5spondyloarthropaties Seronegative Arthritis


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5spondyloarthropaties Seronegative Arthritis

  1. 1. Spondylo-arthritis
  2. 2. Objectives • Gain a basic understanding of the Spondylo-Arthritis • Learn specific Characteristics from SpA • Differentiate SpA from other chronic Arthritis ( RA, OA ) • Become familiar with joints, and extra- articular manifestations of SpA • Understand the current treatment paradigm and medications used
  3. 3. Introduction • Spondyloarthropathies = • Seronegative Spondyloarthritis – Absence of Rheumatoid Factor or other autoantibody serologic abnormalities: • Psoriatic Arthritis-PsA • Ankylosing Spondylitis-AS (Prototype) • Reactive Arthritis-ReA • Enteropathic Arthritis-IBD • Undifferentiated Spondyloarthropathy-SpA
  4. 4. Criteria for classification of spondyloarthropathy • Inflammatory spinal pain or synovitis (asymmetric or predominantly in lower limbs) plus more than 1 of the following: – Positive family history – Psoriasis – Inflammatory bowel disease – Urethritis, cervicitis, or acute diarrhea < 1 mo. before arthritis – Buttock pain alternating between right and left gluteal areas – Enthesopathy – Sacroiliitis • Sensitivity 78.4% and specificity 89.6%
  5. 5. Spondyloarthropathies • Are a diverse group of chronic inflammatory conditions linked by distinctive clinical, radiographic, and genetic features • Refers to inflammatory changes involving the spine and the spinal joints. • subtypes often overlap • may be considered one heterogeneous and phenotypically diverse disease that has the potential to evolve into AS.
  6. 6. Introduction Confusion Can often see peripheral joint symptoms in the absence of spinal symptoms
  7. 7. Spondyloarthropaties • The pathology of spondyloarthropathies is very different from that of RA. In RA, it is the synovitis that plays the major role, and the synovitis leads to bony erosions that don't heal. • In spondyloarthritis there is some synovitis, but it's the enthesitis that is the major problem, especially in the axial disease.
  8. 8. Spondyloarthropaties • Not only is there enthesitis but also the osteitis that follows, which is different because there is reactive bone sclerosis and bone absorption, but then more bone remodeling sets in and it goes on to result in new bone formation that can result in ankylosis
  9. 9. Spondyloarthropaties • In RA, the cytokines lead to excessive osteoclastic activity resulting in bone erosions, • In spondyloarthritis, the cytokines that are playing a major role result in osteoblastic activity • Gradual bony bridging follows after being initiated by the inflammation
  10. 10. Spondyloarthropaties
  11. 11. Spondyloarthropaties
  12. 12. Spondyloarthropathies • Hallmarks of this family of disorders • Inflammatory back pain (IBP) • and Enthesitis: (inflammation at sites where tendons, ligaments, and joint capsule fibers attach to bone, with a strong tendency to produce fibrosis and calcifications).
  13. 13. Spondyloarthropathies • IBP: inflammatory Back Pain • worse in the late night and early morning • pain interferes with sleep to the point that the patient gets up to walk in the middle of the night, • the discomfort can be characterized by alternating buttock pain. • prolonged morning stiffness of greater than 30 minutes.
  14. 14. Spondyloarthropathies • Exercise alleviates the pain of IBP while rest makes it worse. • IBP affects younger patients, • peaking during the mid-20s • onset before the age of 40, • at the height of their productivity.
  15. 15. Spondyloarthropathies • IBP persists for at least 3 months. • detrimental effects on quality of life • increased disability, and morbidity -- equal, and in some cases exceeding, that seen in RA
  16. 16. Spondyloarthropathies • Although new bone formation is central to the pathogenesis of AS, is also associated with osteoporosis and low bone mineral density • ectopic bone formation occurs within the inflamed vertebral enthesis • bone resorption, (increased osteoclast activity), occurs at an unregulated rate within the vertebra and promotes weakening of the spinal column.
  17. 17. Spondyloarthropathies • The spine in the patient with AS fuses through: – ligamentous ossification and – syndesmophytosis, • Rigid hyperkyphotic deformity develops. • Biomechanically, the fused spine acts as a long bone incapable of appropriately dissipating the energy of a traumatic event.
  18. 18. Spondyloarthropathies • Altered spinal biomechanics • Combined with the brittle quality of the osteoporotic bone • Increase susceptibility to vertebral column factures,and Spinal Cord injury, even after minor, often trivial, trauma • Significantly impaired mobility and peripheral joint arthritis: – exacerbate gait unsteadiness – increase susceptibility to falls
  19. 19. Sagittal reformatted CTscan showing a highly displaced thoracic fracture. Asterisk indicates apposition of the caudal fracture fragment on the thoracic aorta
  20. 20. Spondyloarthropathies • Extra-articular manifestations including: – psoriasis, – anterior uveitis, – IBD, – as well as rarer cardiac, renal, and pulmonary manifestations • a wide range of clinical manifestations.
