Seronegative Spondyloarthropathies

1. Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012

2. Definition • Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically predisposed (HLA B27 positive) individuals

3. Disease Subgroups • Ankylosing Spondylitis • Reactive Arthritis ( Reiter's Syndrome) • Enteropathic Arthritis • Psoriatic Arthritis • Undifferentiated spondyloarthropathy • Juvenile spondyloarthropathy

4. Spondyloarthropathy v RA • Different pattern of articular and extra-articular involvement • Absent serum Rheumatoid factor • Strong association with HLA B27

5. Shared rheumatological featuresof the Spondyloarthropaties • Sacroiliac and spinal involvement • Enthesitis: Achilles tendinitis, plantar fasciitis… • Inflammatory arthritis: • Oligoarticular • Asymmetric • Predominantly lower limb • Dactylitis (“sausage” digits)

8. Shared Extra-articularFeatures • Ocular inflammation (Anterior uveitis, conjuntivitis) • Mucocutaneous lesions • Rare Aortic incompetence or heart block • No rheumatoid nodules

11. Ankylosing Spondylitis

12. 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

13. Modified New York Criteria for Diagnosis of Ankylosing Spondylitis 1. Limited lumbar motion 2. Lower back pain for 3 months • Improved with exercise • Not relieved by rest 3. Reduced chest expansion 4. 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

14. 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

15. “A” Disease • Axial Arthritis • Anterior Uveitis • Aortic Regurgitation • Apical fibrosis • Amyloidosis/ Ig A Nephropathy • Achilles tendinitis • Plantar Fasciitis

18. 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

19. Occiput to wall

20. Schober Test

25. Treatment • Home exercises • Physiotherapy • Occupational therapy • NSAID • Disease modifying drugs. SZP, MTX • Anti TNF treatment – Infliximab (Remicade), Adalimumab (Humira) • Corticosteroids

26. Psoriatic Arthritis

27. Definition • Inflammatory arthritis associated with psoriasis • No Rheumatoid nodules • Rheumatoid factor negative

28. 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)

31. Clinical subgroups of psoriatic arthritis • Confined to distal interphalangeal joints (DIP) hands/feet • Symmetric polyarthritis (similar to RA) • Ankylosing Spondylitis with or without peripheral joint involvement • Asymmetric oligoarthritis with dactylitis • Arthritis mutilans

34. Diagnosis • History • Examination • Bloods: • Inflammatory parameters (raised) • Negative RF • X-rays • Marginal erosions and “whiskering” • “Pencil in cup” deformity • Osteolysis • Enthesitis

37. Treatment • Medical • NSAIDs • Corticosteroids/joint injections • Disease Modifying Drugs (MTX,SZP…) • Anti TNF – Etanercept (Enbrel) • Non medical • Physiotherapy • Occupational Therapy • Orthotics, Chiropodist

38. Reactive Arthritis (Reiter's)

39. 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

40. Reiter’s Syndrome • A form of Reactive Arthritis • Triad: - Urethritis - Conjuntivitis - Arthritis

41. Clinical Features I • General Symptoms (fever, fatigue, malaise) • Asymmetrical monoarthritis or oligoarthritis • Enthesitis • Mucocutaneous lesions - Keratodema Blenorrhagica - Circinate balanitis - Painless oral ulcers - Hyperkeratotic nails

45. Clinical Features II • Ocular lesions (unilateral or bilateral) - Conjuntivitis - Iritis • Visceral manifestations - Mild Renal disease - Carditis

47. 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

48. Treatment • Medical: NSAIDs • Corticosteroids • Intra articular (once sepsis ruled out) • Oral • Eye drops • Antibiotics • DMARDs (SZP) - If resistant/chronic • Non medical • Physiotherapy • Occupational therapy

49. Prognosis • Generally good • Recurrences not uncommon • Some develop a chronic form

50. Remember (Spondyloarthropathies) • Associated with HLA B27 • Affect Spine/Joints • Enthesitis • Extra articular features