Title: Seronegative Arthritis

1 Seronegative Arthritis Dr. Andy Thompson Assistant Professor of Medicine Division of Rheumatology University of Western Ontario

2 Objectives Gain a basic understanding of the Seronegative Arthritides Understand the current treatment paradigm and medications used

3 Introduction Spondyloarthritis Refers to inflammatory changes involving the spine and the spinal joints. Seronegative Spondyloarthritis Absence of Rheumatoid Factor Psoriatic Arthritis Ankylosing Spondylitis Reactive Arthritis

Enteropathic Arthritis Undifferentiated Spondyloarthropathy

4 Introduction Confusion Can often see peripheral joint symptoms in the absence of spinal symptoms 5 Seronegative Arthritis A distinct group of diseases from Rheumatoid Arthritis in their characteristics and patterns of involvement Absence of a rheumatoid factor Predilection for inflammatory disease of the spine

6 Who is this This Mick Mars guitarist for Motley Crue(born Robert Alan Deal) 7 Mick Mars Story Diagnosed with Ankylosing Spondylitis at the age of 17 Increasingly impaired his movement resulting in use of chronic narcotics for pain control After Motley Crue split up he went into depression, financial bankruptcy, and lived in a

one room house His girlfriend left him at the same time

8 Mick Mars Story Reformation of Motley Crue inspired Mars who at the time weighed 95 lbs Hip replacement in the fall of 2004 First few concerts he wore a mask in order to trick the audience into thinking he had been replaced Now touring with the band and is more energetic than ever Oh, and he used to have a serious drinking problem (go figure a rockstar)

9 Ankylosing Spondylitis An inflammatory disease of the spine and root joints

10 Ankylosing Spondylitis Typically effects young men ages 15-30 (Mick Mars was 17) Women can be affected but much less than men (31 menwomen)

Affects about 1 in 1000

11 (No Transcript) 12 (No Transcript) 13 (No Transcript) 14 (No Transcript) 15 Ankylosing Spondylitis Begins in the Sacroiliac Joints and progresses upwards and can involve the entire spine

16 (No Transcript) 17 (No Transcript) 18 (No Transcript) 19 (No Transcript) 20 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

21 (No Transcript) 22 Other Joints Involved Inflammatory Arthritis of the hips and shoulders

23 Enthesitis Inflammation at the insertion of tendon, ligament, or articular capsule into bone Lower limb entheses are more commonly involved than the upper limb Patients with AS get funny pains

24 (No Transcript) 25 Enthesitis 26 (No Transcript)

27 Enthesitis Common sites for Enthesitis Heel Most Common (Achilles) Patella Tibial Tubercle Base of the 5th metatarsal Plantar Fascia Other sites include Anserine Bursa Greater Trochanter Iliac Crest Rotator Cuff (Common in Ankylosing Spondylitis) Costochondral

28 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

29 Physical Examination Peripheral Entheseal Involvement

Spinal Involvement

30 Enthesitis Enthesitis Screen Plantar fascia Achilles Patellar (10, 2 and 6) Anserine Bursa Trochanters Ischial Crest

31 Spinal Involvement Measure the Occiput to Wall distance Chest Expansion Place the tape measure at the xiphisternum Deep inhalation, exhalation, then inhalation Measurement is age and sex dependant Useful for following patients over time Modified Schober Test Potentially useful diagnostically Unsure of benefit over time (insensitive)

32 Modified Schober Test 33

Occiput to Wall Test 34 Spinal Involvement Finger Tip to Floor Distance Feet at specified distance apart Measure fingertips to floor Useful for following patients over time Lateral Flexion Stand with back against the wall and feet at specified distance apart Make a mark where the finger tips touch the thigh Ask the patient to flex laterally and place a second mark at the maximal extent of the fingertips Measure the distance between the two marks Useful for following patients over time

35 Spinal Involvement SI Compression Testing Interesting Cervical Spine Examine! Can have Cervical Spine involvement alone Can result in Atlanto-Axial Instability

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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 of general population

37 (No Transcript) 38 Psoriatic Arthritis Lets Switch Gears for a minute

39 Case 1 50 y.o. man presents to the office with painful, swollen fingers Intermittent flares over the last year with limited morning stiffness and slight loss of energy Presents with the following findings

40 Case 1 41 Case 1

42 Case 2 48 year old woman originally from Russia, moved to Canada 1 year ago. Has complained of persistent arthritis and deformities in hands for years. Presents with the following findings

43 Case 2 44 Case 2 45 Case 3 51 year old man has had pain, stiffness, and progressive deformity in the hands for many years Presents with the following findings

46 Case 3 47 Case 4 28 year old man presents with pain and stiffness in both wrists and the left knee Also has intermittent swelling of the toes Has the following findings

