5spondyloarthropaties Seronegative Arthritis

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Spondylo-arthritis

Objectives
• Gain a basic understanding of the
Spondylo-Arthritis
• Learn specific Characteristics from SpA
• Differenti...

Introduction
• Spondyloarthropathies =
• Seronegative Spondyloarthritis
– Absence of Rheumatoid Factor or other
auto...

Criteria for classification of spondyloarthropathy

• Inflammatory spinal pain or synovitis (asymmetric or
predominantly...

Spondyloarthropathies
• Are a diverse group of chronic inflammatory
conditions linked by distinctive clinical,
radiogr...

Introduction

Confusion
Can often see peripheral joint symptoms in
the absence of spinal symptoms

Spondyloarthropaties
• The pathology of spondyloarthropathies is
very different from that of RA. In RA, it is
the syno...

Spondyloarthropaties
• Not only is there enthesitis but also the
osteitis that follows, which is different
because the...

Spondyloarthropaties
• In RA, the cytokines lead to excessive
osteoclastic activity resulting in bone
erosions,
• In s...

Spondyloarthropaties

Spondyloarthropaties

Spondyloarthropathies
• Hallmarks of this family of disorders
• Inflammatory back pain (IBP)
• and Enthesitis: (inflammati...

Spondyloarthropathies
• IBP: inflammatory Back Pain
• worse in the late night and early morning
• pain interferes with sle...

Spondyloarthropathies
• Exercise alleviates the pain of IBP while
rest makes it worse.
• IBP affects younger patients,
•...

Spondyloarthropathies
• IBP persists for at least 3 months.
• detrimental effects on quality of life
• increased disabilit...

Spondyloarthropathies
• Although new bone formation is central to the
pathogenesis of AS, is also associated with
oste...

Spondyloarthropathies
• The spine in the patient with AS fuses
through:
– ligamentous ossification and
– syndesmophy...

Spondyloarthropathies
• Altered spinal biomechanics
• Combined with the brittle quality of the
osteoporotic bone
• Incre...

$Sagittal reformatted CTscan showing a highly displaced thoracic fracture. Asterisk indicates apposition of the caudal frac...$

Spondyloarthropathies
• Extra-articular manifestations including:
– psoriasis,
– anterior uveitis,
– IBD,
– as wel...

Extra-articular manifestations
• Ocular Manifestations
• Uveitis is one of the most common extra-
articular manifestatio...

Extra-articular manifestations
• The uveitis typically presents as acute
unilateral pain and photophobia; blurring
of ...

Extra-articular manifestations
• In addition, conjunctivitis is commonly observed
in SpA (up to 30% to 60% of ReA), typi...

Cutaneous
Manifestations
• Plaque psoriasis, characterized by scaly,
erythematous, hyperkeratotic lesions, is
the most...

Cutaneous Manifestations
• assessment of less conspicuous areas
including the gluteal cleft, scalp and scalp
line, gro...

Psoriasis

Psoriasis

Psoriasis

Psoriasis

Psoriasis

Cutaneous Manifestations
• no strict correlation between the extent of
psoriasis skin disease and the extent of
joint ...

Nail Changes
• Diffuse and numerous nail pitting (plate
depressions), onicholysis (separation of
the nail from underly...

Nail pitting/onicholysis

Nail Pitting

Onicholysis toe nails

Crumbling nail/DIP joint involvement

Pencil in Cup deformities

Other Extra- articular Manifestations

• Aortic regurgitation is perhaps the most
recognized cardiac manifestation, with...

Other Extra- articular Manifestations

• Apical pulmonary fibrosis, mostly
asymptomatic and typically observed in
pati...

Other Extra- articular Manifestations

• Renal disease beyond analgesic and
nonsteroidal anti-inflammatory drug
advers...

Spondyloarthropathies-Gene association

• Up to 70% of individuals suffering from
SpA carry the HLA-B27 gene
• strength ...

