Seronegative Spondyloarthropathies

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Seronegative Spondyloarthropathies

• Jaya Ravindran
• Rheumatologist

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Introduction

• Cases
• Overview sero-ve diseases

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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.

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Physical signs and Diagnosis
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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?

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Case 2

• 1months ago, he developed nausea, cramps, and
  diarrhoea after attending an "all-you-can-eat"
  buffet.
• He has had 5 sexual partners the last year
• eyes "scratchy" of late
• some burning when he urinates

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Physical signs and diagnosis
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Case 3

• 21-year-old male student
• low back pain of 6 months' duration.
• Relevant questions?

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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 an
• ophthalmologist for 2 months at university.

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Case 3

• Diagnosis?
• Likely ocular diagnosis?
• Investigations?

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Investigations

• XR SIJ and L/Spine normal
• CRP, ESR normal

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Investigations

• HLA-B27 ve - referred
• MRI bilateral sacroiliitis

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Spectrum

• Ankylosing spondylitis
• Psoriatic arthritis
• Reactive arthritis
• Enteropathic arthritis
• Undifferentiated spondyloarthritis
• Juvenile AS

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Demography AS

• Prevalence AS 0.05-0.23, 3-4X male
• UHCW catchment area 375-1700 AS pts

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Burden of AS

• SMR 1.5
• 10 less labour participation
• 15 constraints at work
• Poor quality of life cf worse than RA

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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.

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• Features AS?

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Diagnostic criteria Modified New York criteria

• Radiologic criteria sacroiliitis - grade 2
  bilaterally or grade 3-4 unilaterally
• Clinical criteria LBP and stiffness gt 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

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Schobers test
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Sacroiliitis
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AS Clinical Features - axial

• Early AS
• Romanus lesion
• Advanced AS
• bony ankylosis

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AS Clinical Features - peripheral

• 30 hip and
• shoulder disease
• Peripheral
• enthesopathy

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Complications - Fracture

• Traumatic
• C5/6 also C6/7 and C7/T1
• Unstable immobilization
• and fixation
• Osteoporotic (20-60)
• and vertebral fractures (8-15)
• Discitis

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Complications - Spondylodiscitis

• 5, dorsal spine
• Inflammatory
• Posterior
• and instability

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• Features of uveitis ?

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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 exudates
• In anterior chamber

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• Features of Psoriasis ?

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AS extra-articular features

• Psoriasis 10-15

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AS Clinical Features extra-articular
Inflammatory bowel

• GI - Clinically silent enteric mucosal lesions
  30-60
• UC and Crohns 5-15 spinal and 10-20 peripheral
  arthritis

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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)

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AS Clinical Features extra-articular - Upper
lobe fibrosis

• 1.3
• 20 years after onset
• Bilateral linear or patchy opacities
• Later cystic
• Colonized by
• aspergillus

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AS Clinical Features extra-articular

• Neurological fracture dislocation, Cauda
  equina syndrome, atlanto-axial disease
• Renal amyloidosis, IgA nephropathy, analgesic
  nephropathy

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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

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AS treatment

• Physiotherapy
• NSAIDS
• DMARDs and steroids
• TNF alpha blockade
• Surgery

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• PsA features ?

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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

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Burden of PsA

• 4057 have deforming arthritis
• 1119 are disabled
• Mortality is increased, compared with general
  population

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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

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PsA clinical
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PsA bone proliferation and destruction
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Treatment

• NSAIDs
• DMARDs Sulphasalazine, Methotrexate,
  Leflunomide, Cyclosporin
• Steroids
• TNF alpha blockade
• OT, PT
• Surgery
• Dermatology input

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• Reactive arthritis features ?

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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

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Reactive arthritis

• Culture throat, urine, stool, urethra/cervix
• Treatment NSAIDs, steroids intra-articular,
  antibiotics chlamydia, DMARDs eg sulphasalazine

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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

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THANK-YOU