Seronegative Spondyloarthropathies Jaya Ravindran Rheumatologist

Introduction Cases Overview sero-ve diseases

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.

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

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

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

Burden of AS SMR 1.5 10% 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.

Diagnosis 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

Schober’s test

Sacroiliitis

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

Complications - Spondylodiscitis 5%, dorsal spine Inflammatory Posterior # and instability

Features of uveitis ?

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

Features of Psoriasis ?

AS extra-articular features Psoriasis 10-15%

AS Clinical Features – extra-articular – Inflammatory bowel GI - Clinically silent enteric mucosal lesions 30-60% UC and Crohn’s 5-15% spinal and 10-20% peripheral arthritis

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)

AS Clinical Features – extra-articular - Upper lobe fibrosis 1.3% 20 years after onset Bilateral linear or patchy opacities Later cystic Colonized by aspergillus

AS Clinical Features – extra-articular Neurological – fracture dislocation, Cauda equina syndrome, atlanto-axial disease Renal – amyloidosis, IgA nephropathy, analgesic nephropathy

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

AS – treatment Physiotherapy NSAIDS ‘DMARDs’ and steroids TNF alpha blockade Surgery

PsA features ?

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

Burden of PsA 40%–57% have deforming arthritis 11%–19% are disabled Mortality is increased, compared with general population

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

PsA – clinical

PsA –bone proliferation and destruction

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

Reactive arthritis features ?

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

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

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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