SERO-VE

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SERO-VE Powered By Docstoc
					    Seronegative
Spondyloarthropathies
     Jaya Ravindran
     Rheumatologist
              Introduction
• Cases

• Differential diagnoses

• Overview sero-ve diseases
                     Case 1
• A 34-year-old secretary
• painful swelling of her right 2nd and 4th fingers
  12 weeks ago. 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.
• Over the past 3 weeks, her fingernails and
  toenails appeared "thickened and detached."
Physical signs and Diagnosis
                  Case 2
• 22-year-old man, 12 weeks, 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