Excellent presentation on ankylosing spondylitis and psoriatic arthritis

2. Ankylsoing Spondylitis &
Psoriatic Arthritis
 Dr. Sajid Ali Talpur

3. Q.1 The best advice for the patients of
ankylosing spondylitis would be?
 A. Fat free diet
 B. Rest
 C. Excercise
 D. Surgery
 E. A.O.T

4. Q.2 Which of the following investigations is
correlated with ankylosing spondylitis?
 A. Positive R.A factor
 B. X-ray chest showing apical fibrosis
 C. X-ray lumber spine showing nonmarginal, asymmetrical syndesmophytes
 D. Positive HLA B27 in 100% cases
 E. A.O.T

5. Q.3 The radiological feature of
ankylsoing spondylitis is?
 A. bamboo spine
 B. dagger sign
 C. hatchet sign
 D shiny corner sign
 E. A.O.T

6. Q.4 Regarding ankylosing spondylitis
which statement is incorrect?
 A. It is more common in men
 B. it can cause color blindness
 C. usually the prognosis is good
 D. It can run in families
 E. N.O.T

7. Q.5 Regarding Psoriatic arthritis which
statement is incorrect?
 A. it usually involves DIP joints
 B. it can cause arthritis mutilans
 C. Arthritis can occur before the onset of psoriasis
 D. Psoriatic patients with axial disease should be given biological agents
 E. N.O.T

8. Case:
A 25 years old man presents with 4 months
history of lower back pain that is worse in the
morning and lasts for more than 30 min. it
improves on exercise. He is afebrile and also
complains of red eye. He has decreased chest
expansion. In the labs R.F is found negative.
 What is the most likely diagnosis?
 What is differential diagnosis?
 How will you examine this patient?
 How will you investigate?
 How will you manage?

9. The most likely diagnosis?
Ankylosing Spondylitis
It is chronic inflammatory seronegative spondyloarthritis primarily involving spine
and sacroiliac joints, characterized by progressive stiffening and fusion of the
axial skeleton.

10. Diagnostic criteria?
 Modified New York criteria for the diagnosis of A.S.

12. Differential diagnosis
 Reactive Arthritis
 Psoriatic Arthritis
 Enteropathic Arthritis
 Rheumatoid Arthritis
 Herniated nucleus pulposis

13. How will you examine this patient?
 In the lying position
 Inspection
 Straight leg raise
 Examine for the evidence of sacroilitis (compressing iliac bones)
 Assess movement of the hip joint
 See the chest expansion and examine lungs for apical fibrois
 Examine heart for aortic regurgitation
 Examine the eyes (uveitis)
 Examine the foot for Achilles tendinitis and plantar fasciitis

14.  In the standing position
 Inspection for fixed thoracic kyphosis, loss of lumber lordosis and
compensatory hyperextension of neck
 Ask the patient to look up (pt. will not be able to do so)
 Ask the patient to turn either side (whole body turns when patient attempts)
 Ask the patient to stand along the side of wall with the back (pt will be
unable to make contact of body against the wall)
 See the range of the movement of the spine by flexion, extension, and
lateral bending( note any restriction)
 Perform schober test

15. Schober Test

17. Extra-articular manifestations
 Eyes: Uveitis (25%) cases, conjunctivitis (20%)
 Heart: Aortic regurgitation and conduction blocks
 Chest and lungs: chest pain and reduced chest expansion, apical pulmonary
fibrosis, cavitation and later on aspergiloma may occur
 Prostatitis: usually asymptomatic
 Neurological: cauda equana syndrome
 Others: plantar fasciitis, Achilles tendinitis

18. How will you investigate?
 X-ray sacroiliac joints and spine (lumbosacral, dorsal and cervical)
 MRI of lumbosacral spine (more sensitive than X-ray)
 CBC & ESR (ESR may be high)
 R.F( Negative)
 HLA B27 ( Measured in Blood lymphocytes positive in 90% cases)
 CRP (May be high)
 Others according to the complications

20. Dagger sign
The dagger sign is a radiographic feature seen in ankylosing spondylitis as a
single central radiodense line on frontal radiographs related to ossification of the
supraspinous and interspinous ligaments secondary to enthesitis.

22. How will you manage?
 General measures:
 Patient’s counselling and education
 Exercise: swimming is the best activity
 Prolong sitting or inactivity should be avoided
 Physiotherapy

23.  Drugs:
 NSAIDs: for the symptomatic relief of pain
 DMARDs: sulphasalazine or methotrexate are helpful in peripheral arthritis
but no effect on the axial disease
 In the patients with persistent active inflammation anti-TNF drugs
(etanercept. Adalimumab,) may be helpful
 Local steroid injections for perisitent entheopathies and peripheral arthritis
 Other drugs: thalidomide, pamidronate may be used in resistant cases
 Orthopedic measures: may be needed for severe hip, knee or shoulder
restriction.

24. Psoriatic Arthritis
 Psoriatic arthritis is a form of arthritis that affects some people who
have psoriasis— a condition that features red patches of skin topped with
silvery scales. Most people develop psoriasis first and are later diagnosed
with psoriatic arthritis, but the joint problems can sometimes begin before
skin lesions appear.