  21. 21. Extra-articular manifestations • Ocular Manifestations • Uveitis is one of the most common extra- articular manifestations of the SpA, • occurring in 25% to 40% of patients. • there appears to be no correlation between the course of inflammatory eye disease and that of the arthritis.
  22. 22. Extra-articular manifestations • The uveitis typically presents as acute unilateral pain and photophobia; blurring of vision may also occur. • Recurrence despite successful treatment is common. Cataracts and glaucoma with associated increased intraocular pressure and posterior synechiae can also be observed
  23. 23. Extra-articular manifestations • In addition, conjunctivitis is commonly observed in SpA (up to 30% to 60% of ReA), typically in a more transient and less relapsing course than uveitis • patients who present with visual complaints in the SpA setting should be referred promptly to an ophthalmologist for thorough evaluation including slit lamp examination.
  24. 24. Cutaneous Manifestations • Plaque psoriasis, characterized by scaly, erythematous, hyperkeratotic lesions, is the most common form of psoriasis and is an important component of diagnosing PsA. • Careful examination of the skin should be performed in SpA evaluation,
  25. 25. Cutaneous Manifestations • assessment of less conspicuous areas including the gluteal cleft, scalp and scalp line, groin, and posterior auricular regions should be performed.
  26. 26. Psoriasis
  27. 27. Psoriasis
  28. 28. Psoriasis
  29. 29. Psoriasis
  30. 30. Psoriasis
  31. 31. Cutaneous Manifestations • no strict correlation between the extent of psoriasis skin disease and the extent of joint disease
  32. 32. Nail Changes • Diffuse and numerous nail pitting (plate depressions), onicholysis (separation of the nail from underlying nail bed), and crumbling of the nail plate can be observed in both psoriasis and PsA. • The extent of nail involvement in PsA parallels both skin and joint disease
  33. 33. Nail pitting/onicholysis
  34. 34. Nail Pitting
  35. 35. Onicholysis toe nails
  36. 36. Crumbling nail/DIP joint involvement
  37. 37. Pencil in Cup deformities
  38. 38. Other Extra- articular Manifestations • Aortic regurgitation is perhaps the most recognized cardiac manifestation, with scar tissue in the aorta and aortic valve cusps leading to incompetent valves. • Conduction abnormalities and heart block have also been described, characterized by extension of the fibrosis process into the AV bundle
  39. 39. Other Extra- articular Manifestations • Apical pulmonary fibrosis, mostly asymptomatic and typically observed in patients with substantial disease duration, has been noted in a small percentage of AS patients
  40. 40. Other Extra- articular Manifestations • Renal disease beyond analgesic and nonsteroidal anti-inflammatory drug adverse effects has appeared in 2 forms in AS, both of which are rarely observed: IgA nephropathy that can manifest as proteinuria and hematuria, and secondary amyloidosis manifested by nephrotic syndrome and, if associated with renal failure, generally a poor prognosis.
  41. 41. Spondyloarthropathies-Gene association • Up to 70% of individuals suffering from SpA carry the HLA-B27 gene • strength of the association between HLA- B27 and disease susceptibility varies among SpA subtypes and ethnic groups • the B27 gene accounts for only 35% of the SpA genetic load.[1]
  42. 42. Associations with HLA-B27 Degree of associations Rheumatic diseases Ankylosing spondylitis >90% Reiter’s syndrome/reactive >80% arthritis ~75% IBD related arthritis ~50% Psoriatic arthritis Normal Associations Native Americans 13% Caucasians 8% Blacks 4%
  43. 43. Ankylosing Spondylitis • An inflammatory disease of the spine and axial joints • Typically affects young men ages 15-30 • Women can be affected but much less than men (3:1 men:women) • Affects about 1 in 1000 • women with AS may present differently from men, complaining of neck and breast pain without the typical inflammatory low back pain
  44. 44. Ankylosing Spondylitis New York criteria for diagnosis of ankylosing spondylitis • Definite ankylosing spondylitis If: Criterion 4 or 5 plus 1, 2, or 3. – 1. Limited lumbar motion – 2. Low back pain for 3 months improved with exercise not relieved by rest – 3. Reduced chest expansion – 4. Bilateral, grade 2 to 4, sacroiliitis on X-ray – 5. Unilateral, grade 3 to 4, sacroiliitis on X-ray
  45. 45. Ankylosing Spondylitis
  46. 46. Previous Picture Hx • A photographic series of a patient with ankylosing spondylitis was taken over a period of 26 years. By 1957 a thoracic kyphosis has become apparent, and loss of the normal lumbar lordosis has occurred. There are early flexion contractures of the hips and knees. In the next two sequences, increasing flexion contractures of the hips and knees have occurred along with progressive ankylosis of the spine. In 1973, bilateral total hip arthroplasties were performed, which improved the patient's posture.
