Case 1 A 34-year-old secretary 3 months painful swelling of her right 2 nd and 4th fingers 2 weeks later tenderness and swelling in the 2nd MCPs and the 3 rd and 5th right PIPs, diffuse painful swelling of the 3rd toe of her left foot.
Physical signs and Diagnosis
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?
Case 2 1months ago, he developed nausea, cramps, and diarrhoea after attending an "all-you-can-eat" buffet. eyes "scratchy" of late some burning when he urinates
Physical signs and diagnosis
Case 3 21-year-old male student low back pain of 6 months' duration. Relevant questions?
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.
Case 3 Diagnosis? Likely ocular diagnosis? Investigations?
Investigations XR SIJ and L/Spine normal CRP, ESR normal
Investigations HLA-B27 +ve - referred MRI bilateral sacroiliitis
Demography AS Prevalence AS %, 3-4X male UHCW catchment area – AS pts
Burden of AS SMR % less labour participation 15% constraints at work Poor quality of life cf worse than RA
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.
Diagnostic criteria – Modified New York criteria Radiologic criteria : sacroiliitis - grade 2 bilaterally or grade 3-4 unilaterally Clinical criteria : LBP and stiffness > 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
AS Clinical Features - axial Early AS Romanus lesion Advanced AS bony ankylosis
AS Clinical Features - peripheral 30% hip and shoulder disease Peripheral enthesopathy
Complications - Fracture Traumatic C5/6 also C6/7 and C7/T1 Unstable – immobilization and fixation Osteoporotic (20-60%) and vertebral fractures (8-15%) Discitis