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Seronegative Spondyloarthropathies

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Presentation on theme: "Seronegative Spondyloarthropathies"— Presentation transcript:

1 Seronegative Spondyloarthropathies
Phase II Musculoskeletal Lecture 23/02/2012

2 Definition Family of inflammatory arthritides characterized by involvement of both the spine and joints, principally in genetically predisposed (HLA B27 positive) individuals

3 Disease Subgroups Ankylosing Spondylitis
Reactive Arthritis ( Reiter's Syndrome) Enteropathic Arthritis Psoriatic Arthritis Undifferentiated spondyloarthropathy Juvenile spondyloarthropathy

4 Spondyloarthropathy v RA
Different pattern of articular and extra-articular involvement Absent serum Rheumatoid factor Strong association with HLA B27

5 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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8 Shared Extra-articular Features
Ocular inflammation (Anterior uveitis, conjuntivitis) Mucocutaneous lesions Rare Aortic incompetence or heart block No rheumatoid nodules

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11 Ankylosing Spondylitis

12 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

13 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

14 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

15 “A” Disease Axial Arthritis Anterior Uveitis Aortic Regurgitation
Apical fibrosis Amyloidosis/ Ig A Nephropathy Achilles tendinitis Plantar Fasciitis

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18 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

19 Occiput to wall

20 Schober Test

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25 Treatment Home exercises Physiotherapy Occupational therapy NSAID
Disease modifying drugs. SZP, MTX Anti TNF treatment – Infliximab (Remicade), Adalimumab (Humira) Corticosteroids

26 Psoriatic Arthritis

27 Definition Inflammatory arthritis associated with psoriasis
No Rheumatoid nodules Rheumatoid factor negative

28 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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31 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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34 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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37 Treatment Medical Non medical NSAIDs Corticosteroids/joint injections
Disease Modifying Drugs (MTX,SZP…) Anti TNF – Etanercept (Enbrel) Non medical Physiotherapy Occupational Therapy Orthotics, Chiropodist

38 Reactive Arthritis (Reiter's)

39 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

40 Reiter’s Syndrome A form of Reactive Arthritis Triad: - Urethritis
- Conjuntivitis - Arthritis

41 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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45 Clinical Features II Ocular lesions (unilateral or bilateral)
- Conjuntivitis - Iritis Visceral manifestations - Mild Renal disease - Carditis

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47 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

48 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

49 Prognosis Generally good Recurrences not uncommon
Some develop a chronic form

50 Remember (Spondyloarthropathies)
Associated with HLA B27 Affect Spine/Joints Enthesitis Extra articular features

51 Questions ?


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