SERONEGATIVE SPONDYLOARTHROPATHY.pptx

SERONEGATIVE SPONDYLOARTHROPATHY

1. SERONEGATIVE SPONDYLOARTHROPATHY Dr Nihal Ahmed Apollo Cancer Centre Teynampet , Chennai

2. Terminology Spondyloarthropathies ( SpA ), are a group of musculoskeletal syndromes linked by common clinical features and immunopathologic mechanisms. Diagnostic criteria: Absence of RF Sacroiliitis with/without AS Peripheral arthropathy Clinical overlap including 2 or more of following:- Psoriatic skin or nail lesion Conjuctivitis /GUT infection Ulceration of mouth, intestine or genitals Eryhtema nodosum

3. Diseases Five subgroups of spondyloarthritis are distinguished: Ankylosing spondylitis : ~90% HLAB27 positive Psoriatic arthritis : ~60% Reactive arthritis : ~85% Enteropathic arthritis  (i.e. extraintestinal manifestation of  IBD ) Undifferentiated spondyloarthritis

4. ANKYLOSING SPONDYLITIS A chronic, progressive inflammatory disease resulting in fusion ( ankylosis ) of the spine and sacroiliac (SI) joints. Mostly affects young adults(3 rd decade), Male predilection of 3:1. The axial skeleton is predominantly affected, although in ~20% of cases the peripheral joints are also involved. Associations A nterior uveitis  (25-40%) Cardiovascular disease, A ortic valve disease A pical/upper lobe predominant  interstitial lung disease  with small cystic spaces (in ~1% of patients)  A rachnoiditis

5. Radiographic features SACRUM Sacroiliitis  is usually the first manifestation – Bilateral, symmetrical Subchondral demineralization - equivalent of subchondral bone marrow hyperintensity seen on MRI. Subchondral erosions, sclerosis (>5mm) on the iliac side of the SI joints. At end-stage, total ankylosis /complete obliteration of joint space.

6. Sacroiliitis grading (New York criteria)

7. SPINE Begins in the thoracolumbar spine and progresses cranially . Small erosions at the corners of vertebral bodies with reactive sclerosis:  Romanus lesions  ( shiny corner sign ) Vertebral body squaring Noninfectious  spondylodiscitis :  Andersson lesion Diffuse syndesmophytic ankylosis - Bamboo spine (Lat) Interspinous ligament ossification - Dagger spine (AP) Ossification of facet joint – Tram track sign Enthesophyte Complications – carrot stick fractures

8. Hips Bilateral and symmetric, uniform joint space narrowing, axial migration of the femoral head, protrusio acetabuli , and a collar of osteophytes at the femoral head-neck junction. Pelvis Whiskering of the pelvic bones primarily affects the ischial tuberosities/iliac crest. Bridging or fusion of the pubic symphysis . Knees Knees demonstrate uniform joint space narrowing with bony proliferation. Shoulders Large erosion of the anterolateral aspect of the humeral head -  'hatchet' deformity , glenohumeral joint involvement is not uncommon

9. PSORIATIC ARTHRITIS Inflammatory arthritis seen in ~30% of patients with psoriasis. In contrast to many other arthropathies , there is no gender predilection , mean age: 20-40 years. Dermatological features of psoriasis precede arthritis in 70-75% of cases. Strong association with nail involvement, particularly for distal interphalangeal joint arthritis . Pathogenesis – Chronic synovitis – joint destruction

10. Classification( Moll and Wright ) Five subtypes   : Symmetric polyarthritis (similar in appearance to RA) Asymmetric mono- or oligoarthritis Spinal column involvement ( spondylitis ) Distal interphalangeal arthritis of the hands and feet Arthritis mutilans

11. Radiographic features The hallmark of psoriatic arthritis is the combination of bone erosions with bone proliferation and predominantly distal distribution. (e.g.  interphalangeal more than metacarpophalangeal joints). Enthesitic  and marginal bone erosions; “Pencil in cup” deformities are common, but not pathognomonic for PsA. Joint subluxation, joint space - preserved . Periostitis Dactylitis :   Soft tissue swelling of a whole digit- “Sausage digit”; underlying synovitis and tenosynovitis Acro-osteolysis Arthritis mutilans : osteolysis and articular collapse-"telescoping fingers" Ivory phalanx : Classically involving the distal phalanx of the great toe

12. Sacroiliitis : often asymmetrical Spondylitis :  Osteophytes – coarse, asymmetric, non marginal Parasyndesmophytes

13. REACTIVE ARTHRITIS Sterile inflammatory monoarticular or oligoarticular arthritis that follows an infection at a different site, commonly enteric or urogenital . Reiter syndrome - Urethritis , arthritis and conjunctivitis. Similar appearance to psoriatic arthritis  - ill-defined erosions, enthesopathy, bone proliferation and fusiform soft tissue swelling.  

14. Radiographic features Lower extremity involvement - MTP joint, DIP rarely involved* Enthesitis - Calcaneus at the sites of Achilles tendon and plantar fascia attachment. Large bulky paravertebral ossification "floating osteophyte" Sacroiliitis -usually unilateral,asymmetric Knee > Ankle > Sacroiliac joint) is more prevalent than upper extremity.  

15. ENTEROPATHIC ARTHRITIS Enteropathic arthritis (EA)  is a form of chronic, inflammatory arthritis associated with IBD( Crohns,UC ), Whipples disease. Location – 3 patterns Peripheral joint arthritis Sacroiliitis Spondylitis identical to AS – can precede bowel disease*

16. UNDIFFERENTIATED SPONDYLOARTHRITIS Non-specific mono or polyarthropathy . Early presentation of a more well-known form of arthritis. A specific diagnosis is usually reached within three months – commonly RA (30%), AS HLA B-27 positive in ~75% cases

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