Seronegative Arthritis

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Seronegative Arthritis

• Dr. Andy Thompson
• Assistant Professor of Medicine
• Division of Rheumatology
• University of Western Ontario

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Objectives

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

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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

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Introduction
Confusion Can often see peripheral joint symptoms
in the absence of spinal symptoms
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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

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Who is this?
This Mick Mars guitarist for Motley Crue(born
Robert Alan Deal)
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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

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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?)

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Ankylosing Spondylitis

• An inflammatory disease of the spine and root
  joints

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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

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Ankylosing Spondylitis

• Begins in the Sacroiliac Joints and progresses
  upwards and can involve the entire spine

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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

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Other Joints Involved

• Inflammatory Arthritis of the hips and shoulders

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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

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Enthesitis
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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

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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

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Physical Examination

• Peripheral Entheseal Involvement
• Spinal Involvement

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Enthesitis

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

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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)

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Modified Schober Test
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Occiput to Wall Test
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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

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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

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Psoriatic Arthritis

• Lets Switch Gears for a minute

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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

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Case 1
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Case 1
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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

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Case 2
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Case 2
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Case 3

• 51 year old man has had pain, stiffness, and
  progressive deformity in the hands for many years
• Presents with the following findings

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Case 3
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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

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Case 4
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Case 4
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Case 5

• 35 year old man presents with low back pain and
  stiffness which improves with exertion
• He has the following findings

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Case 5
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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)

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

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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

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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

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

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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

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History - Progression
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History Rheumatologic Review of Systems

• Mucocutaneous Involvement
• Psoriatic skin lesions
• Psoriatic Nail lesions
• Entheseal Involvement
• Dactylitis
• Ocular Involvement

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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)

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Psoriatic Plaque Under the Knee
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Psoriatic Plaque on the Elbow
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Umbilical Psoriasis
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Psoriasis Behind the Ear
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Psoriasis in the Crease
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Psoriasis in the Nails
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Psoriasis in the Nails
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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

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History - Dactylitis
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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

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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

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Peripheral Joint Involvement

• Inflammatory Joint Count
• Number of Joints Involved
• Prognostic Importance
• Therapeutic Importance
• Pattern of Joints Involved
• Diagnostic Importance
• Evidence of Damage
• Dactylitis

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How to Tell the Difference between RA and PsA?
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How to Tell the Difference
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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

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Radiology
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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

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Management

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

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Management DMARDs
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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!

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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.

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Its UP TO YOU
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TO BECOME A RHEUMATOLOGIST
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OR TO GET THEM TO US
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A little more light reading

• For those of you interested

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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

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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

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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

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Terminology
Reiters Syndrome Reactive Arthritis