Ankylosing spondylitis.

1. SERONEGATIVE
SPONDYLOARTHROPATHIES
Dr. Rohit Rajeevan CK

4. ANKYLOSING SPONDYLITIS

5.  Inflammatory disorder of unknown cause
 Primarily affects axial skeleton
 2nd or 3rd decade
 Male : female = 2:1 to 3:1
 Axial spondyloarthritis – early/mild forms not meeting AS criteria

6. EPIDEMIOLOGY
 HLA B27 – 90% of patients with AS
 Autosomal co-dominant

7. IMMUNOPATHOLOGY
 Increased faecal carriage of Klebsiella aerogenes in pts with established
AS
 Abnormal host response to intestinal microbiota with TH17 cells
involvement
 Inflammatory cytokine production – IL 12, IL 23, IL 17 , TNF α 
enthesitis and other inflammatory lesions

9. CLINICAL FEATURES
 Usually first noticed – late adolescence/adulthood
 Median age 23 yr
 Initial symptom – dull pain, insidious onset, deep in lower lumbar /
gluteal region + low back morning stiffness for few hrs that improves
with activity
 Nocturnal exacerbations

10.  Bony tenderness + ( costosternal jn, spinous processes, iliac crests,
greater trochanter, ischial tuberosities, tibial tubercles, heel)
 Arthritis in hip and shoulders – 25 – 35% pts
 Arthritis of peripheral joints – 30% pts
 Neck pain and stiffness – late manifestations

11. ON EXAMINATION
 Loss of spinal mobility
 Limitation of motion – out of proportion to degree of ankyloses
 Modified Schober test ≤4cm – decreased mobility

12. STOOPED OVER POSITION

15. LABORATORYFINDINGS
 No laboratory test is diagnostic of AS.
 HLA-B27 is present in 90% of patients.
 Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are
elevated.
 Mild anemia may be present.

16.  Patients with severe disease may show an elevatedalkaline
phosphatase level.
 Elevated serum IgAlevels are common.
 Rheumatoid factor ,Anti-Cyclic Citrullinated peptide (CCP), and
Antinuclear Antibodies (ANAs) are absent.

17. RADIOGRAPHIC FINDINGS
 Earliest signs - detected 3-6 months after onset.
 SacroIliacJoints–Early patchy osteoporosis develop around the
distal third of both the bones.
 Joint margins become illdefined and the joint intervals become
widened.
 Subchondral erosions start and when multiple produce a rosary
effect.

18. GRADES OF SACROILIITIS- ACCORDING TO THE NEW YORK CRITERIA
Grade 0-Normal

19. • Grade1-Suspicious changes at the left sacroiliac joint in the
formof slightly irregularjoint facets.

20. • Grade2-Minimalabnormalities inthe formof small erosions (black
arrow)andslightly condensed bone (sclerosis)(white arrow)

21. • Grade3-Manifestabnormalities in the formof erosion andsclerosis
in addition to wideningof the middle part of both sacroiliac joints.

22. • Grade4-Total ankylosis of both sacroiliac joints

23. LUMBARSPINE-
 Earliest change - squaring
of the anterior portion of
the vertebral bodies.
Anterior concavity of the
body islost.
 Initially found atthe
upper lumbar and lower
thoracic regions.
 Loss oflumbar lordosis +

24. SHINY CORNER SIGN/ROMANUS SIGN

25.  Paravertebral ossification develops beneath the anteriorlongitudinal ligaments
withintheannulusat each level.
 The ossification develops vertically in contrast to those developed in the OA.
 Finally theappearance is of Bamboospine.

27. TREATMENT
 General Treatment
 Patient education
 Exercises
 Avoid smoking
 NSAIDS
 Oral glucocorticoid or IM methylprednisolone

28.  NSAIDS – 1st line of pharmacotherapy
 Dramatic responses to anti-TNFα therapy
 Infliximab – IV 3-5mg/kg , repeated at 2 weeks , 6 weeks and then at 8
week intervals
 Adalimumab – 40mg S/C bi weekly
 Golimumab – 50-100mg S/C every 4 weeks
 All patients to be tested for tuberculin reactivity before initiation of
anti-TNFα agents ; reactors to be treated with ATT

29.  Most common indication for surgery – severe hip joint arthritis 
arthroplasty
 Surgical correction of extreme flexion deformities of the spine
 Uveitis – local glucocorticoid + mydriatic agent

30. REACTIVE ARTHRITIS

31.  Acute non-purulent arthritis complicating an infection elsewhere in the
body
 Primarily to refer to SpA following enteric and urogenital infections

32. TRIGGERS
 Chlamydia
 Campylobacter
 Salmonella
 Shigella
 Yersinia
 Mycoplasma
 Borrelia
 Streptococci
 Mycobacteria

33. CLINICAL FEATURES
 M/C age group 18–40 years.
 Can occur in children over 5 years of
age and in older adults.
 Men > Women ( 10:1 )

34. CLINICAL FEATURES
 Wide spectrum – isolated, transient monoarthritis/enthesitis  severe
multisystem disease
 H/O antecedent infection 1-4 wk before onset of symptoms
 Constitutional symptoms – fatigue, malaise , fever , weight loss
 Musculoskeletal symptoms – acute in onset
 Arthritis – symmetric and additive; new joint involvement over few days to
1-2 wk
 Joints of lower extremities – M/C involved ; wrist and fingers can be
involved as well

36.  Tendo Achilles tendinitis and Plantar fasciitis are common.
 In males, urethritis and in females, cervicitis or
salpingitis are common.
 Ocular disease is common, ranging from asymptomatic
conjunctivitis to an aggressive anterior uveitis.
 The characteristic skin lesions, are keratoderma blenorrhagica.

38.  Nail changes – onycholysis , distal yellowish discoloration , heaped up
hyperkeratosis
 Rare – cardiac conduction defects , aortic insufficiency , central or
peripheral nervous system lesions, pleuropulmonary infiltrates
 Chronic joint symptoms – 15% of pts
 HLA B27 positive pts – worse outcome

39. INVESTIGATIONS
 CRP , ESR – raised
 Mild anemia +/-
 Synovial fluid – inflammatory
 PCR for chlamydial DNA – urine – high sensitivity
 Early/mild disease – Radio changes absent / confined to juxta – articular
osteoporosis
 Long standing disease – marginal erosions , loss of joint space
 Periostitis with reactive new bone formation
 Sacroileitis and spondylitis – late sequelae

40. TREATMENT
 Most benefit with high dose NSAIDs
 Indomethacin 75-150mg/day – initial treatment of choice
 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.
 Sulfasalazine upto 3gm/day – beneficial in pts with persistent ReA
 Azathioprine 1-2mg/kg/day
 Methotrexate upto 20mg / week

41.  Glucocorticoids – Tendinitis and other enthisitic lesions
 Uveitis may require aggressive treatment
 Skin lesions – symptomatic Rx
 HIV+ReA – respond to ART

42. Thank You