1. SERONEGATIVE ARTHRITIS

2. A group of inflammatory conditions causing arthritis of the spine and peripheral joints, often associated with HLA B27, but without a positive rheumatoid factor, hence "seronegative".
The joint involvement is more limited than in rheumatoid arthritis, and has different distribution - the lumbo-sacral spine, distal interphalangeal joints, depending on the subtype.
Enthesopathy (ligament/ tendon to bone junction inflammation) is more common.
Share similar pathogenesis with RA

3. Seronegative arthritis are more common in Males than in Females

4. Types: Ankylosing spondylitis Reiter’s syndrome Psoriatic Arthropathy
Arthropathy associated with IBD

5. Ankylosing Spondylitis
It is a chronic, inflammatory arthritis
It affects joints in the spine and the sacroiliac joints in the pelvis, causing eventual fusion of the spine.
Complete fusion results in a complete rigidity of the spine, a condition known as bamboo spine
The typical patient is young aged 18-30 years
Associated with HLA-B27(98%)
Men are affected more than women by a ratio about of 3:1.
In 40% of cases, Ankylosing Spondylitis is associated with an inflammation of the eye (iridocyclitis), causing eye pain and photophobia.

6. Clinical features: Recurrent low back pain Stiffness in back
Early morning worsening of symptoms
Pain is often severe on rest, and improves with physical activity.
Chest pain: Aggravated by breathing results from involvement of the costovertebral joints
Another common symptom is generalized fatigue.
May affect other joints: Ankle, Knee, Elbow
When Ankylosing Spondylosis occurs before 18 years It causes pain and swelling of large limb joints, particularly the knee, the spine may be affected later on.

7. Clinical features:
Failure to obliterate the lumbar lordosis on forward flexion
Pain on sacroiliac compression
Tenderness over bony prominence such as iliac crest, ischial tuberosity and greater trochanter
Restrictions of movements of lumbar spine in all directions
As the disease progresses, stiffness increases throughout the spine
Schober's test- Positive

8. Schober's test
The examiner makes a mark approximately at the level of L5.
The examiner then places one finger 5 cm below this mark, and another, second, finger, 10 cm above this mark.
The patient is asked to touch his/her toes.
By doing so, the distance between the two fingers of the examiner increases.
However, a restriction in the lumbar flexion of the patient reduces this distance
If the distance increases less than 5 cm, then there is an indication that the flexion of the lower back is limited.

9. Extra-articular features of Ankylosing spondylitis
Anterior uveitis
Conjunctivitis
Cardiovascular diseases
Aortic incompetence
Mitral incompetence
Cardiac conduction defects
Pericarditis
Amyloidosis
Atypical upper lobe pulmonary fibrosis

13. Investigations Rheumatoid factor  Negative/ Low titre positive
ESR,CRP Elevated/ Normal
X-Ray spine/ SI joint
Sacroilitis
Irregularity/ Loss of cortical Margins
Widening of Joint spaces
Marginal Sclerosis
Narrowing
Fusion
Lateral views of Thoracolumbar spine
Anterior Squaring of vertebrae
Due to  Erosion+ Sclerosis of anterior corners with periostitis
Bridging syndesmophytes
Ossification of Anterior longitudinal ligament
Facet joint fusion
 Fusion of two vertebral bodies giving typical Bamboo Spine.
HLA-B 27/ HLA-B7/B*2705 heterozygotes Highest risk

14. NOTE
The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), is an index designed to detect the inflammatory burden of active disease.
The BASDAI can help to establish a diagnosis of AS in the presence of other factors such as
HLA-B27 positivity
Persistent buttock pain which resolves with exercise, and
X-ray or MRI evident involvement of the sacroiliac joints.
Assesses a patient's need for additional therapy
A patient with a score of 4 out of a possible 10 points while on adequate NSAID therapy is usually considered a good candidate for biologic therapy.
The Bath Ankylosing Spondylitis Functional Index (BASFI) is a functional index which can accurately assess a patient's functional impairment due to the disease as well as improvements following therapy.
The BASFI is not usually used as a diagnostic tool but rather as a tool to establish a patient's current baseline and subsequent response to therapy.