Associations with HLA-B27
Degree of
associations
Rheumatic disea...

Ankylosing Spondylitis
• An inflammatory disease of the spine and axial
joints
• Typically affects young men ages 15-30
...

Ankylosing Spondylitis
New York criteria for diagnosis of ankylosing
spondylitis

• Definite ankylosing spondylitis If:
...

Ankylosing Spondylitis

Previous Picture Hx
• A photographic series of a patient with
ankylosing spondylitis was taken over a period of
26 yea...

Ankylosing spondylitis: lumbar vertebrae, bamboo
spine (radiograph)

• This anteroposterior projection of the lumbar
spine shows the characteristic changes of
syndesmophyte formation or "...

Sacroiliitis grading
0-normal
1-possible
2-minimal
3-moderate
4-ankylosing

Ankylosing Spondylitis
• Begins in the Sacroiliac Joints and progresses
upwards and can involve the entire spine
• Beyon...

Ankylosing Spondylitis
• Inflammatory Stages
– Can be extremely painful (flares)
– Prolonged morning stiffness (hours)...

Enthesitis
• Inflammation at the insertion of tendon,
ligament, or articular capsule into bone
• Lower limb entheses are...

Achilles Enthesopathy

Enthesitis

Enthesitis
• Common sites for Enthesitis
– Heel – Most Common (Achilles)
– Patella
– Tibial Tubercle
– Bas...

Physical Examination
• Peripheral Entheseal Involvement
• Spinal Involvement

Spinal Involvement
• Measure the Occiput to Wall distance
• Chest Expansion
– Place the tape measure at the xiphisternum...

Modified Schober Test

Occiput to Wall Test

Spinal Involvement
• Finger Tip to Floor Distance
– Feet at specified distance apart
– Measure fingertips to floor
–...

Finger Tip to Floor Distance

Spinal Involvement
• SI Compression Testing

• Cervical Spine
– Examine!
– Can have Cervical Spine involvement alone
...

Laboratory Investigations
• Evidence of Inflammation
– CBC Normochromic normocytic anemia
– Elevated ESR/CRP
– React...

Juvenile Ankylosing Spondylitis
Onset 8 to 14
Sex Ratio M:F 7 to 1
HLA-B27 91 %
...

PSORIATIC ARTHRITIS

Case #1
• 50 y.o. man presents to the office with
painful, swollen fingers
• Intermittent flares over the last year with...

Case #1

Case #1

Case #2
• 48 year old woman originally from Russia,
moved to Canada 1 year ago.
• Has complained of persistent arthritis...

Case #2

Case #2

Case #3
• 51 year old man has had pain, stiffness,
and progressive deformity in the hands for
many years
• Presents wi...

Case #3

Case #4
• 28 year old man presents with pain and
stiffness in both wrists and the left knee
• Also has intermittent swel...

Case #4

Case #4

Case #5
• 35 year old man presents with low back
pain and stiffness which improves with
exertion
• He has the followin...

Case #5

What is the Diagnosis?
• In all of these cases the diagnosis is
Psoriatic Arthritis!
• 5 Presentations
– DIP Involveme...

What is the Diagnosis?

Confusion
Psoriatic Arthritis is a heterogenous disease
which can present in a m...

Psoriasis/Nail changes/arthritis
DIPs and Sausage deformity

Psoriatic Arthritis PsA
• Subchondral bone resorption of the distal
interphalangeal joint of the thumb and
middle fing...

Fusion

Pencil in Cup
deformity

Who Gets Psoriatic Arthritis?
• Most common age of onset is 30-50 years
old
• 1-3% of the population has psoriasis
• 6-4...

History – Initial Presentation
• Typical presentation is a peripheral
inflammatory joint disease – usually a
mono or o...

History - Progression
• Oligoarticular in 40-50%
• Polyarticular in 30-50%
– Like Rheumatoid Arthritis
• Predominant Spi...

