Seronegative Spondyloarthropathies Phase II Musculoskeletal Lecture 23/02/2012

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

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

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

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

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

Ankylosing Spondylitis

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

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

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

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

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

Occiput to wall

Schober Test

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

Psoriatic Arthritis

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

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)

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

Diagnosis History Examination Bloods: X-rays Inflammatory parameters (raised) Negative RF X-rays Marginal erosions and “whiskering” “Pencil in cup” deformity Osteolysis Enthesitis

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

Reactive Arthritis (Reiter's)

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

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

Clinical Features I General Symptoms (fever, fatigue, malaise) Asymmetrical monoarthritis or oligoarthritis Enthesitis Mucocutaneous lesions - Keratodema Blenorrhagica - Circinate balanitis - Painless oral ulcers - Hyperkeratotic nails

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

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

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

Prognosis Generally good Recurrences not uncommon Some develop a chronic form

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

Questions ?