5. ο Inflammatory disorder of unknown cause
ο Primarily affects axial skeleton
ο 2nd or 3rd decade
ο Male : female = 2:1 to 3:1
ο Axial spondyloarthritis β early/mild forms not meeting AS criteria
7. IMMUNOPATHOLOGY
ο Increased faecal carriage of Klebsiella aerogenes in pts with established
AS
ο Abnormal host response to intestinal microbiota with TH17 cells
involvement
ο Inflammatory cytokine production β IL 12, IL 23, IL 17 , TNF Ξ± ο
enthesitis and other inflammatory lesions
8.
9. CLINICAL FEATURES
ο Usually first noticed β late adolescence/adulthood
ο Median age 23 yr
ο Initial symptom β dull pain, insidious onset, deep in lower lumbar /
gluteal region + low back morning stiffness for few hrs that improves
with activity
ο Nocturnal exacerbations
10. ο Bony tenderness + ( costosternal jn, spinous processes, iliac crests,
greater trochanter, ischial tuberosities, tibial tubercles, heel)
ο Arthritis in hip and shoulders β 25 β 35% pts
ο Arthritis of peripheral joints β 30% pts
ο Neck pain and stiffness β late manifestations
11. ON EXAMINATION
ο Loss of spinal mobility
ο Limitation of motion β out of proportion to degree of ankyloses
ο Modified Schober test β€4cm β decreased mobility
15. LABORATORYFINDINGS
ο No laboratory test is diagnostic of AS.
ο HLA-B27 is present in 90% of patients.
ο Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are
elevated.
ο Mild anemia may be present.
16. ο Patients with severe disease may show an elevatedalkaline
phosphatase level.
ο Elevated serum IgAlevels are common.
ο Rheumatoid factor ,Anti-Cyclic Citrullinated peptide (CCP), and
Antinuclear Antibodies (ANAs) are absent.
17. RADIOGRAPHIC FINDINGS
ο Earliest signs - detected 3-6 months after onset.
ο SacroIliacJointsβEarly patchy osteoporosis develop around the
distal third of both the bones.
ο Joint margins become illdefined and the joint intervals become
widened.
ο Subchondral erosions start and when multiple produce a rosary
effect.
23. LUMBARSPINE-
ο Earliest change - squaring
of the anterior portion of
the vertebral bodies.
Anterior concavity of the
body islost.
ο Initially found atthe
upper lumbar and lower
thoracic regions.
ο Loss oflumbar lordosis +
25. ο Paravertebral ossification develops beneath the anteriorlongitudinal ligaments
withintheannulusat each level.
ο The ossification develops vertically in contrast to those developed in the OA.
ο Finally theappearance is of Bamboospine.
26.
27. TREATMENT
ο General Treatment
ο Patient education
ο Exercises
ο Avoid smoking
ο NSAIDS
ο Oral glucocorticoid or IM methylprednisolone
28. ο NSAIDS β 1st line of pharmacotherapy
ο Dramatic responses to anti-TNFΞ± therapy
ο Infliximab β IV 3-5mg/kg , repeated at 2 weeks , 6 weeks and then at 8
week intervals
ο Adalimumab β 40mg S/C bi weekly
ο Golimumab β 50-100mg S/C every 4 weeks
ο All patients to be tested for tuberculin reactivity before initiation of
anti-TNFΞ± agents ; reactors to be treated with ATT
29. ο Most common indication for surgery β severe hip joint arthritis ο
arthroplasty
ο Surgical correction of extreme flexion deformities of the spine
ο Uveitis β local glucocorticoid + mydriatic agent
31. ο Acute non-purulent arthritis complicating an infection elsewhere in the
body
ο Primarily to refer to SpA following enteric and urogenital infections
33. CLINICAL FEATURES
ο M/C age group 18β40 years.
ο Can occur in children over 5 years of
age and in older adults.
ο Men > Women ( 10:1 )
34. CLINICAL FEATURES
ο Wide spectrum β isolated, transient monoarthritis/enthesitis ο severe
multisystem disease
ο H/O antecedent infection 1-4 wk before onset of symptoms
ο Constitutional symptoms β fatigue, malaise , fever , weight loss
ο Musculoskeletal symptoms β acute in onset
ο Arthritis β symmetric and additive; new joint involvement over few days to
1-2 wk
ο Joints of lower extremities β M/C involved ; wrist and fingers can be
involved as well
35.
36. ο Tendo Achilles tendinitis and Plantar fasciitis are common.
ο In males, urethritis and in females, cervicitis or
salpingitis are common.
ο Ocular disease is common, ranging from asymptomatic
conjunctivitis to an aggressive anterior uveitis.
ο The characteristic skin lesions, are keratoderma blenorrhagica.
37.
38. ο Nail changes β onycholysis , distal yellowish discoloration , heaped up
hyperkeratosis
ο Rare β cardiac conduction defects , aortic insufficiency , central or
peripheral nervous system lesions, pleuropulmonary infiltrates
ο Chronic joint symptoms β 15% of pts
ο HLA B27 positive pts β worse outcome
39. INVESTIGATIONS
ο CRP , ESR β raised
ο Mild anemia +/-
ο Synovial fluid β inflammatory
ο PCR for chlamydial DNA β urine β high sensitivity
ο Early/mild disease β Radio changes absent / confined to juxta β articular
osteoporosis
ο Long standing disease β marginal erosions , loss of joint space
ο Periostitis with reactive new bone formation
ο Sacroileitis and spondylitis β late sequelae
40. TREATMENT
ο Most benefit with high dose NSAIDs
ο Indomethacin 75-150mg/day β initial treatment of choice
ο Majority of patients with chronic ReA due to Chlamydiabenefited
significantly from a 6-month course of rifampicin 300 mg daily plus
azithromycin 500 mg daily for 5 days then twice weekly, or 6 months of
rifampicin 300 mg daily plus doxycycline 100 mg twice daily.
ο Sulfasalazine upto 3gm/day β beneficial in pts with persistent ReA
ο Azathioprine 1-2mg/kg/day
ο Methotrexate upto 20mg / week
41. ο Glucocorticoids β Tendinitis and other enthisitic lesions
ο Uveitis may require aggressive treatment
ο Skin lesions β symptomatic Rx
ο HIV+ReA β respond to ART