Seronegative Spondyloarthropthies
Definition
-Spondyloarthropathies (SA) are cluster of interrelated and overlapping chronic inflammatory rheumatic disease.
-The primary pathologic sites are
-Enthesis
-Axial skeleton including the sacroiliac joints
-Limb joints
-Nonarticular structures: gut,skin,eye,aortic valve
Etiology
SA occur in genetically predisposed persons and are triggered by enviromental factors.
SA are not associated with rheumatoid factor
There is strong association with HLA-B27
Association of SA with HLA-B27
Disease HLA-B27 (%)
Ankylosing Spondylitis 90
Reactive Arthritis 40-80
Psoriatic Arthropathy 40-50
Enteropathic Arthritis 35-75
Undifferentiated SA 70
Healthy population (white) 8
Classification Criteria for SAI. Inflammatory back pain or asymmetrical arhritis with lower
limb predominance
II. One or more of the following criteria:
-Positive family history: AS, reactive arthritis, psoriasis, IBD, uveitis
-Psoroasis
-IBD
-Uerthritis, cervicitis, diarrhea month before onset
-Buttock pains
-Enthesitis
-Sacroileitis
Ankylosing Spondylitis (AS)
AS is a chronic inflammatory disease of unknown etiology.
Affects mainly the axial skeleton (spine & sacroiliac joints).
Strong association with HLA-B27
Epidemiology
Annual prevalence(USA white): 6.6/105
HLA-B27 +: 1-2%
+ 10 degree affected relative: 10-20%
M>F X2-3
Clinical Presentation
1. Mild constitutional symptoms: anorexia, weight loss, fever 2. Inflammatory back pain- 75%
-Insidious onset
-3 months
-Morning stifness
-Worsening with inactivity
-Improvement with physical exercise, hot tub
Clinical Presentation
3. Involvement of hip and shoulder joints- 33%
4. Peripheral arthritis- 33%
Asymmetrical, non-erosive, lower limbs
5. Enthesopathy- plantar fascia, Achilles, patella, pelvis
Clinical Presentation
6. Extra-articular manifestations:
-Acute anterior uveitis- 25-30%
-Cardiovascular: Aortic insufficiency, ascending aortitis, conduction disturbances
-Lung fibrosis- apex
-Neurological manifestations due to cervical spine (+fractures) involvement
Physical examination
1. Sacroileitis
2. Limited spine movements (hyperextension, lateral flexion)
3. Loss of lumbar lordosis+ thoracic kyphosis
4. Limited chest expansion
5. Peripheral arthritis
6. Enthesitis
Diagnostic Criteria
1. LBP3 months improved with exercise, not relieved by rest
2. Limited lumbar spine motion
3. Decreased chest expansion
4. Sacroiileitis
Definite AS= 4+ any one
Reactive Arthritis
Aseptic peripheral arthritis occurring within 1 month of a primary infection elsewhere in the body.
Triggering infection:
1. Genitourinary infection- Chlamydia trachomatis
2. Enteritis due to gram negative enterobacteria: Salmonella, Shigella, Yersinia, Campylobacter
3. Treatment with BCG injection for bladder cancer
Epidemiology
Annual Prevalence: 30-40/105
HLA-B27: 40-80%
HLA-B27+ X50 risk for developing the disease
F=M.
Usually young adults
Clinical Presentation
1. General symptoms: malaise, fatigue, fever
2.Musculoskeletal symptoms
-Monoarthritis or asymmetyric olygoarthritis
Weight bearing joints: Knees,ankles,hips
- Enthesitis:Achilles tendonitis, plantar fasciitis
- Dactylitis (“sausage digits”)
15-30% develop chronic/recurrent arthritis sacroiileitis
Clinical Presentation
3. Genitourinary symptoms:
- Urethritis, cystitis,
- Cervicitis, prostatitis
4. Ocular lesions:
- Conjuctivitis (33%)
2. Anterior uveitis (5%)
Clinical Presentation5. Mucocutaneous lesions
- Keratoderma Blenorrhagicum
- Circinate Balanitis/ Vulvitis
- Painless ulcer in the mouth
- Nail lesions
6. Cardiac involvement-rare
- Carditis
-Conduction disturbances
Reiter syndrome= arthritis+urethritis+conjuctivitis
Psoriatic Arthritis (PsA)
Inflammatory arthritis associated with psoriasis
Prevalence of psoriasis: 1-3%
Prevalence of arthritis in psoriasis: 7-42%
-75% psoriasis precedes PsA
-15% synchronous onset
-10% arthritis precedes psoriasis
M=F
PsA usually begins between 30- 50 years
Clinical presentation
I. Articular patterns:
1. Asymmetric oligoarthritis- most common
2. Arthritis of distal interphalangeal joints
3. Symmetric polyarthritis (dd: RA)
4. Arthritis mutilans
5. Spondyloarthropathy
II. Dactylitis- 30%
III. Enthesopathy
Enteropathic Arthritis
Inflammatory arthritis associated with:
1. Inflammatory bowels disease(Crohn’s disease, ulcerative colitis)
2. Infectious enterocolitis
3. Whipple’s disease
4. Intestinal bypass surgery
5. Coeliac disease
Clinical Presentation
I. Articular manifestations
1. Monoarthritis, asymmetrical olygoarthritis:2-20%
large+small joints of lower limbs
less frequent- hips, shoulders
+enthesopathy
correlates with GI manifestations
M=F
Clinical Presentation
I. Articular manifestations
2. Axial involvement: 5-12%
sacroiileitis,spondylitis
no correlation with GI
M.>F X3
Clinical Presentation
II. Acute anterior uveitis 3-11%
HLA-B27 +
+ Axial involvement
III. Skin lesions: 10-25%
1. Erythema nodosum
2. Pyoderma gangrenosum
Investigations in SA
I. Lab tests
1. ESR, CRP- 75%
2. Mild normocytic anemia- 15%
3. IgA
4. ALP
5. RF, ANA, C- normal
6. HLA-B27 (not diagnostic)
Investigations in SA
II. X-ray film
1. Sacroiileitis- postage stamp, pseudowidening, sclerosis, ankylosis
2. Spondylitis- squaring, syndesmophytes, bamboo spine, osteoporosis
3. Enthesitis
III. Bone scan- sacroiileitis?
Management in SA
Goals:
1. Relief of pain & rigidity
2. Maintaining posture & movement
Management in SA
I. Drug therapy
1. NSAID !
2. Steroids- for short term, local injections
3. Second line therapy: sulfasalazine, methotrexate
4. Anti-TNF-
II. Physical exercise (swimming!)
III. Physiotherapy (hydrotherapy, passive streching etc.)
Top Related