  47. 47. Ankylosing spondylitis: lumbar vertebrae, bamboo spine (radiograph)
  48. 48. • This anteroposterior projection of the lumbar spine shows the characteristic changes of syndesmophyte formation or "bambooing." Ossification is present deep to the lateral collateral ligaments, and it follows the contour of the intervertebral disc spaces. This ossification involves the outer layers of the intervertebral disc (annulus fibrosus). In contrast, degenerative spurs will extend almost at right angles to the vertebral bodies, rather than snugly following the contour of the disc as in ankylosing spondylitis.
  49. 49. Sacroiliitis grading 0-normal 1-possible 2-minimal 3-moderate 4-ankylosing
  50. 50. Ankylosing Spondylitis • Begins in the Sacroiliac Joints and progresses upwards and can involve the entire spine • Beyond the spine, axial joints including the shoulders and hips can be involved with varying degrees of severity particularly in AS. • Shoulder involvement can be detected radiographically with characteristic erosive changes at the rotator cuff insertion.[ • Hip involvement is considered a poor prognostic factor in AS
  51. 51. Ankylosing Spondylitis • Inflammatory Stages – Can be extremely painful (flares) – Prolonged morning stiffness (hours) – Fatigue (pain & lack of sleep) • Ankylosis – Stiffness increases – Significantly reduced ROM – Abnormal posture
  52. 52. Enthesitis • Inflammation at the insertion of tendon, ligament, or articular capsule into bone • Lower limb entheses are more commonly involved than the upper limb • Patients with AS get “funny” pains
  53. 53. Achilles Enthesopathy
  54. 54. Enthesitis
  55. 55. Enthesitis • Common sites for Enthesitis – Heel – Most Common (Achilles) – Patella – Tibial Tubercle – Base of the 5th metatarsal – Plantar Fascia – Other sites include: • Anserine Bursa • Greater Trochanter • Iliac Crest • Rotator Cuff (Common in Ankylosing Spondylitis) • Costochondral
  56. 56. Physical Examination • Peripheral Entheseal Involvement • Spinal Involvement
  57. 57. Spinal Involvement • Measure the Occiput to Wall distance • Chest Expansion – Place the tape measure at the xiphisternum – Deep inhalation, exhalation, then inhalation – Measurement is age and sex dependant – Useful for following patients over time • Modified Schober Test – Potentially useful diagnostically – Unsure of benefit over time (insensitive)
  58. 58. Modified Schober Test
  59. 59. Occiput to Wall Test
  60. 60. Spinal Involvement • Finger Tip to Floor Distance – Feet at specified distance apart – Measure fingertips to floor – Useful for following patients over time • Lateral Flexion – Stand with back against the wall and feet at specified distance apart – Make a mark where the finger tips touch the thigh – Ask the patient to flex laterally and place a second mark at the maximal extent of the fingertips – Measure the distance between the two marks – Useful for following patients over time
  61. 61. Finger Tip to Floor Distance
  62. 62. Spinal Involvement • SI Compression Testing • Cervical Spine – Examine! – Can have Cervical Spine involvement alone – Can result in Atlanto-Axial Instability
  63. 63. Laboratory Investigations • Evidence of Inflammation – CBC Normochromic normocytic anemia – Elevated ESR/CRP – Reactive thrombocytosis • HLA-B27 found in 90-95% of patients with Ank Spond vs 6% of general population
  64. 64. Juvenile Ankylosing Spondylitis Onset 8 to 14 Sex Ratio M:F 7 to 1 HLA-B27 91 % Systemic symptoms rare Iritis 10 to 27 % Polyarticular 97% Prognosis Probably good
  66. 66. Case #1 • 50 y.o. man presents to the office with painful, swollen fingers • Intermittent flares over the last year with limited morning stiffness and slight loss of energy • Presents with the following findings:
  67. 67. Case #1
  68. 68. Case #1
  69. 69. Case #2 • 48 year old woman originally from Russia, moved to Canada 1 year ago. • Has complained of persistent arthritis and deformities in hands for years. • Presents with the following findings:
  70. 70. Case #2
  71. 71. Case #2
  72. 72. Case #3 • 51 year old man has had pain, stiffness, and progressive deformity in the hands for many years • Presents with the following findings:
  73. 73. Case #3
