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					    Seronegative
Spondyloarthropathies
     Jaya Ravindran
     Rheumatologist
             Introduction
• Cases

• Overview sero-ve diseases
                  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.
Physical signs and Diagnosis
                  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?
                 Case 2
• 1months ago, he developed nausea,
  cramps, and diarrhoea after attending an
  "all-you-can-eat" buffet.
• He has had 5 sexual partners the last year
• eyes "scratchy" of late
• some burning when he urinates
Physical signs and diagnosis
                 Case 3
• 21-year-old male student
• low back pain of 6 months' duration.
• Relevant questions?
                       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.
                 Case 3
• Diagnosis?
• Likely ocular diagnosis?
• Investigations?
           Investigations
• XR SIJ and L/Spine normal

• CRP, ESR normal
              Investigations
• HLA-B27 +ve - referred
• MRI bilateral sacroiliitis
                  Spectrum
•   Ankylosing spondylitis
•   Psoriatic arthritis
•   Reactive arthritis
•   Enteropathic arthritis
•   Undifferentiated spondyloarthritis
•   Juvenile AS
          Demography AS
• Prevalence AS 0.05-0.23%, 3-4X male



• UHCW catchment area – 375-1700 AS pts
             Burden of AS
• SMR 1.5

• 10% less labour participation

• 15% constraints at work

• Poor quality of life cf worse than RA
                            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.
• Features AS?
 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
Schober’s test
Sacroiliitis
    AS Clinical Features - axial
• Early AS
 Romanus lesion

• Advanced AS
bony ankylosis
 AS Clinical Features - peripheral

• 30% hip and
shoulder disease
• Peripheral
enthesopathy
     Complications - Fracture
• Traumatic
• C5/6 also C6/7 and C7/T1
• Unstable – immobilization
and fixation
• Osteoporotic (20-60%)
and vertebral fractures (8-15%)
• Discitis
    Complications - Spondylodiscitis
• 5%, dorsal spine
• Inflammatory
• Posterior #
and instability
• Features of uveitis ?
    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
• Features of Psoriasis ?
    AS extra-articular features
• Psoriasis 10-15%
    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
    AS Clinical Features – extra-
        articular - Cardiac
• 2%
• 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)
    AS Clinical Features – extra-
    articular - Upper lobe fibrosis
• 1.3%
• 20 years after onset
• Bilateral linear or patchy opacities
• Later cystic
• Colonized by
aspergillus
    AS Clinical Features – extra-
              articular
• Neurological – fracture dislocation, Cauda
  equina syndrome, atlanto-axial disease

• Renal – amyloidosis, IgA nephropathy,
  analgesic nephropathy
             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
              AS – treatment
• Physiotherapy

• NSAIDS

• ‘DMARDs’ and steroids

• TNF alpha blockade

• Surgery
• PsA features ?
          Demography - PsA
• No widely accepted criteria for diagnosis of PsA

• BSR guidelines estimate prevalence of 0.1% -
  1% - 500-1000 patients in UHCW

• Peak age of onset: 35-50 years



• Equal sex distribution
            Burden of PsA
• 40%–57% have deforming arthritis



• 11%–19% are disabled



• Mortality is increased, compared with
  general population
         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
PsA – clinical
PsA –bone proliferation and
       destruction
             Treatment
• NSAIDs
• DMARDs – Sulphasalazine, Methotrexate,
  Leflunomide, Cyclosporin
• Steroids
• TNF alpha blockade
• OT, PT
• Surgery
• Dermatology input
• Reactive arthritis features ?
           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
           Reactive arthritis
• Culture – throat, urine, stool, urethra/cervix

• Treatment – NSAIDs, steroids –intra-
  articular, antibiotics – chlamydia, DMARDs
  eg sulphasalazine
               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
THANK-YOU

				
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posted:10/24/2012
language:Latin
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