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Seronegative Spondyloarthropathies

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Seronegative Spondyloarthropathies Jaya Ravindran Rheumatologist Introduction Cases Overview sero-ve diseases Case 1 A 34-year-old secretary 3 months painful swelling ... – PowerPoint PPT presentation

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Title: Seronegative Spondyloarthropathies


1
Seronegative Spondyloarthropathies
  • Jaya Ravindran
  • Rheumatologist

2
Introduction
  • Cases
  • Overview sero-ve diseases

3
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.

4
Physical signs and Diagnosis
5
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?

6
Case 2
  • 1months ago, he developed nausea, cramps, and
    diarrhoea after attending an "all-you-can-eat"
    buffet.
  • He has had 5 sexual partners the last year
  • eyes "scratchy" of late
  • some burning when he urinates

7
Physical signs and diagnosis
8
Case 3
  • 21-year-old male student
  • low back pain of 6 months' duration.
  • Relevant questions?

9
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.

10
Case 3
  • Diagnosis?
  • Likely ocular diagnosis?
  • Investigations?

11
Investigations
  • XR SIJ and L/Spine normal
  • CRP, ESR normal

12
Investigations
  • HLA-B27 ve - referred
  • MRI bilateral sacroiliitis

13
Spectrum
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Reactive arthritis
  • Enteropathic arthritis
  • Undifferentiated spondyloarthritis
  • Juvenile AS

14
Demography AS
  • Prevalence AS 0.05-0.23, 3-4X male
  • UHCW catchment area 375-1700 AS pts

15
Burden of AS
  • SMR 1.5
  • 10 less labour participation
  • 15 constraints at work
  • Poor quality of life cf worse than RA

16
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.

17
  • Features AS?

18
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19
Diagnostic criteria Modified New York criteria
  • Radiologic criteria sacroiliitis - grade 2
    bilaterally or grade 3-4 unilaterally
  • Clinical criteria LBP and stiffness gt 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

20
Schobers test
21
Sacroiliitis
22
AS Clinical Features - axial
  • Early AS
  • Romanus lesion
  • Advanced AS
  • bony ankylosis

23
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24
AS Clinical Features - peripheral
  • 30 hip and
  • shoulder disease
  • Peripheral
  • enthesopathy

25
Complications - Fracture
  • Traumatic
  • C5/6 also C6/7 and C7/T1
  • Unstable immobilization
  • and fixation
  • Osteoporotic (20-60)
  • and vertebral fractures (8-15)
  • Discitis

26
Complications - Spondylodiscitis
  • 5, dorsal spine
  • Inflammatory
  • Posterior
  • and instability

27
  • Features of uveitis ?

28
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

29
  • Features of Psoriasis ?

30
AS extra-articular features
  • Psoriasis 10-15

31
AS Clinical Features extra-articular
Inflammatory bowel
  • GI - Clinically silent enteric mucosal lesions
    30-60
  • UC and Crohns 5-15 spinal and 10-20 peripheral
    arthritis

32
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)

33
AS Clinical Features extra-articular - Upper
lobe fibrosis
  • 1.3
  • 20 years after onset
  • Bilateral linear or patchy opacities
  • Later cystic
  • Colonized by
  • aspergillus

34
AS Clinical Features extra-articular
  • Neurological fracture dislocation, Cauda
    equina syndrome, atlanto-axial disease
  • Renal amyloidosis, IgA nephropathy, analgesic
    nephropathy

35
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

36
AS treatment
  • Physiotherapy
  • NSAIDS
  • DMARDs and steroids
  • TNF alpha blockade
  • Surgery

37
  • PsA features ?

38
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

39
Burden of PsA
  • 4057 have deforming arthritis
  • 1119 are disabled
  • Mortality is increased, compared with general
    population

40
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

41
PsA clinical
42
PsA bone proliferation and destruction
43
Treatment
  • NSAIDs
  • DMARDs Sulphasalazine, Methotrexate,
    Leflunomide, Cyclosporin
  • Steroids
  • TNF alpha blockade
  • OT, PT
  • Surgery
  • Dermatology input

44
  • Reactive arthritis features ?

45
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

46
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47
Reactive arthritis
  • Culture throat, urine, stool, urethra/cervix
  • Treatment NSAIDs, steroids intra-articular,
    antibiotics chlamydia, DMARDs eg sulphasalazine

48
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

49
THANK-YOU
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