Seronegative spondyloarthropathy - Rheumatology

Question 1

Seronegative spondyloarthropathy definition, pathogenesis and pathology?

Answer 1

Definition:
б It is a group of inflammatory arthropathies that share distinctive clinical, radiological, and genetic features.
б Characterized by involvement of sacroiliac joint, by peripheral inflammatory arthropathy and by absence of Rheumatoid factor.

Pathogenesis:
б Unknown, theories
б infection with certain organism,
б or exposure to unknown antigen,
б in a genetically susceptible patient (HLA-B27), is
б hypothesized to result in clinical expression of AS.

Pathology:
1. Primary lesion
» is inflammation of the enthesis i.e., enthesopathy (the site of insertion of ligaments, joint capsule, tendon, or fascia into bone).
2. Erosion,
» new bone formation at joint margin, narrowing of joint bony fusion (ankylosis)
3. Peripheral arthritis,
» often asymmetrical & affecting more the lower limb joints.
4. Prevalence of all SpAs ~1-2%, like RA.
5. Patient not fulfilling individual criteria but possessing many features from every disease
» may be classified as having undifferentiated spondyloarthropathy (uSpA)

Question 2

Seronegative spondyloarthropathy investigations and DD?

Answer 2

Investigations:
1. X- ray:
1. Sacroiliac joint:
» Erosions,
» blurring,
» narrowing,
» reactive sclerosis
» bony ankylosis.
2. Lumber Spine:
» Vertebrae appear square due to erosion of their corners “squared off ” appearance.
» Vertical bridging osteophytes or syndesmophytes” spread up and down from v. body fusion bamboo sp.
» Ossification of ant. Longitudinal ligament.
2. MRI:
it is more sensitive for detection of early & inflammatory changes of SIJ.
1. Reiter`s syndrome:
» soft tissue swelling.
» Joint space narrowing & erosion.
» Sacroiliitis or spondylitis.
2. Psoriatic arthropathy:
» Erosion &new bone formation at joint margin, bony fusion.
» Whittling of the distal ends at the phalanges
» Extensive bone resorption “Opera glass” appearance.
» Sacroilitis & spondylitis.
3. Laboratory:
1. ESR & CRP.
2. HLA-B 27.
3. RF: negative

Differential diagnosis:
1. Intervertebral disc lesion.
2. Degenerative lesion:
» Lumbar spondylosis.
3. Fractures:
» Direct trauma.
» Vertebral tumor.
4. Soft tissue lesions:
» Sprains.
» Tears of spinal ligaments or muscles.
5. Deformities & congenital defects:
» Kyphosis.
» Lordosis.
» Scoliosis.
» Spina bifida.
» Spinal stenosis.
6. Arthritis & infectious lesion of the spine:
» T.B. » Osteomyelitis.
7. Neoplasm of the spine:
8. Metabolic bone diseases:
» Osteoporosis. » Osteomalacia
9. Psychogenic.
10. Referred pain.

Question 3

Modified New York Criteria for Ankylosing Spondylitis?

Answer 3

1. Low back pain for at least 3 months, improved by exercise, not relieved by rest.
2. Limitation of lumbar spine movement in frontal and sagittal planes.
3. Diminished chest expansion relative to normal values to age and sex.
4. Unilateral sacroillitis G 3-4. or bilateral sacoiliitis G 2-4.

Question 4

Seronegative spondyloarthropathy Treatment?

Answer 4

1. Medical ttt.
2. Analgesics: NSAIDs or acetaminophen.
3. Muscle relaxants for acute or chronic pain to control muscle spasm & relief pain.
4. Local steroid injection: for enthesopathies.
5. Sulfasalazine &methotrexate: for peripheral arthritis but have little effect on axial dis.
6. TNF blockers are effective.
7. Physical ttt.
8. Stay physically active.
9. Spinal extension exercises
10. Acupuncture: for trigger points.
11. Transcutaneous electrical nerve stimulation (TENS).
12. Deep heat or Ice: to improve the muscle spasm & relief pain.
13. LASER & Interferential current: relief muscle ache.
14. Stretching exercises: will alleviate the tight back muscles through pelvic tilting.
15. Low impact activities:
    » as swimming, walking, and bicycling can increase the overall fitness without straining the back