Seronegative Arthritis Or Spondyloartropaties - PowerPoint PPT Presentation

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Seronegative Arthritis Or Spondyloartropaties

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  1. Seronegative ArthritisOrSpondyloartropaties

  2. Introduction Spondyloarthritis or Seronegative Spondyloarthritis • Refers to inflammatory changes involving the spine and the spinal joints. • Absence of Rheumatoid Factor and ANA

  3. Spondyloarthritis • A group of autoimmunediseases that in commonappear mediated by activationof autoreactive CD8 T cells • Primarily affect joints, skin, eyes and mucous membranes • Physical stress, inflammation and infection with specificmicroorganisms trigger the immune response

  4. Spondyloarthropathies (SpA) • Frequent – prevalence ~ 0.5% • Chronic • Inflammatory • With potential disabling outcomes • Consist of several disorders

  5. SpA consist of several disorders • Ankylosing spondylitis (ASp) • Reiter’s syndrome (RS) / reactive arthritis (ReA) • Psoriatic arthritis (PsA) • Undifferentiated spondyloarthritis (USpA) • Enteropathic arthritis (ulcerative colitis, regional enteritis)

  6. Spondyloarthritis Diseases-features common to all 1. Clinical: • - Affect joints, skin, eyes and mucous membranes invarying proportions with characteristic joint involvement: • Spondylitis(inflammation of vertebral discs), • sacroiliitis (sacroiliac joints) and • enthesitis (tendon insertions). • All with granulomatous fibrosis and newbone formation

  7. Spondyloarthritis Diseases-features common to all • peripheral articular involvement • asymmetric mono-oligoarticular • Common in male • Sausage digits

  8. Spondyloarthritis Diseases-features common to all • Enthesopathy– Achilles tenosynovitis • Extra-articular manifestations • Oral aphtae, Erythema nodosum, uveitis • Absence of RF and Rheumatoid nodules • Absence of Raynoud’s phenomenon

  9. Spondylitis leads to the development of syndesmophytes and ankylosis T cells invade the junction of annulus fibrosis and vertebral body forming granulation tissue (activated macrophages, T cells and fibroblasts) Annulus fibers are eroded, then replaced by fibrocartilage that ossifies to form a syndesmophyte. Subperiosteal new bone formation ensues Progressive cartilaginous and periosteal ossification forms a “bamboo spine”, osteoporosis develops

  10. Sacroiliitis The cartilage on the iliac side is erodedfirst, causing bone plate blurring, jointspace “widening” and reactive sclerosis. Ultimately the resultant fibrous ankylosisis replaced by bone, obliterating the SI joint The subchondral regions of the synarthrotic SI joints are invaded by T cells leading to the formulation of granulation Tissue

  11. Enthesitis (enthesopathy) Entheses are the specialized fibrocartilagenous region of bone where ligaments, tendons, fascia or joint capsules insert Infiltration of entheses by T cells, enthesitis, produces a combinationof bone erosions and heterotopic new bone formation. Calcaneal spurs at insertion of plantar fascia and Achilles ligament are classic examples .

  12. Inflammatory back pain • Onset before age 40 • Insidious persistent (> 3 mo) dull deep buttock or low back pain • Stiffness/pain upon arising in the morning, or during sleep • Improvement with exercise Due to the initial inflammation of enthesitis, spondylitis or sacroiliitis • Poorly localized, does not follow nerve root

  13. Geneticepidemiology • HLA-B27 increased, but unevenly, among spondylitis diseases HLA-B27 frequency (%) • Ankylosingspondylitis 95 • Reiter’ssyndrome (reactivearthritis) 70 • Psoriaticarthritis 20-40 • Ethnicallymatchedcontrols 8 • Other class I alleles may also be involved, especially in PsA

  14. Primary Inflammatory Back Pain OR Synovitis Asymmetric Predominantly in lower extremities Secondary Plus one of following: Psoriasis IBD Positive family history Urethritis, cervicitis, or acute diarrhea within 1 month of arthritis Alternating buttock pain Enthesopathy Sacroiliitis SpondyloarthropathiesESSG Criteria

