Seronegative Spondyloarthropathies M.Valešová

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

Ankylosing spondylitis (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.

Features AS?

Physical signs and diagnosis

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

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

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

Psoriatic arthritis (PsA)

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

Physical signs and Diagnosis

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