1. Seronegative Spondyloarthropathies
Phase II Musculoskeletal Lecture 23/02/2012

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

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

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

5. 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

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

11. Ankylosing Spondylitis

12. 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

13. 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

14. 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

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

18. 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

19. Occiput to wall

20. Schober Test

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

26. Psoriatic Arthritis

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

28. 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)

31. 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

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

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

38. Reactive Arthritis (Reiter's)

39. 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

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

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

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

47. 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

48. 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

49. Prognosis Generally good Recurrences not uncommon
Some develop a chronic form

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

51. Questions ?