Title: Seronegative Spondyloarthropathies
1Seronegative Spondyloarthropathies
2Spectrum
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
- Enteropathic arthritis
- Undifferentiated spondyloarthritis
- Juvenile AS
3Ankylosing spondylitis(AS)
4Demography AS
- Prevalence AS 0.05-0.23, 3-4X male
- UHCW catchment area 375-1700 AS pts
5Burden of AS
- SMR 1.5
- 10 less labour participation
- 15 constraints at work
- Poor quality of life cf worse than RA
6Aetiology
- 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.
7 8Physical signs and diagnosis
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10Diagnostic 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
11Schobers test
12Sacroiliitis
13AS Clinical Features - axial
- Early AS
- Romanus lesion
- Advanced AS
- bony ankylosis
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15AS Clinical Features - peripheral
- 30 hip and
- shoulder disease
- Peripheral
- enthesopathy
16Complications - Fracture
- Traumatic
- C5/6 also C6/7 and C7/T1
- Unstable immobilization
- and fixation
- Osteoporotic (20-60)
- and vertebral fractures (8-15)
- Discitis
17Complications - Spondylodiscitis
- 5, dorsal spine
- Inflammatory
- Posterior
- and instability
18AS 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
19AS extra-articular features
20AS 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
21AS 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)
22AS Clinical Features extra-articular - Upper
lobe fibrosis
- 1.3
- 20 years after onset
- Bilateral linear or patchy opacities
- Later cystic
- Colonized by
- aspergillus
23AS Clinical Features extra-articular
- Neurological fracture dislocation, Cauda
equina syndrome, atlanto-axial disease - Renal amyloidosis, IgA nephropathy, analgesic
nephropathy
24Investigations
- 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
25AS treatment
- Physiotherapy
- NSAIDS
- DMARDs and steroids
- TNF alpha blockade
- Surgery
-
26Psoriatic arthritis (PsA)
27Demography - 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
28Burden of PsA
- 4057 have deforming arthritis
- 1119 are disabled
- Mortality is increased, compared with general
population
29PsA 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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31Physical signs and Diagnosis
32PsA bone proliferation and destruction
33Treatment
- NSAIDs
- DMARDs Sulphasalazine, Methotrexate,
Leflunomide, Cyclosporin - Steroids
- TNF alpha blockade
- OT, PT
- Surgery
- Dermatology input
34- Reactive arthritis features ?
35Reactive 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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37Reactive arthritis
- Culture throat, urine, stool, urethra/cervix
- Treatment NSAIDs, steroids intra-articular,
antibiotics chlamydia, DMARDs eg sulphasalazine
38Summary
- 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