spondyloarthropathies

definition

· diseases with

· absence of rheumatoid factor and thus rheumatoid nodules

· inflammatory peripheral arthritis

· sacroiliitis (esp. ankylosing spondylitis)

· clinical overlap between diseases

· familial aggregation and association with HLA B27

· includes

· ankylosing spondylitis

· Reiter’s disease

· psoriatic arthritis

· enteropathic arthritis

Reiter’s disease

definition

· syn. reactive arthritis

· syndrome consisting of

· polyarthritis

· non-specific urethritis

· conjunctivitis

· following

· sexual exposure

· bacterial dysentery

epidemiology

· almost exclusively young males

· M:F 50:1

· age 16-35 yrs

aetiology

· obscure but thought to be

· post-infectious in

· genetically predisposed

· infection may be

· Shigella or Salmonella

· Mycoplasma or Chlamydia

· increased incidence of HLA B27

· 75% of patients

pathology

· similar to ankylosing spondylitis

clinical

Arthritis and tendinitis

· arthritis is

· acute

· asymmetrical

· polyarticular

· in joints of lower limbs

· esp. knee and ankle

· inflammation at tendinous insertions

· heel pain

· plantar fasciitis

· Achilles tendinitis

· back pain is a feature

· arthritis settles after 2 weeks and disappears after 3 months

· 50% have chronic disease

· mild recurrent polyarthritis

· severe cases left with residual

· spondylitis (back pain)

· heel pain

· forefoot arthritis (sausage toes)

Urethritis

· may be asymptomatic

Conjunctivitis and iritis

· may be mild and transient

Mucocutaneous lesions

· circinate balanitis

· painless ulcerated lesions around external meatus and corona

· oral ulceration

· keratoderma blenorrhagica

· uncommon

· pustular lesions on soles of feet and palms of hands

Other

· constitutional

· fever, weight loss

· cardiac

· arrhythmias

· aortic incompetence

investigations

Laboratory

· raised ESR

· HLA B27 positive in 75%

Radiology

· nil initially

· with chronic disease

· periarticular osteoporosis

· joint erosions

· periostitis in feet and pelvis

· calcaneal spurs

· sacroiliitis

· spine changes

· paravertebral ossification (separated from vertebral body and disc)

· large, coarse, asymmetrical, noncontiguous

differential diagnosis

· septic arthritis

· crystal arthropathy

· acute gonococcal arthritis

· other seronegative spondyloarthropathies

prognosis

· most attacks settle in 2-3 months

· active disease after 20 yrs in 10%

treatment

· symptomatic

· NSAIDs

Psoriatic arthritis

definition

· inflammatory arthropathy associated with psoriasis

· arthritis occurs in 7% of patients with psoriasis

classification

1. classic

· involvement of DIP joints of hands

2. deforming

· with ankylosis and arthritis mutilans

3. RA-like

· similar to RA but without RF

4. monarthritis

5. ankylosing spondylitis-like

pathology

· joint changes similar to rheumatoid arthritis

· spine and SI joint changes similar to ankylosing spondylitis

clinical

Joints

· usually mild asymmetrical polyarthritis

· of IP joints of hands and toes

· condition usually progresses slowly

· severe cases have deformities of hands and feet

· arthritis mutilans

· 1/3 have spondylitis and sacroiliitis

Skin

· typical skin lesions of psoriasis

· usually precede arthritis

· scaling erythematous papules

· on scalp and extensor aspects of arms and legs

· esp. elbows and knees

Nails

· 80% have nail changes

· cf. 30% with psoriasis alone

· changes are

· pitting

· subungual keratosis

· transverse ridging

· generalised discoloration

investigations

Laboratory

· HLA B27 positive in 60% with sacroiliitis

Radiology

· changes seen with chronic disease

Hands

· periarticular phalangeal erosions along phalangeal shaft with scalloping

· periosteal new bone formation along metacarpal and metatarsal shafts

· whittling of distal ends of phalanges

· distal phalangeal tuft resorption

· typical ‘pencil in cup’ deformity of DIP joints

Sacroiliac joints

· indistinguishable from ankylosing spondylitis

Large joints

· similar to rheumatoid arthritis

differential diagnosis

· Reiter’s disease

· Heberden’s osteoarthritis

· gout

treatment

· similar to rheumatoid arthritis

Enteropathic arthritis

definition

· inflammatory arthritis associated with inflammatory bowel disease

· Crohn’s disease

· ulcerative colitis

· peripheral arthropathy occurs in 15% of patients

· spondyloarthropathy occurs in 5%

clinical features

Peripheral arthritis

· acute migratory attacks

· 1 per year

· associated with flare of bowel disease

· affects large joints

· transient

· lasts < 1 month

· non-deforming

· synovitis only

Spine

· classical ankylosing spondylitis

· persists if present

treatment

· treatment of IBD causes peripheral arthritis to abate

· sulphasalazine effective

· spondyolarthropathy treated as ankylosing spondylitis