seronegatice arthritis

8/2/2019 Seronegatice Arthritis

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SERONEGATIVE ARTHRITISBy Samantha Mascarenhas

MODERATOR: Dr. Nagraj Shetty


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Types of seronegative arthr

The following are types of seronegative arthritcan be described as Rh-factor negative:

Psoriatic Arthritis

Reiters syndrome

Enteropathic arthritis

Reactive Arthritis

Ankylosing Spondylitis

Undifferentiated seronegative arthritis


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What are they?

The seronegative arthritis family is differentiated f

rheumatoid arthitis in many ways. Namely, rheumarthritis is prevalent in the female population, wheseronegative arthritis is more frequently seen in m

They are a group of related disorders

Often associated with HLA B27

Negative for Rh-Factor and other antibodies

They have a familial tendency

They are more common in Caucasians


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AETIOLOGY:

An association with HLA-B27 occurs in all seronspondarthrides but is particularly strong for an

spondylitis and Reiters disease and when thersacroilitis, uveitis or balanitis

The suggested pathogenesis is an aberrant resinfection in a genetically predisposed person

In some situations a triggering microorganism identified, as in Reiters disease following bactdysentry or chlamydial urethritis, but in othersenvironmental trigger remains obscure.


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Psoriatic Arthritis:INTRODUCTION

Psoriasis is a hyper-inflammatory disease that contributes to th

of demarcated erythematous scaly plaques.

Psoriatic arthritis is due to inflammation in and around the join

wrists, knees, ankles, lower back and neck.

Up to 30% of psoriasis patients may develop psoriatic arthritis.

On average, psoriatic arthritis appears about 10 years after the

psoriasis.

60-80% of patients with Psoriatic Arthritis may have psoriasis.

Majority have a negative Rheumatoid Factor, and it is usually re

"seronegative arthritis.


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CLINICAL PRESENTATION Pattern of joints affected with psoriatic arthritis is different than those

rheumatoid arthritis.


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There is a high frequency of distal joint

involvement in psoriatic arthritis comparheumatoid arthritis.

The onset is usually between 25 and 40 yage, most commonly in patients with por current psoriasis.


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CLINICAL PRESENTATION

Symptoms/Sings:

Morning stiffness lasting more than 30 minutes.

Patients present with pain and stiffness and swelling in the affected jo

Nail changes are found in 80-90% of patients with psoriatic arthritis anfollowing:

Onycholysis (elevation of the nail bed), and nail pitting .


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RADIOLOGICAL

DEFORMITIES There is coexistence of erosive changes and new bone formation in distal joint

cup-and-pencil deformity is erosion of one end of bone with expansion of t

contiguous bone.

Resorption of tufts of terminal phalanges.

There is usually no osteoporosis. Osteoporosisoccurs in RA.

Joint-space widening or narrowing.

Periosteal bone formation.

There may be surrounding soft tissue swelling (dactilitis).

Presence ofanykolysis: intra-articular bone fusion, specially of DIP and PIP join


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Sacroiliitis: inflammation of the sacro-illiac joints, which lead to ersclerosis of SI joints.

Spondylitis: Inflammation of one or more vertebrae, which may l

paravertebral ossification.

Enthesitis: Inflammation at the site of tendon insertion into bone,

achilles tendon.

Arthritis mutilans: Destructive changes and joint deformity of the

pan-compartmental ankylosis of the wrist.


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5 PATTERS OF PSORIATIC ARTHR

1. Symmetrical polyarthritis

Most common type, may affect as much as 25% of patients.

The hands, wrists, ankles, and feet may be involved.

It can be differentiated from RA by

Characteristic radiographic findings (as noted before) A history of psoriasis

Presence of DIP involvement

Absence of subcutaneous nodules on xray

A negative rheumatoid factor


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2. Asymmetrical oligoarticular arthritis

2nd most common form of presentation.

As many as 4 large joints may be affected, often with acute scattered i

of the metatarsophalangeal, PIP and DIP joints.

Dactylitis (sausage digits) may be present.


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3. Distal interphalangeal (DIP) arthropathy

DIP joint involvement occurs in 5-10% of patients with psoriatic arthritis.

One or several DIP joints may be involved.

Clinically, there is periarticular swelling and acute inflammation with wa


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Radiograph of both hands demonstrates cup-in-pencil deformities of both t

erosion of DIP joint of left middle finger


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4. Arthritis mutilans

Occurs in 5% of patients with psoriatic arthritis. It targets fingers and toes. Marked

and bone attrition leads to loss of the joint and instability. The encasing skin appeatelescoped(main en lorgnette) and traction ca pull the finger back to its original l


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5. Spondyloarthropathy

This includes both sacroiliitis and spondylitis.

Clinical evidence of spondylitis, sacroiliitis, or both can occur in conju

other subgroups of psoriatic arthritis.

Bilateral sacroiliitis is most common. There may be erosion and sclerosis


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Spondylitis may occur without radiologic evidence of sacroiliitis and may a

radiologically without the classic symptoms of morning stiffness in the lowe

With spondylitis, there is loss of the concavity of the vertebral body, result

the vertebral bodies . There is also fusion of vertebral bodies due to bridgin

syndesmophytes resulting in bamboo spine.


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INVESTIGATIONS:

The ESR and CRP may be raised especially with podisease, but are often unimpressive.

Tests for rheumatoid factor and antinuclear antibogenerally negative

X-rays may be normal or may show erosive changejoint space narrowing

Features that show distinction from rheumatoid ainclude marginal proliferative erosions, retained bdensity, and increased sclerosis of small bones


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MANAGEMENT:

Nonsteroidal Anti-inflammatory Drugs (NSAIDs) COX-2 inhibitors Both NSAIDS and Cox-2 inhibitors are used to control the inflammation and help improve

life. But they do not stop the progression of underlying disease (erosion) and may not be eterm. Cox-2 inhibitors are being used less due to cardiovascular side effects.

Disease Modifying Antirheumatic Drugs (DMARDS) (ie) Methotrexate, Cyclosporine or Azathioprine

These agents slow or stop the progression of disease and joint erosion. However, their sid(liver and kidney damage, immune suppression, cancers) prevent long term use.

Biologics: Agents that are synthesized by recombinant DNA technology and target specific proteins o

agents are gaining momentum rapidly. They stop progression of disease and are so far we

Enbrel (etanercept) is the only biologic so far approved for psoriatic arthritis. Unfortunateexpensive (Enbrel costs $15,000/yr).


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