Sero negative Spondyloarthritis

This term is applied to a group of inflammatory joint diseases, distinct from rheumatoid arthritis, that are thought to share similar pathogenesis, they all show considerable overlap and similarity of articular and extra articular clinical features

Seronegative Spondyloarthritis 1.Ankylosing Spondylitis 2.Reactive arthritis including Reiters syndrome 3.Psoriatic arthritis 4.Arthropathy associated with IBD

Clinical features common to Sero –ve SP Asymmetrical inflammatory oligoarthritis ( lower limbs more than upper limbs) Sacroilitis and inflammatory spondylitis Inflammatory ethesitis Tendency for familial aggregation -ve RF Absence of nodules Association with HLA - B27

Clinical features common to Sero –ve SP Overlapping extra articular features Mucosal surface inflammation ( conjunctivitis, buccal ulceration, urethritis, prostatitis, bowel ulceration, postural skin lesion and nail dystrophy ) Anterior uveitis Aortic root fibrosis Erythema nodosum

conjunctivitis

postural skin lesion and nail dystrophy

Erythema nodosum

Ankylosing Spondylitis It’s chronic inflammatory arthritis with predilection to the sacroiliac J. and spine, characterized by progressive stiffening and fusion of the axial skeleton

Epidemiology Peak onset in second to third decade Male : female ratio about 3:1 90% of the affected persons are HLA-B27 +ve Increase faecal carriage of Klebsiella aerogenes

Clinical features Low back pain with morning stiffness, radiate to the buttock or posterior thigh Symptoms relieved by movement The lumbosacral area are first affected followed by neck and thoracic symptoms The disease tend to ascend the spine slowly and eventually become ankylosed, spinal rigidity and secondary osteoporosis which predispose to spinal fracture

Clinical features Pleuritic chest pain Plantar fasciitis, Achiles tendonitis and tenderness of bony prominence as iliac crest, greater trochanter Peripheral arthritis in 40 % of cases Early physical signs : 1. Failure to obliterate the lumbar lordosis on forward flexion

Loss of lordosis

Clinical features 2. Pain on sacroiliac compression 3.Restriction of movement of the lumbar spine in all directions 4.Restriction of chest expansion 5.Flexion deformity, Kyphosis of the dorsal and cervical spine

Clinical features 6.Extra articular features : Ant. Uveitis 25% and conjunctivitis 25 % Prostatitis 20 % Aortic incompetence, MI, cardiac conductive defect, pericarditis Amyloidosis Atypical upper lobe pulmonary fibrosis

Investigations Elevated ESR, CRP, ( may be normal ) RF –ve Radiographic signs : Takes many years to develop Sacroiliitis ( irregularity at lower synovial part with loss of lower cortical margin ), widening of the J. space and then marginal sclerosis, narrowing and fusion

Bilateral Sacroiliitis

Bilateral Sacroiliitis ( widening of J.space )

Sclerosis and widening of J space

Fusion of SI joint

Complete Fusion of SI joint

Investigations Ossifications of the ant. Longitudinal ligaments and facet J. fusion, bridging syndesmophyte ( symmetrical and marginal ), the combination of all these result in bamboo spine Ant squaring of the vertebrae due to erosion and sclerosis of the ant. corners Erosive changes seen in symphysis pubis, ischial tuberosity and peripheral J. Osteoporosis and atlanto axial dislocation

Interspinous ligament ossification

Squaring of vertebrae

Bamboo spine (fusion )

Bamboo spine ( complete fusion )

Interspinous ligament ossification

Cervical ankylosis

Management Daily back extension exercise Swimming is ideal exercise Avoid poor bed and chair posture NSAIDs for reliving of pain DMARDs as Salfasalazin, MTX, Azathioprine control peripheral synovitis Local corticosteroid injection in plantar fasciitis ( other enthesopathy ) Surgery may be needed

Prognosis 75 % of patients are able to remain in employment Severe hip, knee or shoulder disease carry poor prognosis

Reactive arthritis

Reiter’s disease is the triad of : 1. non- specific urethritis 2.conjunctivitis 3. Reactive arthritis Reiter’s disease follows : 1.Bacterial Dysentery mainly salmonella, shigella, campylobacter or yersinia 2.Sexually acquired infection with chlamydia

conjunctivitis

Epidemiology Sex ratio male to female 15 : 1 Aged 16 – 35 years

Clinical features Onset : acute ( classical condition ) inflammatory oligoarthritis affecting large and small Js of lower limbs, 1 -3 weeks following sexual exposure or an attack of dysentery Systemic disturbance with fever, weight loss and vasomotor changes in the feet Subacute or insidious single J. involvement over days turns into asymmetric oligoarthritis symptoms of urethritis, conjunctivitis may be minimal or absent

Acute Reactive arthritis of PIP & MCP Js.

Chronic severe arthritis with deformity and nail pathology

Chronic arthritis with onycolysis and onycomycosis

Clinical features Extra articular manifestations : Circinate balanitis ( %) Keratoderma blenorrhagica ( 15 % ) Nail dystrophy with sub unqual hyperkeratosis Buccal lesion (10 % )

Keratoderma blenorrhagica

Clinical features The first attack of arthritis is self limiting with spontaneous remission of symptom within 2-4 m. of onset 60 % had recurrent or chronic arthritis % of chronic arthropathy develop Sacroliitis 30 % of patients with recurrent arthritis develop uveitis Other features are uncommon : Peripheral neuropathy, CNS disease as seizures, meningoencephalitis

Investigations Increase ESR, CRP, normocromic normocytic anaemia Synovial fluid : Low viscosity, presence of Giant macrophage (Reiter’s cells ) Urethritis confirmed by presence of mucoid threads in the first void specimen of urine High vaginal swab may reveal Chlamydia Stool culture are usually negative at time of arthritis -ve RF, ANA

Investigations X-RAY –ve in acute condition Periarticular osteopenia, J. space narrowing and marginal proliferative erosion may develop with chronic disease Large fluffy cacaneal spur Radiologic SI often asymmetrical and sometime unilateral Syndesmophyte are coarse non marginal

Erosions of PIP Js.

Deformities with cystic lesions of DIP Js.

MTP J erosion, sublaxation and deformity

Calcaneal spur

Syndesmophytes

Bilateral sacroiliitis

Management NSAIDs in acute attacks Intra articular steroids Systemic steroids rarely required Severe arthritis and keratoderma blenorrhagica need Azathiprine or MTX Short course Tetracycline for urethritis