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Seronegative Spondyloarthropathies
Phase II Musculoskeletal Lecture 23/02/2012
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Definition Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically predisposed (HLA B27 positive) individuals
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Disease Subgroups Ankylosing Spondylitis
Reactive Arthritis ( Reiter's Syndrome) Enteropathic Arthritis Psoriatic Arthritis Undifferentiated spondyloarthropathy Juvenile spondyloarthropathy
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Spondyloarthropathy v RA
Different pattern of articular and extra-articular involvement Absent serum Rheumatoid factor Strong association with HLA B27
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Shared rheumatological features of the Spondyloarthropaties
Sacroiliac and spinal involvement Enthesitis: Achilles tendinitis, plantar fasciitis… Inflammatory arthritis: Oligoarticular Asymmetric Predominantly lower limb Dactylitis (“sausage” digits) Enthesis. Site of insertion of a tendon, ligament or articular capsule into bone. Enthesopathy. Alteration of this site
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Shared Extra-articular Features
Ocular inflammation (Anterior uveitis, conjuntivitis) Mucocutaneous lesions Rare Aortic incompetence or heart block No rheumatoid nodules
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Ankylosing Spondylitis
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Definition Chronic systemic inflammatory disorder that primarily affects the spine. Hallmark- Sacroiliac joint involvement (sacroiliitis) Peripheral arthritis uncommon (shoulder and hip) Enthesopathy Late adolescence or early adulthood More common in men 3-5:1
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Modified New York Criteria for Diagnosis of Ankylosing Spondylitis
1. Limited lumbar motion 2. Lower back pain for 3 months Improved with exercise Not relieved by rest 3. Reduced chest expansion 4. Bilateral, Grade 2 to 4, sacroiliitis on X ray 5. Unilateral, Grade 3 to 4, sacroiliitis on X ray Definite AS if Criterion 4 or 5, plus 1,2 or 3
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Clinical features Back pain (neck, thoracic, lumbar) Enthesitis
Peripheral arthritis (shoulders,hips) – rare Extra articular features: Anterior uveitis Cardiovascular involvement (aortic valve/root ) Pulmonary involvement (fibrosis upper lobes) Asymptomatic enteric mucosal inflammation Neurological involvement (Rarely A-A subluxation) Amyloidosis
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“A” Disease Axial Arthritis Anterior Uveitis Aortic Regurgitation
Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis Plantar Fasciitis
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Diagnosis History Examination: Bloods X-rays - Sacroiliitis
Tragus/occiput to wall Chest expansion Modified Schober test Bloods Inflammatory parameters (ESR, CRP, PV) HLA B27 X-rays - Sacroiliitis - Syndesmophytes - “Bamboo” spine
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Occiput to wall
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Schober Test
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Treatment Home exercises Physiotherapy Occupational therapy NSAID
Disease modifying drugs. SZP, MTX Anti TNF treatment – Infliximab (Remicade), Adalimumab (Humira) Corticosteroids
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Psoriatic Arthritis
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Definition Inflammatory arthritis associated with psoriasis
No Rheumatoid nodules Rheumatoid factor negative
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Clinical features Inflammatory Arthritis (5 subgroups) Sacroiliitis:
often asymmetric may be associated with spondylitis Nail involvement (Pitting, onycholysis) Dactylitis Enthesitis: Achilles tendinitis Plantar fasciitis Extra articular features (eye disease)
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Clinical subgroups of psoriatic arthritis
Confined to distal interphalangeal joints (DIP) hands/feet Symmetric polyarthritis (similar to RA) Ankylosing Spondylitis with or without peripheral joint involvement Asymmetric oligoarthritis with dactylitis Arthritis mutilans
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Diagnosis History Examination Bloods: X-rays
Inflammatory parameters (raised) Negative RF X-rays Marginal erosions and “whiskering” “Pencil in cup” deformity Osteolysis Enthesitis
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Treatment Medical Non medical NSAIDs Corticosteroids/joint injections
Disease Modifying Drugs (MTX,SZP…) Anti TNF – Etanercept (Enbrel) Non medical Physiotherapy Occupational Therapy Orthotics, Chiropodist
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Reactive Arthritis (Reiter's)
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Introduction Urogenital. Chlamydia
Infection induced systemic illness characterized primarily by an inflammatory synovitis from which viable microorganisms cannot be cultured Symptoms 1-4 weeks after infection Most common infections: Urogenital. Chlamydia Enterogenic. Salmonella, Shigella, Yersinia Young adults (20-40) Equal sex distribution HLA B27 + Infection
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Reiter’s Syndrome A form of Reactive Arthritis Triad: - Urethritis
- Conjuntivitis - Arthritis
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Clinical Features I General Symptoms (fever, fatigue, malaise)
Asymmetrical monoarthritis or oligoarthritis Enthesitis Mucocutaneous lesions - Keratodema Blenorrhagica - Circinate balanitis - Painless oral ulcers - Hyperkeratotic nails
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Clinical Features II Ocular lesions (unilateral or bilateral)
- Conjuntivitis - Iritis Visceral manifestations - Mild Renal disease - Carditis
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Diagnosis History Examination Bloods: Cultures (blood, urine, stool)
Inflammatory parameters (ESR,CRP,PV) FBC, U&Es HLA B27 (rarely necessary) Cultures (blood, urine, stool) Joint fluid analysis (rule out infection) X-ray of affected joints Ophthalmology opinion
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Treatment Medical: NSAIDs Non medical Corticosteroids Antibiotics
Intra articular (once sepsis ruled out) Oral Eye drops Antibiotics DMARDs (SZP) - If resistant/chronic Non medical Physiotherapy Occupational therapy
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Prognosis Generally good Recurrences not uncommon
Some develop a chronic form
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Remember (Spondyloarthropathies)
Associated with HLA B27 Affect Spine/Joints Enthesitis Extra articular features
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Questions ?
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