25. Differential Diagnosis
 Rheumatoid arthritis
 Erosive osteoarthritis
 Reactive arthritis (Reiter syndrome)

26. Essentials of diagnosis
 Psoriasis precedes onset of arthritis in 75-80% of cases
 Arthritis usually asymmetric with sausage appearance of fingers and toes
 Sacroiliac joint involvement common; ankylosis of sacroiliac joints may occur
 Radiographic findings: Osteolysis, pencil in cup deformity, relative lack of
osteoporosis, bony ankylosis, asymmetrical sacroilitis and atypical
syndesmophytes

27. Types
 The patients may present in varying forms
 Asymmetrical inflammatory oligoarthritis
 Symmetrical seronegative polyarthritis (like rheumatoid arthritis but absence
of rheumatoid nodules and presence of psoriatic nail changes help to
diagnose)
 Predominant DIP joints arthritis: DIP joints are primarily affected. pitting of
nails and onycolysis frequently accompany the DIJ involvement
 Spondylitic form: in which sacroilitis and spinal involvement predominate
 Arthritis mutilans which presents as severe deforming arthritis with marked
osteolysis

28. Investigations
 labs
 CBC & ESR (ESR may be high)
 Serum Uric acid: elevated
 R.F. Negative
 CRP: High

29.  Imaging
 Enthesitis and marginal bone erosions; "pencil-in-cup” deformity
 joint subluxation or interphalangeal ankylosis may be present.
 bone proliferation results in an irregular, “fuzzy” appearance to the bone around the affected
joint
 periostitis:dactylitis: which can present as a “sausage digit” which refers to soft tissue
swelling of a whole digit
 ivory phalanx classically involving the distal phalanx of the great toe
 Sacroiliitis: often asymmetrical
 spondylitis: asymmetric paravertebral ossifications and relative sparing of the facet joint
 arthritis mutilans: a severe form of either PsA or rheumatoid arthritis caused by marked bony
resorption and the consequent collapse of soft tissue; when this affects the hands, it can
cause a phenomenon sometimes referred to as "telescoping fingers"

31. Treatment
 EULAR recommendations
 Nonsteroidal anti-inflammatory drugs (NSAIDs) can be given to relieve
musculoskeletal signs and symptoms
 Treatment with disease-modifying antirheumatic drugs (DMARDs)—eg,
methotrexate, sulfasalazine, and leflunomide—should be considered at an
early stage for patients with active disease
 If a patient with active psoriatic arthritis also has clinically relevant psoriasis,
preference should be given to treatment with methotrexate or other DMARDs
that are also effective against psoriasis
 Adjunctive treatment with local corticosteroid injections should be
considered; cautious use of systemic steroids, if administered at the lowest
effective dose, can also be considered

32.  If active psoriatic arthritis fails to adequately respond to 1 or more synthetic,
DMARDs (eg, methotrexate), tumor necrosis factor (TNF)–inhibitor therapy
should be employed
 TNF-inhibitor therapy should also be considered if active enthesitis and/or
dactylitis does not show sufficient response to NSAIDs or local steroid
injections
 TNF-inhibitor therapy should be considered if a patient has active,
predominantly axial disease that does not respond sufficiently to NSAIDs
 Exceptional use of TNF-inhibitor therapy may be considered if a very active
patient is DMARD-treatment naïve
 If a TNF inhibitor produces an inadequate response, consideration should be
given to replacing it with another TNF inhibitor
 If adjustments are made in a patient’s therapy, then comorbidities, safety
concerns, and other considerations beyond the psoriatic arthritis itself should
be factored into the change

33. Q.1 The best advice for the patients of
ankylosing spondylitis would be?
 A. Fat free diet
 B. Rest
 C. Excercise
 D. Surgery
 E. A.O.T

34. Q.2 Which of the following investigations is
correlated with ankylosing spondylitis?
 A. Positive R.A factor
 B. X-ray chest showing apical fibrosis
 C. X-ray lumber spine showing nonmarginal, asymmetrical syndesmophytes
 D. Positive HLA B27 in 100% cases
 E. A.O.T

35. Q.3 The radiological feature of
ankylsoing spondylitis is?
 A. bamboo spine
 B. dagger sign
 C. hatchet sign
 D shiny corner sign
 E. A.O.T

36. Q.4 Regarding ankylosing spondylitis
which statement is incorrect?
 A. It is more common in men
 B. it can cause color blindness
 C. usually the prognosis is good
 D. It can run in families
 E. N.O.T

37. Q.5 Regarding Psoriatic arthritis which
statement is incorrect?
 A. it usually involves DIP joints
 B. it can cause arthritis mutilans
 C. Arthritis can occur before the onset of psoriasis
 D. Psoriatic patients with axial disease should be given biological agents
 E. N.O.T

38. References
 Short cases in Clinical Medicine, ABM Abdullah, 5th Edition
 CMDT 2017
 Images taken from internet