PSORIATIC ARTHRITIS
Possible Indicators of Bad Prognosis

Younger age at onset, including children
...

History - Progression
• Sacroiliac Involvement
– Sacroiliitis in 1/3 of patients
– Usually asymmetric (unilateral)
–...

History – Rheumatologic Review of
Systems
• Mucocutaneous Involvement
– Psoriatic skin lesions
– Psoriatic Nail lesion...

History - Psoriasis
• Do you have Psoriasis?
– Psoriasis present before the onset of joint disease
(70%)
– Psorias...

Umbilical Psoriasis

Psoriasis Behind the Ear

Psoriasis in the Crease

Psoriasis in the Nails

History - Dactylitis
• Have you ever had a finger or toe swell up
on you like a sausage?
• Entire digit is involved comp...

History - Dactylitis

History – Family History
• Family studies suggest a 50-fold increase
in the risk of psoriatic arthritis in 1st degree
...

Physical Examination
• Skin and Nail Involvement
• Peripheral Joint Involvement
• Peripheral Entheseal Involvement
•...

Peripheral Joint Involvement
• Inflammatory Joint Count
– Number of Joints Involved
• Prognostic Importance
• ...

How to Tell the Difference

Red Flags – When to Call the
Rheumatologist
• Cervical Spine Instability
– Acute onset neck pain or headache
– Weaknes...

Radiology

Reiter’s Syndrome: Diagnostic Criteria
Seronegative asymmetric arthropathy
And at least 1 of the following:
Urethritis or ...

BACTERIA MOST COMMONLY FOUND
TRIGGERING REACTIVE ARTHRITIS
Borrelia burgdorferi
Campylobacter jejuni
...

Reiter’s Syndrome
Frequency Difficult to
define
Male – Female ratio 4 t...

Reiter’s Syndrome
Clinical Manifestations
Arthritis Oligoarticular, Lower
extremities.
Enthesitis ...

Arthritis Conjunctivitis

Cervicitis

Urethritis

Circinate Balanitis. Meatitis, mild balanitis, severe balinitis

• Left, previous photograph demonstrates
meatitis and early balanitis. The lesion is
erythematous, moistened by the ur...

ReA superficial erosions of the
tongue

Superficial oral ulcers can be seen in
ReA and are typically painless

• ReA has as part of its constellation of
symptoms characteristic lesions including
keratoderma blennorrhagica charact...

Keratoderma Blenorrhagicum

Pustules ReA KB incipient

Advanced KB

ARTHRITIS AND INFLATORY
BOWEL DISEASE
Crohn’s Disease

Ulcerative Colitis

IBD associated arthritis
Arthritis Peripheral Specially lower
extremities
Self limited 4 to 6 weeks
Central SI joints an...

In IBD-associated SpA, erythema nodosum can be
observed in Crohn's disease

pyoderma gangrenosum can be associated with
ulcerative colitis.

SINDROME DE SAPHO
SYNOVITIS
ACNE CONGLOBATA, FULMINANS E
HIDRAENITIS SUPURATIVA
PUSTULOSIS PALMO PLANTAR
HYPEROSTOSIS EST...

Management - Overview
• Goals of Treatment
– Improve pain
– Improve Function
– Prevent Long-term Damage
– Safely

Management
• NSAIDs
– Can be useful in some cases of mono/oligo
arthritis
– Useful for enthesitis
– Useful for s...

Management: DMARDs
Ankylosing
Medication Psoriatic
...

Management: Biologics
• Biologics Approved for Psoriatic Arthritis
and Ankylosing Spondylitis
– Etanercept (Enbrel®)
...

Management: Biologics
• Dramatic clinical efficacy with the greatest
amount of data to date coming from
studies of ank...

SPONDYLOARTHOPATHIES Summary

Absence of rheumatoid factor
Involvement of sacroiliac and
spinal joints
Peripheral arthriti...

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