Seronegative Spondyloarthropathies

Jaya Ravindran

Rheumatologist

Introduction

• Cases

• Overview sero-ve diseases

Case 1

• A 34-year-old secretary

• 3 months painful swelling of her right 2nd and 4th fingers

• 2 weeks later tenderness and swelling in the 2nd MCPs and the 3rd and 5th right PIPs, diffuse painful swelling of the 3rd toe of her left foot.

Physical signs and Diagnosis

Case 2

• 22-year-old man, 3 months history of pain in 2 areas of his left foot (toes and heel).

• left knee has been getting sore and stiff.

• Relevant Questions?

Case 2

• 1months ago, he developed nausea, cramps, and diarrhoea after attending an "all-you-can-eat" buffet.

• eyes "scratchy" of late

• some burning when he urinates

Physical signs and diagnosis

Case 3

• 21-year-old male student

• low back pain of 6 months' duration.

• Relevant questions?

Case 3

• The onset insidious over the course of the previous 6 months.

• worse in the morning, improves with activity• wakes up in the middle of the night with back pain that

goes away after he walks around. • pain is located in the low back and intermittently goes

down the back of one leg or the other to the knee. • He has an uncle, age 50, who has "always" had a stiff

back. • painful red eye 6 months ago, which was treated by anophthalmologist for 2 months at university.

Case 3

• Diagnosis?

• Likely ocular diagnosis?

• Investigations?

Investigations

• XR SIJ and L/Spine normal

• CRP, ESR normal

Investigations

• HLA-B27 +ve - referred

• MRI bilateral sacroiliitis

Spectrum

• Ankylosing spondylitis

• Psoriatic arthritis

• Reactive arthritis

• Enteropathic arthritis

• Undifferentiated spondyloarthritis

• Juvenile AS

Demography AS

• Prevalence AS 0.05-0.23%, 3-4X male

• UHCW catchment area – 375-1700 AS pts

Burden of AS

• SMR 1.5

• 10% less labour participation

• 15% constraints at work

• Poor quality of life cf worse than RA

Aetiology• AS has been closely associated with the expression of the HLA-B27 gene

• The response to the therapeutic blockade of TNFalpha indicates that this cytokine plays a central role in AS

• Examination of inflamed SI joints in AS patients has demonstrated high levels of CD4+ and CD8+ T cells and macrophages.

• The overlapping features with reactive arthritis and IBD (SpAs) suggests a possible role for intestinal bacteria in the pathogenesis of AS.

• Diagnosis AS?

Diagnostic criteria – Modified New York criteria

• Radiologic criteria : sacroiliitis - grade 2 bilaterally or grade 3-4 unilaterally

• Clinical criteria : LBP and stiffness > 3 months improved with exercise and not relieved by rest, limitation of L/spine motion in frontal and sagittal planes, limitation of chest expansion relative to normal values correlated with age and sex

• Diagnosis : radiologic criteria and at least one clinical

Schober’s test

Sacroiliitis

AS Clinical Features - axial

• Early AS

Romanus lesion

• Advanced AS

bony ankylosis

AS Clinical Features - peripheral

• 30% hip and

shoulder disease

• Peripheral

enthesopathy

Complications - Fracture

• Traumatic

• C5/6 also C6/7 and C7/T1

• Unstable – immobilization

and fixation

• Osteoporotic (20-60%)

and vertebral fractures (8-15%)

• Discitis

Complications - Spondylodiscitis

• 5%, dorsal spine

• Inflammatory

• Posterior #

and instability

• Features of uveitis ?

AS Clinical Features – extra-articular - Uveitis

• 20-30%• B27 +ve• Acute unilateral pain, increased

lacrimation, photophobia, blurred vision• Circumcorneal congestion, iris discoloured• Pupil small (irregular)• Slit lamp – exudatesIn anterior chamber

• Features of Psoriasis ?

AS extra-articular features

• Psoriasis 10-15%

AS Clinical Features – extra-articular – Inflammatory bowel

• GI - Clinically silent enteric mucosal lesions 30-60%

• UC and Crohn’s 5-15% spinal and 10-20% peripheral arthritis

AS Clinical Features – extra-articular - Cardiac

• 2%

• Increases with age, duration and peripheral arthritis

• Aortic regurgitation – 3.5% (after 15years) and 10% (after 30 years)

• Conduction defects – 2.7% (after 15years) and 8.5% (after 30 years)

AS Clinical Features – extra-articular - Upper lobe fibrosis

• 1.3%

• 20 years after onset

• Bilateral linear or patchy opacities

• Later cystic

• Colonized by

aspergillus

AS Clinical Features – extra-articular

• Neurological – fracture dislocation, Cauda equina syndrome, atlanto-axial disease

• Renal – amyloidosis, IgA nephropathy, analgesic nephropathy

Investigations

• L/spine and SIJ x-rays

• CRP and ESR

• HLA B-27 – high clinical suspicion but x-ray not diagnostic – if positive worth referring as MRI can confirm pre-radiographic AS

AS – treatment

• Physiotherapy

• NSAIDS

• ‘DMARDs’ and steroids

• TNF alpha blockade

• Surgery

• PsA features ?

Demography - PsA

• No widely accepted criteria for diagnosis of PsA

• BSR guidelines estimate prevalence of 0.1% -1% - 500-1000 patients in UHCW

• Peak age of onset: 35-50 years

• Equal sex distribution

Burden of PsA

• 40%–57% have deforming arthritis

• 11%–19% are disabled

• Mortality is increased, compared with general population

PsA – clinical features

5 clinical subgroups:

• (Symmetrical) polyarthritis (RA-like) – 50% cases

• Asymmetrical oligoarthritis - 35% cases

• DIP disease - 5% cases

• Spondylitis (axial involvement) – 5% cases

• Arthritis mutilans - 5% cases

……..but much overlap

PsA – clinical

PsA –bone proliferation and destruction

Treatment

• NSAIDs• DMARDs – Sulphasalazine, Methotrexate,

Leflunomide, Cyclosporin• Steroids• TNF alpha blockade• OT, PT• Surgery• Dermatology input

• Reactive arthritis features ?

Reactive arthritis

• Young adults, equal sex

• Incidence of 30-40/100,000

• Post urethritis/cervicitis or infectious diarrhoea eg campylobacter, salmonella, shigella, yersinia,chlamydia – 1-6 weeks

• Sero-ve features + conjunctivitis, balanitis, oral ulcers, pustular psoriasis

Reactive arthritis

• Culture – throat, urine, stool, urethra/cervix

• Treatment – NSAIDs, steroids –intra-articular, antibiotics – chlamydia, DMARDs eg sulphasalazine

Summary

• Young adults

• Enthesitis, peripheral arthritis, spinal inflammation

• Psoriasis, inflammatory bowel disease, anterior uveitis, prior GU/GI infection

• B27 screening in inflammatory back pain with normal x-rays

• TNF alpha blockers – new hope

THANK-YOU