Sronegative Spondyloarthropathies

1. SronegativeSpondyloarthropathies

2. Sronegative Spondyloarthropathies • Ankylosing spondylitis(AS) • Reiter's syndrome, reactive arthritis • Psoriatic arthritis • Enteropathic arthritis and spondylitis • Juvenile-onset spondyloarthropathy • Undifferentiated spondyloarthropathy

3. Psoriatic Arthritis (PsA)

4. Definition Psoriaticarthritis (PsA) is a chronic inflammatory arthritis that affects 5 to 42% of people with psoriasis.

5. PSORIASIS • One of the most common dermatologic diseases, affecting up to 1 to 2% of the world's population • A chronic inflammatory skin disorder clinically characterized by erythematous, sharply demarcated papules and rounded plaques, covered by silvery micaceous scale

6. Psoriasis(types) Plaque type • The most common areas for plaque psoriasis to occur are the elbows, knees, gluteal cleft, and the scalp

8. Psoriasis(types) • Eruptive psoriasis (guttate psoriasis) is most common in children and young adults

10. Psoriasis(types) • Postular psoriasis

11. Etiology • The etiology of psoriasis is still poorly understood • There is clearly a genetic component to psoriasis. Over 50% of patients with psoriasis report a positive family history, and a 65 to 72% concordance among monozygotic twins has been reported in twin studies • HLA-Cw6

12. Etiology • Role for T cells • Psoriatic lesions are characterized by infiltration of skin with activated memory T cells, with CD8+ cells predominating in the epidermis • Presumably, cytokines from activated T cells elaborate growth factors that stimulate keratinocyte hyperproliferation.

13. Arthritis with psoriasis Patterns of arthritis

14. Arthritis with psoriasisPatterns of arthritis DIP joints (with nail changes) Mono-articular arthritis Oligo-articular asymmetrial arthritis Pseudo-rheumatoid polyarthritis Spondyloarthropathy Arthritis mutilans

15. Arthritis with psoriasisPatterns of arthritis PresentationPercent DIP joints (with nail changes) 11-17 Mono- and oligo-articular asymmetrial arthritis 14-53 Pseudo-rheumatoid polyarthritis 35-78 Spondyloarthropathy 16-53 Arthritis mutilans 5-16

16. Arthritis with psoriasisPatterns of arthritis DIP joints (with nail changes)

18. DIP arthritis with nail changes

19. DIP arthritis with nail changes

21. DIP arthritis with progressive erosive destruction DIP joint

22. Arthritis with psoriasisPatterns of arthritis DIP joints (with nail changes) Mono-articular arthritis

23. Monoarticular arthritis

24. Arthritis with psoriasisPatterns of arthritis DIP joints (with nail changes) Mono-articular arthritis Oligo-articular asymmetrial arthritis

25. Oligo-articular arthritis • Asymmetrical • Inflammatory • Large and small joints • Upper and lower extremity joints • men = women • Psoriasis tends to precede the arthritis by years • sausage-shaped digits

27. Oligo-articular arthritis • PIP and DIP joints are commonly involved • knees, hips, ankles, temporomandibular joints, and wrists are less frequently involved • Most patients have onychodystrophy • prognosis is good • one-fourth of the patients developing progressive destructive disease; one-third develop inflammatory ocular complications (conjunctivitis, iritis, episcleritis).

28. Arthritis with psoriasisPatterns of arthritis DIP joints (with nail changes) Mono-articular arthritis Oligo-articular asymmetrial arthritis Pseudo-rheumatoid polyarthritis

29. Pseudo-rheumatoid arthritis (Clinical)

30. symmetric arthritis • Twice as frequently in women • Psoriasis and inflammatory arthritis usually develop simultaneously • All patients have onychodystrophy • Over half of the patients in this group go on to develop destructive arthritis, including arthritis mutilans • Eye complications are uncommon

31. symmetric arthritis • Subcutaneous nodules are not present • One-fourth of patients have rheumatoid factors

32. Pseudo-rheumatoid arthritis (Clinical)

33. Pseudo-rheumatoid arthritis (X-rays)

34. psoriatic spondylitis • With or without peripheral joint involvement • Psoriasis tends to precede the arthritis by a few years • more common in men • About half the patients in this group have spondylitis and the other half have sacroiliitis • Usually slowly progressive

35. psoriatic spondylitis • Little clinical deterioration as compared with ankylosing spondylitis • The peripheral disease also tends not to be destructive • Enthesopathy • Many patients have onychodystrophy • Few have inflammatory ocular complications

36. AsymmeticalSacroiliitisPsoriatic spondylitis abnormal normal

37. Symmetical SacroiliitisAnkylosing spondylitis (abnormal) (abnormal)

38. Arthritis mutilans

40. Arthritis mutilans(resorptive, pencil-in-cup)

41. pathology Is similar to that seen in rheumatoid arthritis: • synoviocytic hyperplasia, • early PMN infiltration and later mononuclear cell infiltration, cartilage erosion, and pannus formation. • However, in PsA, the synovium is more vascular, Fibrosis of the joint capsule and marrow is prominent in many patients.

42. LABORATORY FINDINGS • ESR • CRP • RF • Uric acid

43. Radiologic investigationperipheral joints • Soft tissue swelling, loss of the cartilage space, erosions, bony ankylosis of fingers, subluxations, and subchondral cysts; of note, there is less demineralization • pencil-in-cup • Telescoping of one bone into its neighbor, leading to the "opera-glass" deformity

44. Radiologic investigation Axial skeleton • Asymmetric or unilateral sacroiliitis • Asymptomatic paravertebral ossification, including cervical involvement, and large asymmetric nonmarginal syndesmophyte

48. DIAGNOSIS • The diagnosis of PsA should be considered in individuals with arthritis and psoriasis • It is often difficult to distinguish Reiter's syndrome from PsA, since both manifest dactylitis. Reiter's syndrome

49. TREATMENT • NSAIDS • Sulfasalazine • MTX • Azathioprine • Biologic agents • Cytotoxics