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.
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 – 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. Diagnosis AS?

18. 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

19. Schober’s test

20. Sacroiliitis

21. AS Clinical Features - axial
Early AS
Romanus lesion
Advanced AS
bony ankylosis

23. AS Clinical Features - peripheral
30% hip and
shoulder disease
Peripheral
enthesopathy

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

25. Complications - Spondylodiscitis
5%, dorsal spine
Inflammatory
Posterior #
and instability

26. Features of uveitis ?

27. 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

28. Features of Psoriasis ?

29. AS extra-articular features
Psoriasis 10-15%

30. 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

31. AS Clinical Features – extra-articular - Cardiac2%
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)

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

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

34. 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

35. AS – treatment Physiotherapy NSAIDS ‘DMARDs’ and steroids
TNF alpha blockade
Surgery

36. PsA features ?

37. Demography - PsA No widely accepted criteria for diagnosis of PsA
BSR guidelines estimate prevalence of 0.1% -1% patients in UHCW
Peak age of onset: years
Equal sex distribution

38. Burden of PsA 40%–57% have deforming arthritis 11%–19% are disabled
Mortality is increased, compared with general population

39. 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

40. PsA – clinical

41. PsA –bone proliferation and destruction

42. Treatment
NSAIDs
DMARDs – Sulphasalazine, Methotrexate, Leflunomide, Cyclosporin
Steroids
TNF alpha blockade
OT, PT
Surgery
Dermatology input

43. Reactive arthritis features ?

44. 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. Reactive arthritis Culture – throat, urine, stool, urethra/cervix
Treatment – NSAIDs, steroids –intra-articular, antibiotics – chlamydia, DMARDs eg sulphasalazine

47. 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

48. THANK-YOU