seronegative spondyloarthropathies phase ii musculoskeletal lecture 23/02/2012
TRANSCRIPT
![Page 1: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/1.jpg)
Seronegative Spondyloarthropathies
Phase II Musculoskeletal Lecture 23/02/2012
![Page 2: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/2.jpg)
Definition
Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically predisposed (HLA B27 positive) individuals
![Page 3: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/3.jpg)
Disease Subgroups
Ankylosing Spondylitis Reactive Arthritis ( Reiter's Syndrome) Enteropathic Arthritis Psoriatic Arthritis Undifferentiated spondyloarthropathy Juvenile spondyloarthropathy
![Page 4: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/4.jpg)
Spondyloarthropathy v RA
Different pattern of articular and extra-articular involvement
Absent serum Rheumatoid factor Strong association with HLA B27
![Page 5: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/5.jpg)
Shared rheumatological featuresof the Spondyloarthropaties
Sacroiliac and spinal involvement Enthesitis: Achilles tendinitis, plantar
fasciitis… Inflammatory arthritis:
Oligoarticular Asymmetric Predominantly lower limb
Dactylitis (“sausage” digits)
![Page 6: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/6.jpg)
![Page 7: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/7.jpg)
![Page 8: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/8.jpg)
Shared Extra-articular Features
Ocular inflammation (Anterior uveitis, conjuntivitis)
Mucocutaneous lesions Rare Aortic incompetence or heart block No rheumatoid nodules
![Page 9: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/9.jpg)
![Page 10: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/10.jpg)
![Page 11: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/11.jpg)
Ankylosing Spondylitis
![Page 12: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/12.jpg)
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
![Page 13: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/13.jpg)
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
![Page 14: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/14.jpg)
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
![Page 15: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/15.jpg)
“A” Disease
Axial Arthritis Anterior Uveitis Aortic Regurgitation Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis Plantar Fasciitis
![Page 16: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/16.jpg)
![Page 17: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/17.jpg)
![Page 18: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/18.jpg)
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
![Page 19: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/19.jpg)
Occiput to wall
![Page 20: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/20.jpg)
Schober Test
![Page 21: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/21.jpg)
![Page 22: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/22.jpg)
![Page 23: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/23.jpg)
![Page 24: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/24.jpg)
![Page 25: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/25.jpg)
Treatment
Home exercises Physiotherapy Occupational therapy NSAID Disease modifying drugs. SZP, MTX Anti TNF treatment – Infliximab (Remicade),
Adalimumab (Humira) Corticosteroids
![Page 26: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/26.jpg)
Psoriatic Arthritis
![Page 27: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/27.jpg)
Definition
Inflammatory arthritis associated with psoriasis
No Rheumatoid nodules Rheumatoid factor negative
![Page 28: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/28.jpg)
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)
![Page 29: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/29.jpg)
![Page 30: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/30.jpg)
![Page 31: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/31.jpg)
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
![Page 32: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/32.jpg)
![Page 33: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/33.jpg)
![Page 34: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/34.jpg)
Diagnosis
History Examination Bloods:
Inflammatory parameters (raised) Negative RF
X-rays Marginal erosions and “whiskering” “Pencil in cup” deformity Osteolysis Enthesitis
![Page 35: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/35.jpg)
![Page 36: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/36.jpg)
![Page 37: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/37.jpg)
Treatment
Medical NSAIDs Corticosteroids/joint injections Disease Modifying Drugs (MTX,SZP…) Anti TNF – Etanercept (Enbrel)
Non medical Physiotherapy Occupational Therapy Orthotics, Chiropodist
![Page 38: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/38.jpg)
Reactive Arthritis (Reiter's)
![Page 39: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/39.jpg)
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
![Page 40: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/40.jpg)
Reiter’s Syndrome
A form of Reactive Arthritis Triad:
- Urethritis
- Conjuntivitis
- Arthritis
![Page 41: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/41.jpg)
Clinical Features I
General Symptoms (fever, fatigue, malaise) Asymmetrical monoarthritis or oligoarthritis Enthesitis Mucocutaneous lesions
- Keratodema Blenorrhagica
- Circinate balanitis
- Painless oral ulcers
- Hyperkeratotic nails
![Page 42: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/42.jpg)
![Page 43: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/43.jpg)
![Page 44: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/44.jpg)
![Page 45: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/45.jpg)
Clinical Features II
Ocular lesions (unilateral or bilateral)
- Conjuntivitis
- Iritis Visceral manifestations
- Mild Renal disease
- Carditis
![Page 46: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/46.jpg)
![Page 47: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/47.jpg)
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
![Page 48: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/48.jpg)
Treatment
Medical: NSAIDs Corticosteroids
• Intra articular (once sepsis ruled out)• Oral• Eye drops
Antibiotics DMARDs (SZP) - If resistant/chronic
Non medical Physiotherapy Occupational therapy
![Page 49: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/49.jpg)
Prognosis
Generally good Recurrences not uncommon Some develop a chronic form
![Page 50: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/50.jpg)
Remember (Spondyloarthropathies)
Associated with HLA B27 Affect Spine/Joints Enthesitis Extra articular features
![Page 51: Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012](https://reader030.vdocuments.us/reader030/viewer/2022032611/56649e8e5503460f94b913d2/html5/thumbnails/51.jpg)
Questions ?