Seronegative arthropathies

rheumatology lectures

1. Seronegative arthropathies
(spondyloarthropathies(

2. Definition
It is a group of inflammatory
arthropathies that share
distinctive clinical, radiological
and genetic features .
Characterized by involvement of
sacroiliac joint, by peripheral
inflammatory arthropathy and by
absence of Rheumatoid factor.

4. Mechanical
LBP
Inflammatory
LBP
Example Disc prolapse Spondyloarthropathy
History:
Age Any age > young around 30 yrs.
Sex Any sex Males > females
Onset sudden Incidious
Associations Trauma,
Spondylosis
HLA- B 27
Family H. -ve +ve
Morning Stiff. > 30 min. > One hour

5. Symptoms
duration
> 4 Weeks > 3 Months
Effect of rest Improve the
condition
Worsen the
condition
Effect of
exercises
Worsen the
condition
Improve the
condition
Examination:
Location of pain Localized Diffuse
Symmetry of pain Unilateral Bilateral
Systemic Dis. -ve +ve
Deformities Scoliosis L. flattening, D. &
C. kyphosis

6. Neurological S. Sciatica, Femoral
neuralgia or
radicular
manifes.
With AS (post.
lumbo-sacral
arachn.
Diverticula,

Cauda
Equina).
Muscle spasm Asymmetrical Symmetrical
Spinal tendeness

Radiation


Localized
Down to heel
Diffuse, SIJ‘s
tenderness
Not below the
knees

7. 
It includes:
1- Ankylosing Spondylitis.
2-Enteropathic arthropathy.
(Crohn's dis. &
Ulcerative colitis).
3- Psoriatic Arthropathy.
4- Rieter 's syndrome.
5-Undifferentiated
spondyloarthropathy.

11. Modefied New York Criteria for Ankylosing
Spondylitis
1- Low back pain for at least 3
months, improved by exercise, not
relieved by rest.
2- Limitation of lumbar spine
movement in frontal and sagittal
planes.
3- Diminished chest expansion
relative to normal values to age and
sex.
4- Unilateral sacroillitis G 3-4. or
bilateral sacoiliitis G 2-4.

12. Prevalence of all SpAs ~ 1-2
%,like RA.
Patient not fulfilling individual
criteria but possessing many
features from every disease, may
be classified as having (uSpA).

13. They may be involved with other
muco-cutaneous manifestation
(iritis, psoriasis, conjunctivitis,
oro-genital ulcers)
 Strong association with HLA-
B27& +ve family history.
 Infection is implicated as a
triggering factor.

14. Pathogenesis
Unknown, theories, infection
with certain organism, or
exposure to unknown antigen,
in a genetically susceptible
patient ( HLA-B27), is
hypothesized to result in
clinical expression of AS.

15. Pathology
Primary lesion is inflammation of the
enthesis i.e. enthesopathy) (the site of
insertion of ligaments, joint capsule,
tendon or fascia into bone).
Erosion , new bone formation at joint
margin, narrowing of joint bony fusion
( ankylosis)
 Peripheral arthritis, often asymmetrical
& affecting more the lower limb joints.

20. Features
Ankylosing
spondylitis
Reiter's
syndrome
Psoriatic
arthritis IBD
Prevalence 0.1% to 0.2% 0.1% 0.2% to 0.4% Rare
Age Late teens to
early
adulthood
Late teens to
early
adulthood
35 to 45 yearsAny age
Male / female 3:1 5:1 1:1 1:1
HLA-B27 90% to 95% 80% 40% 30%
Sacroiliitis
- Frequency %100 40% to 60% 40% 20%
-
Distribution
SymmetricAsymmetricAsymmetric Symmetric

21. Syndesmophytes Delicate,
marginal
Bulky,
nonmarginal
Bulky,
nonmarginal
Delicate,
marginal
Peripheral arthritis
- Frequency OcassionalCommon Common Common
- Distribution Asymmetric,
lower limbs
Asymmetric,
lower limbs
Asymmetric,
upper>lowerl.
joint
Asymmetric,
lower limbs
Enthesitis Common Very commonVery commonOccasional
Dactylitis
UncommonCommon Common Uncommon
Skin lesions None Circinate
balanitis,
keratoderma
blennorrhagica
PsoriasisErythema
nodosum,
pyoderma
gangrenosum
Nail changes None Onycholysis Pitting,
onycholysis
Clubbing