  74. 74. Case #4 • 28 year old man presents with pain and stiffness in both wrists and the left knee • Also has intermittent swelling of the toes • Has the following findings:
  75. 75. Case #4
  76. 76. Case #4
  77. 77. Case #5 • 35 year old man presents with low back pain and stiffness which improves with exertion • He has the following findings:
  78. 78. Case #5
  79. 79. What is the Diagnosis? • In all of these cases the diagnosis is Psoriatic Arthritis! • 5 Presentations – DIP Involvement (Case #1) – Arthritis Mutilans (Case #2) – Symmetric Polyarthritis (Case #3) – Oligoarthritis (Case #4) – Spondylitis (Case #5)
  80. 80. What is the Diagnosis? Confusion Psoriatic Arthritis is a heterogenous disease which can present in a multitude of ways
  81. 81. Psoriasis/Nail changes/arthritis DIPs and Sausage deformity
  82. 82. Psoriatic Arthritis PsA • Subchondral bone resorption of the distal interphalangeal joint of the thumb and middle fingers has resulted in the "pencil- in-cup" appearance. A flexion deformity of the distal interphalangeal joint of the small finger is present, and the corresponding joint of the ring finger has fused. • (Next slide)
  83. 83. Fusion Pencil in Cup deformity
  84. 84. Who Gets Psoriatic Arthritis? • Most common age of onset is 30-50 years old • 1-3% of the population has psoriasis • 6-42% of people with psoriasis get psoriatic arthritis • Therefore, it is rare (about 1 in 1000)
  85. 85. History – Initial Presentation • Typical presentation is a peripheral inflammatory joint disease – usually a mono or oligo arthritis – Knees – Wrists • May occasionally present with polyarthritis • Initial presentation of inflammatory spinal disease is rare
  86. 86. History - Progression • Oligoarticular in 40-50% • Polyarticular in 30-50% – Like Rheumatoid Arthritis • Predominant Spinal Disease in 5% – Spinal symptoms usually occur after many years of peripheral arthritis • DIP involvement in 5% • Arthritis Mutilans in 5%
  87. 87. PSORIATIC ARTHRITIS Possible Indicators of Bad Prognosis Younger age at onset, including children Presence of certain HLA antigens: HLA-B27 correlates with spondylitic involvement HLA-DR3, DR4 correlates with erosive disease Extensive skin involvement Polyarticular involvement Lack of clinical response to NSAIDs Association with HIV infection
  88. 88. History - Progression • Sacroiliac Involvement – Sacroiliitis in 1/3 of patients – Usually asymmetric (unilateral) – May be asymptomatic • Spinal Involvement – May affect any part of the spine in a random fashion – Different from ankylosing spondylitis
  89. 89. History – Rheumatologic Review of Systems • Mucocutaneous Involvement – Psoriatic skin lesions – Psoriatic Nail lesions • Entheseal Involvement • Dactylitis • Ocular Involvement
  90. 90. History - Psoriasis • Do you have Psoriasis? – Psoriasis present before the onset of joint disease (70%) – Psoriasis comes with the arthritis (15%) – Psoriasis comes after the arthritis (15%)
  91. 91. Umbilical Psoriasis
  92. 92. Psoriasis Behind the Ear
  93. 93. Psoriasis in the Crease
  94. 94. Psoriasis in the Nails
  95. 95. History - Dactylitis • Have you ever had a finger or toe swell up on you like a sausage? • Entire digit is involved compared to “fusiform” swelling around a joint • Dactylitis – represents inflammation of the flexor tenosynovium – “flexor tenosynovitis”
  96. 96. History - Dactylitis
  97. 97. History – Family History • Family studies suggest a 50-fold increase in the risk of psoriatic arthritis in 1st degree relatives • Fathers are twice as likely to transmit the disease
  98. 98. Physical Examination • Skin and Nail Involvement • Peripheral Joint Involvement • Peripheral Entheseal Involvement • Spinal Involvement – Modified Schober Test – Occiput to Wall Distance – Cervical Spine ROM – Finger tip to floor distance – Lateral flexion
  99. 99. Peripheral Joint Involvement • Inflammatory Joint Count – Number of Joints Involved • Prognostic Importance • Therapeutic Importance – Pattern of Joints Involved • Diagnostic Importance – Evidence of Damage – Dactylitis
  100. 100. How to Tell the Difference
  101. 101. Red Flags – When to Call the Rheumatologist • Cervical Spine Instability – Acute onset neck pain or headache – Weakness or sensory change in extremities – Hyper-reflexia • Flare of disease activity