  15. Ankylosing Spondylitis

  16. Ankylosing Spondylitis • A progressive autoimmune inflammatory disease characterized by widespread spondylitis and sacroiliitis • Onset, age 10-35 with dull pain in lumbar or gluteal regions • Hip, shoulder, knee arthritis in ~30% • Epidemiology: >95% of those affected are positive for HLA-B27 • Affects 1-3% of HLA-B27 individuals, • Begins in the Sacroiliac Joints and progresses upwards and can involve the entire spine

  17. Ankylosing Spondylitis • Inflammatory Stages • Can be extremely painful (flares) • Prolonged morning stiffness (hours) • Fatigue (pain & lack of sleep) • Ankylosis • Stiffness increases • Significantly reduced ROM • Abnormal posture

  18. Postural changes • Postural changes include loss of lumbar lordosis, buttock atrophy and thoracocervical kyphosis, chest expansion compromised • Peripheral joints, notably the hips may develop flexion contractures or ankylosis. Compensatory knee flexion

  19. Other Joints Involved Inflammatory Arthritis of the hips and shoulders • Enthesitis

  20. Extra-Articular Features • Eyes: Acute anterior uveitis (40%) • Lungs: Rigidity of the chest wall and fibrosis in the upper lungs • Kidneys: IgA nephropathy (rare) • Heart: Aortitis (dilation of aortic root), aortic regurgitation

  21. Laboratory Investigations • Evidence of Inflammation • Normochromic normocytic anemia • Elevated ESR/CRP • Reactive thrombocytosis • HLA-B27 found in 90-95% of patients with Ank Spond vs 6-8% of general population

  22. Psoriatic Arthritis

  23. Psoriatic arthritis • Psoriatic arthritis: an often clinically distinctive complex ofenthesitis and arthritis that occurs in the setting of psoriasis • It may involve the spine or peripheral joints in a variety of patterns,and is initiated or exacerbated by stress or non specific infection

  24. Progression • Polyarticular in 30-50% • Like Rheumatoid Arthritis • Oligoarticular in 40-50% • Predominant Spinal Disease in 5% • Spinal symptoms usually occur after many years of peripheral arthritis • DIP involvement in 5% • Arthritis Mutilans in 5%

  25. Arthritis mutilans Osteolytic dissolution of joint with redundant overlying skin and telescoping motion of the digit (opera-glass hand)

  26. Sacroiliac Involvement • Sacroiliitis in 1/3 of patients • Usually asymmetric (unilateral) • May be asymptomatic • Spinal Involvement • May affect any part of the spine in a random fashion • Different from ankylosing spondylitis

  27. Rheumatologic Review of Systems • Mucocutaneous Involvement • Psoriatic skin lesions • Psoriatic Nail lesions • Entheseal Involvement • Dactylitis • Ocular Involvement

  28. Psoriatic Arthritis Nail involvement ~80% Often seen in digit involved with DIP Arthritis • Pitting • Onycholysis • Onychodystrophy • Transverse ridging

  29. History - Psoriasis • Psoriasis present before the onset of joint disease (70%) • Psoriasis comes with the arthritis (15%) • Psoriasis comes after the arthritis (15%)

  30. Psoriatic Plaque Under the Knee

  31. Umbilical Psoriasis

  32. Dactylitis • Entire digit is involved compared to “fusiform” swelling around a joint • Dactylitis – represents inflammation of the flexor tenosynovium – “flexor tenosynovitis”

  33. Progression of DIP arthritis Narrowed joint space & condylar erosions Reactive sub periosteal new bone Pencil in cup appearance

  34. Management AS andPsoriaticArthritis • Goals of Treatment • Improve pain • Improve Function • Prevent Long-term Damage • Safely • Psoriatic arthritis can lead to a deforming and destructive arthropathy in 20-30% • Ankylosingspondylitis can result in significant disability

  35. Management • NSAIDs • Can be useful in some cases of mono/oligo arthritis • Useful for enthesitis • Useful for spinal disease

  36. Management: DMARDs

  37. Management: Biologics • Biologics Approved for Psoriatic Arthritis and Ankylosing Spondylitis • Etanercept (Enbrel®) • Infliximab (Remicade®) • Adalimumab (Humira®) • Biggest advance in the treatment of spondyloarthropathies in decades!

  38. REACTİVE ARTHRITIS

  39. Reactive arthritis Reactive arthritis has generally been defined as sterile synovitis developing after a distant infection. Occurs 2-4 weeks after inciting infection Most responsible organisms have an affinity for mucous membranes