15. Treatment:
MEDICAL:
NSAIDS ibuprofen, phenylbutazone, indomethacin, naproxen and COX-2 inhibitors
Opiate analgesics (extended-release formulations)
DMARDs cyclosporin, methotrexate, sulfasalazine, and corticosteroids
TNFα blockers such as etanercept, infliximab and adalimumab (also known as biologics)helps by slowing the progress of AS
SURGICAL:
Joint replacements, particularly in the knees and hips (Severe cases)
Surgical correction for those with severe flexion deformities
PHYSICAL THERAPIES:
Movements that normally have great benefits to one's health may harm a patient with AS. So, all physical therapies must be approved in advance by a rheumatologist
Physical therapy/physiotherapy
Swimming, one of the preferred exercises since it involves all muscles and joints in a low-impact
Slow movement muscle extending exercises like stretching, yoga, climbing, tai chi, Pilates method, etc.

16. REACTIVE ARTHRITIS/REITER’S SYNDROME
Reactive arthritis is an autoimmune condition that develops in response to an infection in another part of the body.
Coming into contact with bacteria and developing an infection can trigger reactive arthritis
A type of seronegative spondyloarthropathy
“A patient with Reiter’s syndrome can't see, can't pee and can't bend the knee/can't climb a tree".
Male: Female=20:1

17. COMMON TRIGGERS:
HLAB-27
Sexually acquired Chlamydial/ Neisseria gonococcal infection(STD)
Intestinal infections : Salmonella,Shigella and Campylobacter jejuni
HIV

18. Clinical Triad of
Inflammatory arthritis of large joints including commonly the knee and the back (due to involvement of the sacroiliac joint)
Inflammation of the eyes in the form of (conjunctivitis or uveitis), and
Urethritis in men or cervicitis in women.

19. Clinical features: It is an inflammatory arthritis of large joints
Inflammation of the eyes (conjunctivitis and uveitis), and
Non-specific Urethritis
Inflammatory arthritis
Conjunctivitis or uveitis
Urethritis in men or cervicitis in women
Patients can also present with
Mucocutaneous leisons, as well psoriasis-like skin lesions such as
Circinate balanitis (Serpiginous annular dermatitis of the glans penis)
Keratoderma blennorrhagica (Skin lesions commonly found on the palms and soles but which may spread to the scrotum, scalp and trunk also, and which resemble psoriasis)
Enthesitis can involve the Achille's tendon resulting in heel pain.
Clinical features:

21. Systemic features:
-Fever and weight loss are common
-Carditis and aortic regurgitation may occur
First episode: Self limiting
>60% Patients: Recurrent/Chronic arthritis develops
HLAB27 gene: In 90% patients positive
Treatment:
NSAIDS
Steroids
Treat infections
Severe case not responding to other medicines: Immunosuppresives

22. PSORIATIC ARTHROPATHY
Seen in Patients with Psoriasis
Arthritis develops in around 7-10% of patients with posriasis
Age of onset: years
Oligoarthritis=Small joints of hands and feet
Symmetric Polyarthritis= May mimic RA
Arthritis involves DIP joint and usually associated with nail changes: Characteristic
Spondylitis
Arthritis mutilans
Intermittent exacerbations
Presence of other features of Psoriasis
--Scaling lesions typically over extensor surfaces
--Nail changes: Pitting and onycholysis
--Eye :Iritis

24. Treatment:
NSAIDS
Joint injections with corticosteroids - this is only practical if a few joints are affected
Methotrexate, Sulfasalazine, Azathioprine
Splints and prolonged rest are avoided because of increased tendency to fibrous and bony ankylosis
TNF Alpha (Infiximab)
PUVA—May improve skin and joint disease

25. ARTHRITIS ASSOCIATED WITH IBD
Seronegative arthritis associated with Crohn’s disease and ulcerative colitis
Oligoarthritis= Large joints in lower limb
Symptoms coincide with exacerbation of underlying bowel disease
Spondylitis
Enthesitis
Sometimes it may be associated with mouth ulcers,iritis and erythema nodosum

