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Seronegative Spondyloarthropathies

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 2 nd and 4th fingers

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Seronegative Spondyloarthropathies

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  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 – 375-1700 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

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

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

  24. 5%, dorsal spine Inflammatory Posterior # and instability Complications - Spondylodiscitis

  25. Features of uveitis ?

  26. 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

  27. Features of Psoriasis ?

  28. AS extra-articular features • Psoriasis 10-15%

  29. 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

  30. 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)

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

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

  33. 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

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

  35. PsA features ?

  36. 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

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

  38. 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

  39. PsA – clinical

  40. PsA –bone proliferation and destruction

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

  42. Reactive arthritis features ?

  43. 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

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

  45. 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

  46. THANK-YOU

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