Finals revision 2014: Seronegative arthropathies & Vasculitis

1. Finals revision 2014:Seronegativearthropathies& Vasculitis Dr Emma Hodgkins, FY1, Gastroenterology

2. What we’re cramming into 25 minutes • Psoriatic arthritis • Ankylosing spindylitis • Reactive arthritis • Enteropathic spondyloarthropathy • Extra-articular features • Types of Vasculitis • With a couple of cases….

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

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

5. Psoriatic arthritis • Affects 10% of those with psoriasis • Can precede skin symptoms • Rheumatoid factor negative • 5 patterns • Polyarthritis – RA-like • Spinal – can mimic ankylosing spondylitis • DIP joint only • Oligoarthritis • Psoriatic mutilans – rare, severe deformity

6. PA: Investigations • Bloods : FBC, Inflammatory markers, RhF, HLA-B27 • Xray • Erosions, Periarticular oseoporosis • ‘pencil-in-cup’ deformity (whittling & cupping of phylanges)

7. PA: Management • Conservative: physio, splints • Medical • NSAIDS • DMARDs- Methotrexate, ciclosporin • Anti-TNF drugs • Intra-articular steroids • Surgical – when all else fails – fusion etc

8. Ankylosing Spondylitis • Chronic inflammatory disease of the spine and sacroiliac joints • Young men commonest affected • Symptoms and signs • Gradual onset lower back pain and stiffness • worse at night, relieved by exercise • reduced range of spinal movement • Reduced hip rotation • question mark posture • Schrobers test positive

9. Ankylosing Spondylitis • Investigations (Diagnosis is clinical) • Bloods – exclude other causes – FBC, ESR, CRP, RF • Imaging – pelvic xray, MRI (more sensitive) – erosions and sclerosis • Bamboo or rugger jersey spine is rare now • Management • Conservative – weight loss, exercise!! • Medical – NSAIDs, Steroids, DMARDS, Biologics • Surgical – little beyond hip replacements if involved

10. Reactive arthritis • A sterile arthritisoccuring after an extra-articular infection • Causative infection is usually… • Gastrointestinal (salmonella, shigella, campylobacter) • Urogenital (chlamydia – 60%) • Reiter’s syndrome = arthritis, urethritis & conjunctivitis • May present with • Pain in large joints • low back pain (sacroliliitis) • Painful heels (enthesitis/plantar fasciitis) • Dysuria • Conjuctivitis • Oral ulceration • Keratodermablenorrhagica (10%) macules on soles & palms

11. Reactive arthritis • Invesigations • FBC, ESR, CRP, HLA-B27 (70-80%) • Stool & urine cultures, Urethral swabs • Management • Initially rest, NSAIDs (indomethacin) • Mobilise with 2 weeks course of NSAIDs/sulfasalazine • Treat the underlying infection • Topical antibiotics to prevent secondary infection of conjunctivitis

12. Extra-articular features of inflammatory diseases

13. Enteropathic arthritis • Associated with Crohn’s disease and UC • Which are also associated with… • Primary sclerosing cholangitis • Pyodermagangrenosum • Uveitis • Erythema nodosum • Thyroid disease • Usually an oligoarthritis • Treat with disease modifying treatment for IBD

14. And breath…almost there! Just time for one more case!

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

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

17. Vasculitis • Classified by vessels affected • Large vessel • Giant cell/Temporal arteritis – associated with PMR • Takayasu’s arteritis – rare, hypertension with absent peripheral pulses • Medium vessel • PolyarteritisNodosum – don’t need to know • Kawasaki’s disease – affects children- strawberry tongue • Small vessel • Churg Straus Syndrome – asthma, eosinophilia, systemic vasculitis* • Wegener’s Granulomatosis – Upper & lower resp symptoms, renal impairment* • Microscopic polyangitis – don’t need to know* • HenochSchonleinPurpura – affects children, post URTI

18. General symptoms of any/alll vasculitidies Eyes General symptoms Lungs Joints Heart Skin Kidneys Gi system

19. General symptoms of any/alll vasculitidies Eyes Cotton-wool spots Retinal haemorrhages General symptoms Fever, weight loss, night sweats malaise Lungs Dyspnoea, cough, haemoptysis Joints Arthritis Heart Pericarditis Myocarditis Coronary arteritis Skin Vasculitic/purpuric/maculopapular rash Kidneys Glomerulonephritis Renal failure Gi system Abdominal pain Ulceration Diarrhoea

20. And a few specific ones

21. All done! Think inflammatory Think systemic Think steroids Think DMARDs Think MDT

22. Good luck!