Seronegative spondylitis

  • By: Terri
  • Date: November 9, 2010
  • Time to read: 2 min.

General features

  • -ve for Rheumatoid Factor
  • Genetic predispostion
  • Initiated by environmental factors
    • eg. infectious trigger
  • Manifestations are
    • immune mediated T cell response

Spondyloarthropaties

  • Definition
    • A group of inflammatory arthropathies that share distinctive clinical, radiological and genetic features
  • The 4 main diseases
  1. Ankylosing Spondylitis
  2. Reiter’s disease (reactive arthritis)
  3. Psoriatic arthritis
  4. Enteropathic arthritis
  • Crohn’s disease
  • Ulcerative colitis
  • Whipple’s disease
  • Diagnosis
    • History
    • physical examination
  • Key features
    • Inflammation of the axial joints
      • sacroiliitis
      • spondylitis
    • Peripheral arthritis
    • Enthesitis
      • inflammation at tendinous or ligamentous attachment
      • Inflammation of the insertion points (entheses) of ligaments, tendons, fascia and fibrous joint capsule
        • leading to fibrosis & ossification of the insertions
        • Rheumatoid Arthritis attacks the synovial membrane
    • HLA-B27 +ve
  • Common link
    • HLA B-27 +ve
    • Basic pathology is enthesitis

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    1) Ankylosing spondylitis

    • General
      • Chronic inflammation of the axial joints
        • Sacroiliac joints ascending to cervical spine
      • Starts in the 2nd/3rd decade
      • Insidious/gradual onset
      • Men:women, 5:1
      • 90% are HLA-B27 +ve
    • Classical triad of symptoms
      • inflammatory low back pain
      • immobility
      • morning stiffness
    • Typical presentation
      • young man with
        • low back pain
        • immobility
        • morning stiffness
    • Extraspinal manifestation
      • enthesitis
        • high impact areas
        • around hips, ankle
      • uveitis
        • blurry vision
        • painful red eye
        • excessive lacrimation
          • watery eye
      • peripheral arthritis
    • Complications
      • spinal fusion
        • bamboo spine
      • aortic valve insufficiency
    • Investigation
      • AP Xray
        • bamboo spine
        • sacroiliac joint fusion (pelvis)

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    image Bamboo Spine

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    2) Reactive arthritis

    • Classic triad
      • arthritis
      • uretritis/vaginitis
      • conjunctivitis
    • Typically an acute arthritis 1-3 weeks after an infective event
      • Urogenital
        • Chlamydia
        • Ureaplasma urealyticum
      • Gastrointestinal/Enteric
        • shigella
        • salmonella typhimurium
        • campylobacter
      • idiopathic
    • Molecular mimicry
      • Unexpected sharing of limited aminoacid sequence
        • between bacterial antigen and self protein
      • Common aminoacid sequence between HLA-B27 molecule and
        • Klebsiella nitrogenase protein
        • arthrogenic Shigella plasmid peptides
    • HIV & Reactive arthritis
      • HLA-B27+ HIV+ patients
        • have a more severe form of reactive arthritis
      • The incidence is decreased by the use of antivirals
      • Not associated with Ankylosing Spondylitis/uveitis
    • Features
      • Arthritis usually
        • asymmetrical
        • oligoarticular
          • few joints involved
      • Circinate balanitis
        • in male patients
        • A form of skin inflammation around the penis
        • The skin around the shaft and tip (glans) penis can become inflamed and scale
      • Self-limiting course
        • less than 6 months
        • Can be chronic and intermittent
      • Decreasing incidence due to increase use of condoms
    • Complications
      • Acute anterior uveitis
        • inflammation of middle layer of the eye
      • Carditis
      • Bony proliferation

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    3) Psoriatic Arthritis

    • General
      • Chronic inflammatory arthropathy & psoriasis
        • occurs together
      • Occurs in 5 – 10% of patients with psoriasis
      • Typically distal interphalangeal joint involvement
        • pencil in cup deformity
      • Nail changes are prominent
        • pitting
        • discolouration
        • dystrophy
        • onycholysis
      • Course
        • a chronic destructive arthritis in 30% of patients

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    4) Enteropathic arthritis

    • General
      • 5% – 20% of patients with chronic inflammatory bowel disease
      • Risk increases with
        • extent of colonic involvement
        • presence of other extra-intestinal manifestations
    • Peripheral arthritis parallels disease in gut
      • but not the spinal disease
    • Gut disease may be asymptomatic especially ileatis
      • an inflammation of the ileum

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    Lyme disease

    • Only chronic inflammatory arthritis with a known aetiology
      • Borrelia burgdorferi
    • Can be cured

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