48 Case 4 49 Case 4 50 Case 5 35 year old man presents with low back pain and stiffness which improves with exertion He has the following findings

51 Case 5 52 What is the Diagnosis In all of these cases the diagnosis is Psoriatic Arthritis! 5 Presentations Spondylitis (Case 5) Oligoarthritis (Case 4) Symmetric Polyarthritis (Case 3) Arthritis Mutilans (Case 2) DIP Involvement (Case 1)

53 What is the Diagnosis Confusion Psoriatic Arthritis is a heterogenous disease which can present in a multitude of ways

54 Who Gets Psoriatic Arthritis Most common age of onset is 30-50 years old 1-3 of the population has psoriasis 6-42 of people with psoriasis get psoriatic arthritis Therefore, it is rare (about 1 in 1000)

55 History Initial Presentation Typical presentation is a peripheral inflammatory joint disease usually a mono or oligo arthritis Knees Wrists May occasionally present with polyarthritis Initial presentation of inflammatory spinal disease is rare

56 History - 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

57 Who will Progress to Polyarticular Involvement Active Severe Disease at Presentation More than 5 Joints Involved Need for Immunomodulating Medications

58 History - Progression 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

59 History - Progression 60 History Rheumatologic Review of Systems Mucocutaneous Involvement Psoriatic skin lesions Psoriatic Nail lesions Entheseal Involvement

Dactylitis Ocular Involvement

61 History - Psoriasis Do you have Psoriasis Psoriasis present before the onset of joint disease (70) Psoriasis comes with the arthritis (15) Psoriasis comes after the arthritis (15)

62 Psoriatic Plaque Under the Knee 63 Psoriatic Plaque on the Elbow 64 Umbilical Psoriasis 65 Psoriasis Behind the Ear 66 Psoriasis in the Crease 67 Psoriasis in the Nails 68 Psoriasis in the Nails 69 History - Dactylitis

Have you ever had a finger or toe swell up on you like a sausage Entire digit is involved compared to fusiform swelling around a joint Dactylitis represents inflammation of the flexor tenosynovium flexor tenosynovitis

70 History - Dactylitis 71 History Family History Family studies suggest a 50-fold increase in the risk of psoriatic arthritis in 1st degree relatives Fathers are twice as likely to transmit the disease

72 Physical Examination Skin and Nail Involvement Peripheral Joint Involvement Peripheral Entheseal Involvement Spinal Involvement Modified Schober Test Occiput to Wall Distance Cervical Spine ROM Finger tip to floor distance

Lateral flexion

73 Peripheral Joint Involvement Inflammatory Joint Count Number of Joints Involved Prognostic Importance Therapeutic Importance Pattern of Joints Involved Diagnostic Importance Evidence of Damage Dactylitis

74 How to Tell the Difference between RA and PsA 75 How to Tell the Difference 76 Red Flags When to Call the Rheumatologist Cervical Spine Instability Acute onset neck pain or headache Weakness or sensory change in extremities Hyper-reflexia Flare of disease activity

77 Radiology

78 Management - Overview 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 Ankylosing spondylitis can result in significant disability

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

80 Management DMARDs 81 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!

82 Management Biologics Dramatic clinical efficacy with the greatest amount of data to date coming from studies of ankylosing spondylitis and psoriatic arthritis. Substantially improve both peripheral and axial arthritis, as well as various other clinical parameters, and has also slowed the progression of joint damage.

83 Its UP TO YOU 84 TO BECOME A RHEUMATOLOGIST 85 OR TO GET THEM TO US 86 A little more light reading For those of you interested

87 Reactive Arthritis

An INFECTION-INDUCED illness Usually an enterogenic (bowel) or urogenic (urinary tract) infection Starts 2-4 weeks after the initial infection Presents as an additive asymmetric oligoarthritis predominantly affecting the joints of the lower extremities

88 Reiters Syndrome Hans Reiter worked as a military physician on the Western Front and in the Balkans, where he served in the 1st Hungarian Army in the first world war. It was here in 1916 that he reported a German Lieutenant with non-Gonococcal urethritis, arthritis, and uveitis

89 Hans Reiter (1881-1969) Wrote a book on racial hygiene called Deutsches Gold, Gesundes Leben - Frohes Schaffen. As a member of the SS during the Second World War, Hans Reiter designed typhoid inoculation experiments that killed more than 250 prisoners at concentration camps like Buchenwald

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Hans Reiter (1881-1969) He was an enthusiastic supporter of and participant in enforced racial sterilization and euthanasia After the war was convicted of war crimes Died in 1969 at the age of 88

91 Terminology Reiters Syndrome Reactive Arthritis About PowerShow.com