Cases presentationCases presentation

– Prepared by Dr R Musa– SPR rheumatology– St Albans City Hospital

Case (1)Case (1)

GP referral (June 2007)

54 years old LadyProgressive Lower back, left hip and left ankle

pain

Diclofenac without improvement

Rheumatology opinion (Sept 2007)Rheumatology opinion (Sept 2007)

Joints pain mainly lower back & both hips No hands pain but her toe swell up and painful to walk

H/O Patch of psoriasis over her scalp

Blurred vision couple of times although no redness of her eyes

Diarrhoea bowel open 8 times /day with loss stool, no blood

Ex-smoker stopped 20/52 earlier (used to smoke 15 – 20 cigarette/day

Drink 10 – 15 unit/weeks

Past Medical HistoryPast Medical History 2000 Very sever eczematous eruption of both ears & scalp? GP diagnose her with ?allergic contact dermatitis

Dermatology opinion – Psoriasis with secondary eczema

– Betnovate C ointment bd– Aqueous cream– Soft paraffin– Patch test negative (no allergy)

2004 anaemia treated with ferrous sulphate 2005 Ca endometrial (hysterectomy) 2005 vesico-vaginal fistula

On examinationOn examination No nails changes, psoriatic skin rash over her eye braw, ext ear &

scalp. No synovitis in both hands & feet

Eyes look normal (no irregularity of iris)

Cervical spine: very restricted movement to all direction Thoracic spine: chest expansion

Lumber spine: restricted forward flexion <70 Tenderness opposite both SI joints Hips, knees and ankles good range of movement and no synovitis or

tenderness

InvestigationInvestigation FBC Normal (slightly low MCV & MCHC despite long term iron

therapy) ESR 28

Normal (U&E, LFT and CRP)

ANA (+) 1:320 RF (-) DsDNA (-)

Ferritin level normal HLA –B27 (negative)

ImpressionImpression

Sponyloarthritis related to either – IBD or Psoriatic arthritis

Inflammatory bowel disease either

Crohn or Ulcerative colitis

Plan: – x-rays whole spine, SI joints & CXR– Meloxicam 15mg OD– Gastroenterology referral

Gastroenterology opinion (October 07)Gastroenterology opinion (October 07)

Clinically Ulcerative colitis– Colonoscopy (Oct 2007)– Histology (Ulcerative colitis)

Treatment started by Gastroenterologist– Prednisolone 40mg OD on reducing dose– Balsalazide & Mesalazine

December 2007 Gastro OPD– because of good response to treatment – steroid was reduced too quickly (5mg every 5 days) and she

remain on 5mg/day.

Rheumatology clinic (9/1/08)Rheumatology clinic (9/1/08)

Flare up of her arthritis and bowel symptoms

Diarrhoea 4 – 8 times /day pain and stiffness in her spine and peripheral joints

Plan: -– increase steroid to 20mg /day– Switch balsalazide to SSZ 1gm bd

 

Case (2)Case (2)

GP referral

29 years old lady with painful hips for many years

Rheumatology opinion (Sept 07)Rheumatology opinion (Sept 07) C/O: intermittent neck stiffness and low back pain Back pain worse on lying down or site for long time No pain in any of her peripheral joints

She had abdominal pain (colicky) with continues diarrhoea (watery but some times blood in stool around 4-6 times/day)

H/O peri-anal abscess. Weight loss (around 1 Kg in 2/12) despite good appetite

Known with aggressive psoriasis (Rt hands, elbow & feet) Grand-mother had psoriasis Known with iritis in Rt eye diagnosed by ophtolomology

Smoke 20 cigarette/day Drink little

On examinationOn examination Look thin & under Wt (45Kg)

Psoriatic skin rash over her Rt hand, extensor surface of both elbow

Eyes not red (Rt iris irregular)

No nails changes No synovitis in both hands Good movement of all her peripheral joints without pain restriction Good movement of her neck without pain or restriction Lumber spine restricted forward flexion to 80, lateral flexion

good No tenderness opposite SI joints

InvestigationInvestigation

FBC, U&E, LFT all normalESR 25

ANA (-)RF (-)

HLA- B27 (+)

impressionimpression

Spondyloarthritis related to either – Psoriasis or IBD

IBD either (Crohn or Ulcerative colitis)

Plan: – X-ray whole spine, SI joints, CXR– MRI scan of lumber spine & SI joints– Gastroenterology referral – Meloxicam 15mg OD

Follow up (Feb 08)Follow up (Feb 08) Patients not seen by Gastro (she missed two gastroenterology

appointment).

