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 – exudatesIn 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