Finals revision 2014:Seronegative arthropathies& Vasculitis

Dr Emma Hodgkins,

FY1, Gastroenterology

What we’re cramming into 25 minutes

0Psoriatic arthritis0Ankylosing spindylitis0Reactive arthritis0Enteropathic spondyloarthropathy0Extra-articular features0Types of Vasculitis0With a couple of cases….

0 Case scenario: A 45 year old man comes to see you because of increasing pain in the small joints of his hands. They have been troubling him for the last few months but have gotten worse over the last few weeks. They are painful and stiff first thing in the morning, more on the right than the left. They get better after an hour and moving them. The joint occasionally swell and it is disrupting his morning routine and making him late for work. He works as a builder. He suffers from Psoriasis which is well managed with coal tar. He does not smoke and drinks socially. On exam he has obvious scaling of his elbows and behind his ears. He has pitting of his nail beds and he has tender, swollen MCPs and PIP joint, worse on the right than the left. He has good function in both hand and can do buttons and write his name.

0 What are your differentials for this man?0 How will you investigate him?0 What are the different patterns of psoriatic arthropathy?0 How would you manage this gentleman? 0 What are the extra articular features of ankylosing spondylitis?0 What the different types of seronegative arthropathies?

0 Case scenario: A 45 year old man comes to see you because of increasing pain in the small joints of his hands. They have been troubling him for the last few months but have gotten worse over the last few weeks. They are painful and stiff first thing in the morning, more on the right than the left. They get better after an hour and moving them. The joint occasionally swell and it is disrupting his morning routine and making him late for work. He works as a builder. He suffers from Psoriasis which is well managed with coal tar. He does not smoke and drinks socially. On exam he has obvious scaling of his elbows and behind his ears. He has pitting of his nail beds and he has tender, swollen MCPs and PIP joint, worse on the right than the left. He has good function in both hand and can do buttons and write his name.

0 What are your differentials for this man?0 How will you investigate him?0 What are the different patterns of psoriatic arthropathy?0 How would you manage this gentleman? 0 What are the extra articular features of ankylosing spondylitis?0 What the different types of seronegative arthropathies?

Psoriatic arthritis0Affects 10% of those with psoriasis0Can precede skin symptoms0Rheumatoid factor negative05 patterns

0 Polyarthritis – RA-like0 Spinal – can mimic ankylosing spondylitis0 DIP joint only0 Oligoarthritis0 Psoriatic mutilans – rare, severe deformity

PA: Investigations0Bloods : FBC, Inflammatory markers, RhF, HLA-B270Xray

0 Erosions, Periarticular oseoporosis0 ‘pencil-in-cup’ deformity (whittling & cupping of phylanges)

PA: Management0Conservative: physio, splints0Medical

0 NSAIDS0 DMARDs- Methotrexate, ciclosporin0 Anti-TNF drugs

0 Intra-articular steroids0 Surgical – when all else fails – fusion etc

Ankylosing Spondylitis0 Chronic inflammatory disease of the spine

and sacroiliac joints0Young men commonest affected

0 Symptoms and signs0 Gradual onset lower back pain and stiffness 0 worse at night, relieved by exercise0 reduced range of spinal movement0 Reduced hip rotation0 question mark posture0 Schrobers test positive

Ankylosing Spondylitis0 Investigations (Diagnosis is clinical)

0 Bloods – exclude other causes – FBC, ESR, CRP, RF0 Imaging – pelvic xray, MRI (more sensitive) –

erosions and sclerosis0 Bamboo or rugger jersey spine is rare now

0Management0 Conservative – weight loss, exercise!! 0 Medical – NSAIDs, Steroids, DMARDS, Biologics0 Surgical – little beyond hip replacements if involved

Reactive arthritis0 A sterile arthritis occuring after an extra-articular infection0 Causative infection is usually…