On attending rheumatology follow up (she still have continuous diarrhoea). Reason for missing appointment b/c (very busy on Monday) she is single mother and working

Her back much better on Meloxicam

X-ray (show fusion of SI joints & evidence of sacroiliitis) MRI show no oedema around SI joints or spine (inactive Sacroiliitis)

Psoriatic arthritisPsoriatic arthritisThe prevalence of psoriasis among patients with arthritis in the general

population is 2–3% but among patients with arthritis it is 7%, while the incidence of PsA has been varied from 3.4 to 8 per 100 000.

The estimated prevalence of inflammatory arthritis among patients with psoriasis has varied widely from 6% to 42%.

Prevalence of axial disease varies from 25% to 70% of patients with psoriatic arthritis

Wright identified five clinical patterns among patients with PsA: – distal predominant pattern, – Oligoarticular asymmetrical,

– Polyarticular RA-like, – spondylosis, and – arthritis mutilans.

Psoriatic arthritisPsoriatic arthritis

Moll and Wright’s seminal paper identified the majority of PsA patients as having oligoarthritis

PsA occurs just as frequently in both sexes

Nail lesions are very common (occur in about 40–45% of patients with psoriasis uncomplicated by

arthritis and about 87% of patients with PsA)

Distal joints involvment, dactylitis with Lower level of tenderness are also typical features of PsA

Erythema over affected joints

The presence of spinal involvement, enthesitis

RF in only 13%

Arthritis may precede the psoriasis by many years

Psoriasis and RA may coexist with a prevalence of 3:10 000

Subclinical uveitis (asymptomatic)Subclinical uveitis (asymptomatic)

The reported prevalence of uveitis (symptomatic) in patients with inflammatory bowel disease varies from 2% to 10%, (uveitis also associated with Subclinical inflammatory bowel disease).

Adults patients with IBD no evidence of Subclinical uveitis.

Juvenile patients are relatively insensitive compared with adults with respect to the discomfort of an ocular inflammation. Also children may sometimes show a mitigated course of inflammatory disease because of a difference in the immune response in these autoimmune driven diseases, that is why uveitis often asymptomatic in children.

Always it is necessary to referred paediatric patients with seronegative arthritis / IBD for ophthalmology review even if asymptomatic

Subclinical colitisSubclinical colitis

Between 5 and 10% of cases of ankylosing spondylitis (AS) are associated with inflammatory bowel disease (IBD), either Crohn's disease or ulcerative colitis.

Much larger percentage (60%) of AS patients have subclinical gut inflammation manifested either by endoscopic findings or by histology.

The association with HLA-B27 is less strong in IBD-associated AS than in idiopathic AS,

BSR Guideline on Eligability for anti TNF therapy BSR Guideline on Eligability for anti TNF therapy The same as ASAS Consensus (ASsessments in AS working group)The same as ASAS Consensus (ASsessments in AS working group)

Initiation of therapy:– Ankylosing Spondylitis patient satisfies modified New York criteria

– Failed conventional therapy (2 or > NSAID each taken sequentially at maximum tolerated dose for 4 weeks

– Active disease for at least 4 weeks BASDAI =/> 4 and Physician global (specialist) yes/no

– Refractory disease Failed at least 2 NSAIDS at max tolerated doses during 3 month period and

I/A steroids/SSZ if indicated ASAS workshop, Berlin January 2003

BSR definition of response to treatmentBSR definition of response to treatment (the same as ASAS consensus guidelines)(the same as ASAS consensus guidelines)

Response Time of evaluation at 6-12 weeks BASDAI >50% improvement and absolute improvement >2

units and Physician global assessment of response to treatment

Infusions every 6-8 weeks The following assessed in all patients in every follow up:

– Patient pain score – Patient global assessment– Spinal mobility score– CRP– BASDAI

Marzo-Ortega, H et al. Ann Rheum Dis 2003;62:74-76

(A) Sagittal T2 image of the lumbar spine of a patient with Crohn's disease associated spondylitis, showing end plate oedema of the T10 inferior, T11 superior, L4 inferior, and L5 superior vertebral bodies (black asterisks). (B) The follow up scan after treatment with etanercept, showing complete resolution of the bone oedema at all sites.

Marzo-Ortega, H et al. Ann Rheum Dis 2003;62:74-76

Histological section from the large bowel taken at time of colonoscopy show Severe mucosal inflammatory infiltrate (arrowheads) and a crypt abscess (long arrow) can be seen.

End of the slidesEnd of the slides

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