22. Eye Acute anterior
uveitis
Acute anterior
uveitis,
conjunctivitis
Chronic uveitisChronic uveitis
Oral Ulcers Ulcers Ulcers Ulcers
C.V.S Aortic
regurgitation,
conduction
defects
Aortic
regurgitation,
conduction
defects
Aortic
regurgitation,
conduction
defects
Aortic
regurgitation
R.S Upper lobe
fibrosis
None None None
G.I.T None Diarrhea None Crohn's disease,
ulcerative colitis
U.T Amyloidosis,
IgA
nephropathy
AmyloidosisAmyloidosisNephrolithiasis
G.U.T Prostatitis Urethritis,
cervicitis
None None

28.  X- ray for:
I. Sacroiliac joint
Erosin, blurring, narrowing, reactive
sclerosis and bony ankylosis.
II. Lumber Spine:
- Vertebrae appear square due to erosion of
their corners “ squared off ” appearance.
- Vertical bridging osteophytes or
“ syndesmophytes” spread up and down
from v. body fusion bamboo sp.

29. -- Ossification of ant. Longitudinal ligament.
-- MRI is more sensitive for detection of early &
inflammatory changes of SIJ.
- Reiters syndrome:
- - soft tissue swelling.
- - Joint space narrowing & erosion.
- - Sacroiliitis or spondylitis.
- Psoriatc arthropathy:
- - Erosion &new bone formation at joint
margin, bony fusion.
- - Whittling of the distal ends at the
phalanges

30. - Extensive bone resorption “Opera glass”
appearance.
- Sacroilitis & spondylitis.
 Laboratory:
1. ESR & CRP.
2. HLA-B 27.
3- RF.

33. Differential diagnosis:
1- Intervertebral disc lesion.
2- Trauma & degenerative lesion:.
* Lumber spondylosis.
3- Vertebral fractures:
* Direct trauma.
* Sequlae of metabolic diseases.
* Vertebral tumor.

34. 4- Soft tissue lesions:
* Sprains.
* Tears of spinal ligaments.
* Tears of dorsal muscles.
5- Deformities & congenital defects:
* Postural abnormalities:
- Kyphosis. - Lordosis. - Scoliosis.
* Congenital defects of vertebrae:
- Spina bifida.
- Spinal stenosis.

35. 6- Arthritis & infectious lesion of the spine:
* T.B.
* Osteomyelitis.
7- Neoplasm of the spine: Benign, malignant,
multiple myeloma.
8- Metabolic bone diseases:
* Osteoporosis. * Osteomalacia
9- Lesion of sacroiliac joint:
* OA
10- Psychogenic.

36. 13- Soft tissue lesions:
* Enthesopathy at posterior iliac crest.
* Retroperitoneal fat herniation.
14- Referred pain:
* Renal disorders.
* Cancer pancreas.
* Dissecting aortic aneurysm.
* Chronic duodenal ulcer.
* Pelvic disorders.

44. I. Medical ttt.
 Analgesics , NSAIDs or acetaminophen.
 Muscle relaxants for acute or chronic pain to
control muscle spasm & relief pain.
 Local steroid injection: for enthesopathies.
Sulphasalazine &methotraxate: for peripheral
arthritis but have little effect on axial dis.
TNF blockers are effective.
Tetracycline for nonspecific urethritis.
Avoid antimalarial in psoriasis as it cause
exfoliative reaction.

45. II. Physical ttt.
 Stay physically active.
 Spinal extension exercises
 Acupuncture: for trigger points.
 Transcutaneous electrical nerve stimulation
( TENS).
 Deep heat or Ice: to improve the muscle spasm
& relief pain.
 LASER & Interferential current: relief muscle
ache.

46. Stretching exercises: will alleviate the
tight back muscles through pelvic
tilting.
 Low impact activities: as swimming,
walking and bicycling can increase the
overall fitness without straining the
back.
Genetic councilling.