26. INFECTIVE ARTHRITIS

27. SEPTIC ARTHRITIS
Septic arthritis is an acute onset bacterial inflammation, usually involving single joint(>90%).
Most often knee joint and wrists are involved.
In IV drug abusers infection of spine and sacroiliac joints is more common
Etiology:
Staphylococcus aureus
Streptococci
Gram negative Bacilli such as E-coli and Pseudomonas

28. Predisposing Factors: 1. Hematogenous spread:
Microorganisms reach the joint by hematogenous spread following bacteremia, so it is important to look for evidence of :
Septic skin lesion, Abrasions
Endocarditis
Iv drug abuse
Throat or urinary tract infection
2. Direct entry in the joint:
Following penetrating wounds
Local osteomyletis or Joint injection.

29. Clinical features: Sudden onset
Typical presentation is single painful joint, often knee
Other joints are wrist, hip, shoulder and ankle
The joints are red, warm and swollen with a demonstrable effusion
Marked limitation of movement
Fever with chills in 80%

30. Diagnosis: Blood culture: Positive in 50% cases Aspiration of joint:
Synovial fluid is purulent with neutrophil dominant, Increased WBC often>100,000/μL
Gram stain of synovial fluid is positive in 75% of cases.
C/S of fluid
D/D:
Trauma
Gout and Pseudogout
Reactive arthritis

31. Treatment: Joint immobilization/elevation of joint Antiobiotics:
It is given according to culture and sensitivity.
Intravenous antiobiotics for 2-3 weeks, followed by 9-10 weeks of oral antibiotics
Empirical treatment:
IV Ceftriaxone 1-2 gm once daily plus Cloxacillin 1-2 gm 6 hourly
IV Vancomycin 1gm 12 hourly if methicillin resistant staph is suspected
Aminoglycosides should be given to IV drug absuer in which Pseudomans is suspected.

32. Drainage:
Daily drainage of fluid until no further fluid is available
Arthroscopic drainage and lavage is required if repeated needle aspiration fails to relive the symptoms, failure to decrease the volume of effusion and there is no clearance of bacteria from smear.

33. GONOCOCCAL ARTHRITIS
This is one of the most common cause of septic arthritis in previously fit and sexually active young adults.
Recurrent infection should be evaluated for congenital deficiency of complements C7 and C8
Blood culture is positive in about 40% of cases
Cultures is usually positive also from genital organs, throat and rectum
Synovial fluid gram staining is positive in 25%
Treatment:
IV Ceftriaxone 1gm daily for hrs then
Ciprofloxacin 500mg 12 hourly for 7-10 days

34. TUBERCULOUS ARTHRITIS
Tuberculous arthritis is invariably secondary to pulmonary or renal TB due to hematogenous spread of organism
Pathology:
The synovial membrane and periarticular tissues become inflamed and edematous
Later there is destruction of cartilage which may lead to fibrous ankylosis
When spine is involved the infection may track along the fascial plane to produce psoas abscess

35. Clinical features:
Usually single joint involvement affecting the hip or knee(30%) or other joints(20%) and spine(50%)
Onset is insidious of pain and dysfunction of the joint with swelling and synovial proliferation and restriction of movement
Malaise,anorexia,night sweats and weight loss
Spinal involvement may lead to compression of vertebrae and paraplegia

36. Investigations:
Synovial fluids:Synovial fluid culture and sensitivity
Synovial biopsy
X-ray:Initially normal,later narrowing of joint space
T/T:
Anti tuberculous drugs

37. MENINGOCOCCAL ARTHRITIS
This usually occurs as a part of generalised meningococcal septicemia
It is a migratory polyarthritis
Organism cannot be isolated from synovial fluid
Treatment is with Penicillin or Ceftriaxone

38. VIRAL ARTHRITIS Organisms: Rubella virus Mumps Hepatitis
This is particularly a complication of the rubella infection in young adult female
This presents as bilateral, symmetrical Polyarthritis and resolves within few weeks inmost of the cases