the sacroiliac joint. 📍 The Most Accurate Test is an MRI 🔰 Best Initial Test is an x-ray of the joint showing a ‘pencil in cup’
IS CLINICAL.
out infection or crystals) →Aspirated synovial fluid is sterile, with a high neutrophil count. 🔰 Best Initial Test is an x-ray Despite the association with HLA-B27, this is never the “best initial” or “most accurate” test for SPA. R x 🔰 First line NSAIDs injectons:reliving pain *TNF-α-blockers:are highly effective in active inflammatory disease and improve both spinal and peripheral joint inflammation *Methotrexate& Corticosteroid:helps the peripheral arthritis but not spinal disease. ▶ NOTE: Patients with inflammatory bowel disease may also develop sacroiliitis (16%) and AS (6%), which are clinically and radiologically identical to classic AS. These can predate or follow the onset of bowel disease and there is no correlation between activity of the Ankylosing spondylitis and bowel disease IBD. أخذناه بالتئر م االو ل مع ال تذكروا نفس الي
Ankylosing spondylitis back pain vs Mechanical back pain (IMPORTANT IN YOUR CAREER) Features Inflammatory back pain Mechanical back pain Morning stiffness Prolonged more than 1 hour Less than 45 min Max pain\stiffness Early morning Late day Activity Improve symptoms Worsens symptoms Duration Chronic Acute or chronic Age of onset 9 - 40 yrs 20 - 65 yrs Radiographs Sacroiliitis,vertebral ankylosis,syndesmophytes Osteeophytes(bony projection associated with cartilage degeneration) malalignment(displacement) MCQs Taken from 500 Single Best Answers in MEDICINE 1)A 30-year-old man presents to his GP with a 1-week history of painful, swollen knees and a painful right heel. Further history reveals that he has been experiencing burning pains while urinating for the past 2 weeks and that his eyes have become red and itchy. What is the most likely diagnosis? A. Septic arthritis B. Gout C. Ankylosing spondylitis D. Enteropathic arthritis E. Reactive arthritis 2)A 23-year-old man presents to the rheumatology clinic with lower back and hip pain. These have been occurring every day for the past two months. Pain and stiffness are worse in the mornings. He also mentions that his right heel has been hurting. He is previously fit and well, but had occasions of lower back pain when he was a teenager. His symptoms have stopped him from playing tennis. Recent blood tests organized by his GP have shown a raised C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). What is the most appropriate treatment? A. NSAID and spinal exercises B. NSAID and bed rest C. Oral prednisolone D. Methotrexate plus sulfasalazine E. Bed rest 3)A 20-year-old man presents to accident and emergency with sudden onset pain in the right eye, with associated blurred vision and discomfort when gazing at the lights. He has a history of back pain and has recently been diagnosed with ankylosing spondylosis. What is the most likely cause of his eye pain? الدكتور قال يمكن يجيكم سؤال كذا A. Conjunctivitis B. Retinal detachment C. Anterior uveitis D. Corneal ulceration E. Acute glaucoma 4)A 45-year-old woman presents to the rheumatology outpatient clinic with a three month history of stiff hands and wrists. She mentions that the pain is particularly bad first thing in the morning. On examination, the wrists, metacarpophalangeal joints and proximal interphalyngeal joints are swollen and warm. A diagnosis of rheumatoid arthritis is suspected. Which of the following investigations is most specific for confirming the diagnosis? ستايلهم باألسئلة;) A. X-rays B. Rheumatoid factor levels C. Anti-citrullinated peptide antibody (anti-CCP) levels D. C-reactive protein E. Erythrocyte sedimentation rate
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