Seronegative Spondyloarthropathies
Phase II Musculoskeletal Lecture 23/02/2012
Definition
Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically predisposed (HLA B27 positive) individuals
Disease Subgroups
Ankylosing Spondylitis Reactive Arthritis ( Reiter's Syndrome) Enteropathic Arthritis Psoriatic Arthritis Undifferentiated spondyloarthropathy Juvenile spondyloarthropathy
Spondyloarthropathy v RA
Different pattern of articular and extra-articular involvement
Absent serum Rheumatoid factor Strong association with HLA B27
Shared rheumatological featuresof the Spondyloarthropaties
Sacroiliac and spinal involvement Enthesitis: Achilles tendinitis, plantar
fasciitis… Inflammatory arthritis:
Oligoarticular Asymmetric Predominantly lower limb
Dactylitis (“sausage” digits)
Shared Extra-articular Features
Ocular inflammation (Anterior uveitis, conjuntivitis)
Mucocutaneous lesions Rare Aortic incompetence or heart block No rheumatoid nodules
Ankylosing Spondylitis
Definition
Chronic systemic inflammatory disorder that primarily affects the spine.
Hallmark- Sacroiliac joint involvement (sacroiliitis) Peripheral arthritis uncommon (shoulder and hip) Enthesopathy Late adolescence or early adulthood More common in men 3-5:1
Modified New York Criteria for Diagnosis of Ankylosing Spondylitis
1. Limited lumbar motion2. Lower back pain for 3 months- Improved with exercise- Not relieved by rest3. Reduced chest expansion4. Bilateral, Grade 2 to 4, sacroiliitis on X ray 5. Unilateral, Grade 3 to 4, sacroiliitis on X ray• Definite AS if Criterion 4 or 5, plus 1,2 or 3
Clinical features
Back pain (neck, thoracic, lumbar) Enthesitis Peripheral arthritis (shoulders,hips) – rare Extra articular features:
Anterior uveitis Cardiovascular involvement (aortic valve/root ) Pulmonary involvement (fibrosis upper lobes) Asymptomatic enteric mucosal inflammation Neurological involvement (Rarely A-A subluxation) Amyloidosis
“A” Disease
Axial Arthritis Anterior Uveitis Aortic Regurgitation Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis Plantar Fasciitis
Diagnosis
History Examination:
Tragus/occiput to wall Chest expansion Modified Schober test
Bloods Inflammatory parameters (ESR, CRP, PV) HLA B27
X-rays - Sacroiliitis
- Syndesmophytes- “Bamboo” spine
Occiput to wall
Schober Test
Treatment
Home exercises Physiotherapy Occupational therapy NSAID Disease modifying drugs. SZP, MTX Anti TNF treatment – Infliximab (Remicade),
Adalimumab (Humira) Corticosteroids
Psoriatic Arthritis
Definition
Inflammatory arthritis associated with psoriasis
No Rheumatoid nodules Rheumatoid factor negative
Clinical features
Inflammatory Arthritis (5 subgroups) Sacroiliitis:
often asymmetric may be associated with spondylitis
Nail involvement (Pitting, onycholysis) Dactylitis Enthesitis:
Achilles tendinitis Plantar fasciitis
Extra articular features (eye disease)
Clinical subgroups of psoriatic arthritis
1. Confined to distal interphalangeal joints (DIP) hands/feet
2. Symmetric polyarthritis (similar to RA)
3. Ankylosing Spondylitis with or without peripheral joint involvement
4. Asymmetric oligoarthritis with dactylitis
5. Arthritis mutilans
Diagnosis
History Examination Bloods:
Inflammatory parameters (raised) Negative RF
X-rays Marginal erosions and “whiskering” “Pencil in cup” deformity Osteolysis Enthesitis
Treatment
Medical NSAIDs Corticosteroids/joint injections Disease Modifying Drugs (MTX,SZP…) Anti TNF – Etanercept (Enbrel)
Non medical Physiotherapy Occupational Therapy Orthotics, Chiropodist
Reactive Arthritis (Reiter's)
Introduction
Infection induced systemic illness characterized primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured
Symptoms 1-4 weeks after infection Most common infections:
Urogenital. Chlamydia Enterogenic. Salmonella, Shigella, Yersinia
Young adults (20-40) Equal sex distribution HLA B27 + Infection
Reiter’s Syndrome
A form of Reactive Arthritis Triad:
- Urethritis
- Conjuntivitis
- Arthritis
Clinical Features I
General Symptoms (fever, fatigue, malaise) Asymmetrical monoarthritis or oligoarthritis Enthesitis Mucocutaneous lesions
- Keratodema Blenorrhagica
- Circinate balanitis
- Painless oral ulcers
- Hyperkeratotic nails
Clinical Features II
Ocular lesions (unilateral or bilateral)
- Conjuntivitis
- Iritis Visceral manifestations
- Mild Renal disease
- Carditis
Diagnosis
History Examination Bloods:
Inflammatory parameters (ESR,CRP,PV) FBC, U&Es HLA B27 (rarely necessary)
Cultures (blood, urine, stool) Joint fluid analysis (rule out infection) X-ray of affected joints Ophthalmology opinion
Treatment
Medical: NSAIDs Corticosteroids
• Intra articular (once sepsis ruled out)• Oral• Eye drops
Antibiotics DMARDs (SZP) - If resistant/chronic
Non medical Physiotherapy Occupational therapy
Prognosis
Generally good Recurrences not uncommon Some develop a chronic form
Remember (Spondyloarthropathies)
Associated with HLA B27 Affect Spine/Joints Enthesitis Extra articular features
Questions ?