Inflammatory arthropathy with common clinical/radiological features
HLA-B27 positivity:
- Found in 90% of ankylosing spondylitis cases
- 5% of HLA-B27+ individuals develop the disease
- Testing only when clinically indicated
Hallmarks: Inflammatory back pain, enthesitis (tendon/ligament insertion inflammation)
Often affects lower limb, larger joints (e.g., knees, ankles)

Presentation

Inflammatory Back Pain:
- Insidious onset, worse in the morning, improves with activity
- Stiffness >30 minutes
Peripheral Arthritis: Larger joints
Enthesitis: Heel pain (Achilles tendon tenderness)
Spinal Involvement:
- Sacroiliitis: Pain and tenderness in SI joints

Extra-Articular Features

Bloody diarrhoea, abdominal pain (enteropathic arthritis)
Psoriatic rash, nail pitting, keratoderma blennorrhagica (reactive arthritis)
Urethral discharge (reactive arthritis, post-STI)
Uveitis (pain, redness, blurred vision)
Enthesitis
Spondylitis (inflammation of spine) characterised sacroilitis (inflammation SI joints) - lower back pain/stiffness, SI joint tenderness

Investigations

Blood Tests:
- RF/anti-CCP negative (distinguishes from RA)
- ESR/CRP elevated, anaemia of chronic disease
Joint Aspirate: Inflammatory (elevated WCC, neutrophilic predominance)
Imaging:
- X-rays: Sacroiliitis, bamboo spine (ankylosing spondylitis)
- MRI: Early sacroiliitis or spinal inflammation

Management

1. Non-Pharmacological

2. Pharmacological

NSAIDs: First-line in all spondyloarthritides
Corticosteroids:
- Intra-articular: For local joint inflammation
- Oral: 10–50 mg prednisone daily for severe reactive arthritis, taper as symptoms improve
DMARDs: For peripheral joint involvement in psoriatic/enteropathic arthritis (e.g., methotrexate, sulfasalazine)
Biologics: TNF-alpha inhibitors for severe or refractory cases, especially ankylosing spondylitis

Notes

Spondyloarthritides

Types

Pathophysiology

Group of inflammatory arthropathies sharing clinical/radiological features.
HLA-B27 positivity (~90% in AS, but only 5% of HLA-B27 carriers develop disease).
Hallmarks: Inflammatory back pain, enthesitis (inflammation at tendon/ligament insertions).
Commonly affects lower limbs and larger peripheral joints (knees, ankles).

Presentation

Inflammatory Back Pain

Peripheral Arthritis

Enthesitis

Extra-Articular Features

IBD (bloody diarrhoea, abdominal pain) with enteropathic arthritis.
Psoriasis (psoriatic rash, nail pitting) in psoriatic arthritis.
Urethritis and cervicitis with reactive arthritis (post-STI).
Uveitis (eye pain, redness, blurred vision) can occur in all spondyloarthritides.

Investigations

Blood Tests
- RF/anti-CCP typically negative (distinguishes from rheumatoid arthritis).
- ESR/CRP elevated, possible anaemia of chronic disease.
- Joint Aspirate: Inflammatory pattern (raised WCC, mostly neutrophils).
Imaging
- X-ray: Sacroiliitis, “bamboo spine” in ankylosing spondylitis.
- MRI: Early detection of sacroiliitis or spinal inflammation.

Management

1. Non-Pharmacological

Exercise/Physiotherapy: Maintain mobility, stretching, posture training (especially in AS).
Occupational Therapy: Support with adaptive techniques.

2. Pharmacological

NSAIDs

Corticosteroids

Intra-articular injections for local joint flares.
Oral steroids (10–50 mg prednisone daily) for severe reactive arthritis or significant flares; taper as symptoms improve.

DMARDs

For peripheral joint involvement (psoriatic/enteropathic arthritis): Methotrexate, sulfasalazine.
Less effect on spinal disease in ankylosing spondylitis.

Biologics (e.g., TNF-alpha inhibitors)

Notes

Reactive arthritis onset 1–3 weeks post-infection (STI, enteric).
Keratoderma blennorrhagica: Pustular rash on palms/soles (seen in reactive/psoriatic).
Treat underlying infection with antibiotics; arthritis course may be unaffected by antibiotic therapy once the infection is cleared.
HLA-B27 testing useful if clinical suspicion of spondyloarthropathy is high.

Bookmark Failed!

Bookmark Saved!