0 Gastrointestinal (salmonella, shigella, campylobacter)0 Urogenital (chlamydia – 60%)

0 Reiter’s syndrome = arthritis, urethritis & conjunctivitis0 May present with

0 Pain in large joints0 low back pain (sacroliliitis)0 Painful heels (enthesitis/plantar fasciitis)0 Dysuria0 Conjuctivitis0 Oral ulceration0 Keratoderma blenorrhagica (10%) macules on soles & palms

Reactive arthritis0 Invesigations

0 FBC, ESR, CRP, HLA-B27 (70-80%) 0 Stool & urine cultures, Urethral swabs

0Management0 Initially rest, NSAIDs (indomethacin)0 Mobilise with 2 weeks course of NSAIDs/sulfasalazine0 Treat the underlying infection0 Topical antibiotics to prevent secondary infection of

conjunctivitis

Extra-articular features of inflammatory diseases

Enteropathic arthritis0Associated with Crohn’s disease and UC

0Which are also associated with…0 Primary sclerosing cholangitis0 Pyoderma gangrenosum0 Uveitis0 Erythema nodosum0 Thyroid disease

0Usually an oligoarthritis0Treat with disease modifying treatment for IBD

And breath…almost there!

Just time for one more case!

0 A 45 year old man comes to see you with a stuffy nose for the last 5 months. He is troubled by recurrent sinusitis and runny nose. He also feels his nose has changed shape, as if it has “caved in”. He has felt generally unwell with aches and tiredness for the last 3 months. The reason he has come today is that he coughed up blood yesterday and is worried it means he has cancer. On examination his temp is 37.3. He has mild conjunctival pallor and a saddle shaped deformity of his nose. Systemic examination is otherwise unremarkable. You send off some routine bloods and his urea come back at 17 and his creatinine at 350.

0 What are your main differentials for this man?0 How will you investigate him?0 How will you manage him?0 What is the classification for vasculitis? Give examples of each group0 What are the ANCA positive vasculitides?

0 A 45 year old man comes to see you with a stuffy nose for the last 5 months. He is troubled by recurrent sinusitis and runny nose. He also feels his nose has changed shape, as if it has “caved in”. He has felt generally unwell with aches and tiredness for the last 3 months. The reason he has come today is that he coughed up blood yesterday and is worried it means he has cancer. On examination his temp is 37.3. He has mild conjunctival pallor and a saddle shaped deformity of his nose. Systemic examination is otherwise unremarkable. You send off some routine bloods and his urea come back at 17 and his creatinine at 350.

0 What are your main differentials for this man?0 How will you investigate him?0 How will you manage him?0 What is the classification for vasculitis? Give examples of each group0 What are the ANCA positive vasculitides?

Vasculitis0 Classified by vessels affected0 Large vessel

0 Giant cell/Temporal arteritis – associated with PMR0 Takayasu’s arteritis – rare, hypertension with absent peripheral pulses

0 Medium vessel0 Polyarteritis Nodosum – don’t need to know0 Kawasaki’s disease – affects children- strawberry tongue

0 Small vessel0 Churg Straus Syndrome – asthma, eosinophilia, systemic vasculitis*0 Wegener’s Granulomatosis – Upper & lower resp symptoms, renal

impairment*0 Microscopic polyangitis – don’t need to know*0 Henoch Schonlein Purpura – affects children, post URTI

General symptoms of any/alll vasculitidiesGeneral symptoms

KidneysGi system

JointsLungs

Heart

Eyes

Skin

General symptoms of any/alll vasculitidiesGeneral symptomsFever, weight loss, night sweatsmalaise

KidneysGlomerulonephritisRenal failure

Gi systemAbdominal painUlcerationDiarrhoea

JointsArthritis

LungsDyspnoea, cough,haemoptysis

HeartPericarditisMyocarditisCoronary arteritis

EyesCotton-wool spotsRetinal haemorrhages

SkinVasculitic/purpuric/maculopapular rash

And a few specific ones

All done!

Think inflammatoryThink systemicThink steroidsThink DMARDsThink MDT

Good luck!