1. Seronegative Spondyloarthropathies
M.Valešová

2. Spectrum Ankylosing spondylitis Psoriatic arthritis Reactive arthritis
Enteropathic arthritis
Undifferentiated spondyloarthritis
Juvenile AS

3. Ankylosing spondylitis (AS)

4. Demography AS Prevalence AS 0.05-0.23%, 3-4X male
UHCW catchment area – AS pts

5. Burden of AS SMR 1.5 10% less labour participation
15% constraints at work
Poor quality of life cf worse than RA

6. 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.

7. Features AS?

8. Physical signs and diagnosis

10. 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

11. Schober’s test

12. Sacroiliitis

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

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

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

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

18. 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

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

20. 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

21. 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)

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

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

24. 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

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

26. Psoriatic arthritis (PsA)

27. 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

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

29. 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

31. Physical signs and Diagnosis

32. PsA –bone proliferation and destruction

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

34. Reactive arthritis features ?

35. 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

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

38. 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