  102. 102. Radiology
  103. 103. Reiter’s Syndrome: Diagnostic Criteria Seronegative asymmetric arthropathy And at least 1 of the following: Urethritis or cervicitis Diarrhea Inflammatory eye disease Mucocutaneous disease Balanitis, oral ulceration, or keratoderma Other spondyloarthropathies and rheumatic disease excluded
  104. 104. BACTERIA MOST COMMONLY FOUND TRIGGERING REACTIVE ARTHRITIS Borrelia burgdorferi Campylobacter jejuni Chlamydia trachomatis Neisseria gonorrhoeae Salmonella species Shigella flexneri Streptococcus pyogenes Yersinia enterocolitica Yersinia pseudotuberculosis
  105. 105. Reiter’s Syndrome Frequency Difficult to define Male – Female ratio 4 to 1 HLA-B27 90 % Onset Simultaneous or over 3 – 4 weeks Course Self limited Relapsing
  106. 106. Reiter’s Syndrome Clinical Manifestations Arthritis Oligoarticular, Lower extremities. Enthesitis Calcaneous, patella. Urethritis Dysuria more common 30 % urethritis Conjuntivitis 2/3 at onset Mucocutaneous Manifestations Less frequent
  107. 107. Arthritis Conjunctivitis
  108. 108. Cervicitis
  109. 109. Urethritis
  110. 110. Circinate Balanitis. Meatitis, mild balanitis, severe balinitis
  111. 111. • Left, previous photograph demonstrates meatitis and early balanitis. The lesion is erythematous, moistened by the urethral discharge, and, like the later stages, painless. • Center, A discrete, moist, well-circumscribed lesion is seen on the glans. Such lesions often begin as small vesicles or pustules. • Right, More advanced lesions are dry, scaly, and painless. In circumcised patients, the lesions on the glans may become crusted and hyperkeratotic, similar to those seen on the skin, or they may remain moist and weeping.
  112. 112. ReA superficial erosions of the tongue
  113. 113. Superficial oral ulcers can be seen in ReA and are typically painless
  114. 114. • ReA has as part of its constellation of symptoms characteristic lesions including keratoderma blennorrhagica characterized by hyperkeratotic skin lesions on soles and palms and genital lesions such as circinate balanitis, an erythematous and painless lesion of the glans penis.
  115. 115. Keratoderma Blenorrhagicum
  116. 116. Pustules ReA KB incipient
  117. 117. Advanced KB
  118. 118. ARTHRITIS AND INFLATORY BOWEL DISEASE Crohn’s Disease Ulcerative Colitis
  119. 119. IBD associated arthritis Arthritis Peripheral Specially lower extremities Self limited 4 to 6 weeks Central SI joints and enthesitis Frequency 7 to 21 % No relation between the activity of the Arthritis and the IBD.
  120. 120. In IBD-associated SpA, erythema nodosum can be observed in Crohn's disease
  121. 121. pyoderma gangrenosum can be associated with ulcerative colitis.
  123. 123. Management - Overview • Goals of Treatment – Improve pain – Improve Function – Prevent Long-term Damage – Safely
  124. 124. Management • NSAIDs – Can be useful in some cases of mono/oligo arthritis – Useful for enthesitis – Useful for spinal disease
  125. 125. Management: DMARDs Ankylosing Medication Psoriatic Spondylitis Hydroxychloroquine Rarely with little NO (Plaquenil®) evidence Methotrexate Rarely with poor YES efficacy in spinal disease Sulfasalazine YES YES Leflunomide (Arava®) YES NO Gold YES NO Steroids YES YES
  126. 126. Management: Biologics • Biologics Approved for Psoriatic Arthritis and Ankylosing Spondylitis – Etanercept (Enbrel®) – Infliximab (Remicade®) – Adalimumab (Humira®) • Biggest advance in the treatment of spondyloarthropathies in decades!
  127. 127. Management: Biologics • Dramatic clinical efficacy with the greatest amount of data to date coming from studies of ankylosing spondylitis and psoriatic arthritis. • Substantially improve both peripheral and axial arthritis, as well as various other clinical parameters, and has also slowed the progression of joint damage.
  128. 128. SPONDYLOARTHOPATHIES Summary Absence of rheumatoid factor Involvement of sacroiliac and spinal joints Peripheral arthritis (predominantly lower limb) Enthesopathy Familial clustering Increased incidence of HLA-B27 Common spectrum of extra-articular features (predominantly muco-cultaneous)