21. Seronegative spondyloarthritides

Question 1

What diseases belong to seronegative spondyloarthropathies?

Answer 1

• Ankylosing spondylitis
• Reactive arthritis
• Psoriatic arthritis
• Arthropathy of IBD
• Undifferentiated spondyloarthropathies

Question 2

What do seronegative spondyloarthropathies have in common?

Answer 2

• Negative RF
• Strong association with HLA-B27 antigen
• Oligoarthritis (asymmetrical)
• Enthesitis (inflammation at sites of insertion of fascia, ligament, or tendon to bone)
• Inflammatory arthritis (axial and sacroiliac joints)
• Extra-articular features (eyes, skin, genitourinary tract)
• Familial predispositions

Question 3

What are the general features of anykolsing spondylitis?

Answer 3

• Strong association with HLA-B27 (90%)
• 3x more common in males
• Usually presents with family history of it, IBD or psoriasis
• Bilateral sacroiliitis is a prerequisite for making a diagnosis
• Characterized by fusion of the spine in an ascending manner (from lumbar to cervical)
• Slow progressive disease
• Exacerbation is common

Question 4

What are the clinical features of ankylosing spondylitis?

Answer 4

• Lower back pain and stiffness
  
  • Secondary to sacroiliitis
  • Limited motion of lumbar spine
• Neck pain and limited motion
• Enthesitis
  
  • Inflammation at tendinous insertion into the bon (Achilles tendon and supraspinatus)
• Weak spine and prone to fractures
  
  • Severe spinal cord injury may occure
• Chest pain
  
  • Due to thoracic spine involvement
• Constitutional symptoms
• Extra-articular manifestations:
  
  • Acute anterior uveitis (most common)
  • Cardiac, renal, pulmonary and CNS

Question 5

How do we diagnose ankylosing spondylitis?

Answer 5

• Imaging:
  
  • Lumbar spine and pelvis (MRI, CT) reveal sacroiliitis (“bamboo spine”)
• Elevated ESR

Question 6

What is the treatment of ankylosing spondylitis?

Answer 6

• NSAIDs
• Anti-TNF medication
• Surgery sometimes

Question 7

What is reactive arthritis?

Answer 7

• It is an asymmetrical inflammatory oligoarthritis of lower extremities
• Reiter’s syndrome is an example of it
  
  • But most patients don’t have the classical findings with it so now it’s called reactive arthritis

Question 8

What is the etiology of reactive arthritis?

Answer 8

• Previous infectious process that is remote to the site of arthiritis
• HLA-B27 positive (usually)

Question 9

What is undifferentiated spondyloarthropathy?

Answer 9

Features of reactive arthritis, but there is no evidence of previous infections

Question 10

What are the clinical features of reactive arthritis?

Answer 10

• Look for evidence of a previous infection 1-4 weeks prior to symptoms
• Aymmetric arthritis
  
  • New joints may be involved sequentially over days

Question 11

How do we diagnose for reactive arthritis?

Answer 11

Send synovial fluid for analysis to rule out infection or crystals

Question 12

How do we treat reactive arthritis?

Answer 12

• NSAIDs are the 1st line therapy
  
  • If no response, use sulfasalazine

Question 13

What is psoriatic arthritis?

Answer 13

• Develops in < 10% of patients with psoriasis
• Gradual onset
• Usually asymmetric and polyarticular
• Upper extremities most often are involves
• Small joints are more commonly affected than large joints

Treatment:

• NSAIDs