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0

What are the features of Spondyloarthropathies

Radiographic sacroiliitis with or without accompanying spondylitis
Variable inflammatory peripheral arthritis and enthesopathy
Association with chronic inflammatory bowel disease
Association with psoriasis and other mucocutaneous lesions
Tendency for anterior ocular inflammation
Increased familial incidence
Occasional aortitis and heart block
No association with rheumatoid factor
Strong association with HLA-B27

1

Clinical features of Spondyloarthropathies

Men > Women are affected, race also plays a role
Positive family history
Usual onset late teens - early 20s but may also present earlier in
childhood or at an older age
Approximately 50% of patients with acute anterior uveitis test positive for HLA-B27, and more than half of them have some form of spondyloarthropathy.

2

Classification of Spondyloarthropathies

Inflammatory spinal pain with at least 4 of the following components:
1. 3 months duration
2. Onset before the age of 45
3. Insidious gradual onset
4. Impreoved with exercise
5. Morning spinal stiffness

3

General features of ankylosing spondylitis

Affects young people, 26yo
Men >women, with a ratio of roughly 2 to 1.1
About 80% of patients develop the first symptoms at an age younger than 30 years, and less than 5% of patients present at older than 45 years.
There is a correlation between the prevalence of HLA B27 and the
disease.

4

Clinical features of Ankylosing spondylitis

Back pain, bilateral or unilateral symmetric sacroilitis
Pain in morning which goes away with activity and worse with rest
Spinal stiffness and loss of ROM, from inflammation and structural damage (osteoproliferation not osteodestruction)
Syndesmophytes and ankylosis, Low bone density, osteoporosis, and an increased rate of fractures, reduced chest expansion
May have mild constitutional symptoms - malaise, loss of appetite, fever

5

Diagnosing ankylosing spondylitis

Classic features of chronic inflammatory back pain
-insidious onset before 45 years of age,
- worsening with inactivity, and improvement with physical exercise
- are not very specific.
History of acute anterior uveitis, positive family history, or loss ROM or impaired chest expansion further supports diagnosis
Other clinical indicators
-presence of enthesitis, with resultant tenderness

6

Criteria for diagnosing AS

1) Low back pain for at least 3 months, improved by exercise and was not relieved by rest
2) Limited lumbar spinal motion in sagittal and frontal planes (sideways, forward and backward)
3) Chest expansion decreased relative to normal value for sex and age
4) Bilateral/unilateral sacroiliitis
*definite if criteria 4 (radiologic hallmark) and any one of the others

7

Clinical features of reactive arthritis

Aseptic peripheral arthritis occurring within 1 month of a primary infection, usually genitourinary.
Typically acute, asymmetric, and oligoarticular and is frequently
associated with one or more:
- ocular inflammation (conjunctivitis or acute iritis);
- enthesitis (Achilles tendonitis and plantar fasciitis);
- dactylitis (“sausage digits”);
- mucocutaneous lesions;
- urethritis, cervicitis; and,
- on rare occasions, carditis.

8

Clinical features of DISH

Diffuse idiopathic skeletal hyperostosis is a degenerative disorder affecting mostly older subjects (48–85 years old) and M>F (65%)
No specific marker has been found in the HLA system
But the positive familial tendency, and often associated with type II diabetes.
Characterised by a tendency to ossify and/or calcify ligamentous insertions, tendons, ligaments and fasciae in both the axial and the appendicular skeleton.

9

What are the causes of bone overproduction in the axial skeleton

DISH
Spondylosis
Seronegative spondyloarthritis
Acromegaly
Fluorosis
Ochronosis
Neuroarthropathies
Trauma

10

Distinctive signs of DISH

1) vertebral bodies, paravertebral ossification, large osteophytes, bone ankylosis
2) intervertebral discs, normal or slightly reduced height
3) interapophyseal joints, normal or slightly sclerotic
4) peripheral skeleton, para articular osteophytes, whiskering, calcification/ossification of ligaments, hyperostosis

11

Most common symptoms of DISH

The most common symptoms associated with DISH involved with the
spine are rigidity, decreased mobility, spinal column pain and dysphagia from esophageal compression.

12

Diagnostic features of DISH

- Flowing ossification of at least four continguous segments
- Disc height is relatively normal
- Facets and SI joints are normal

13

Clinical features of rheumatoid arthritis

Progressive and irreversible damage (bilaterally symmetric) of the synovial-lined joints
Loss of joint space, deformity of small synovial joints, hands etc
Periarticular swelling, Inflammation signs
Joint pain progressive, intermittent, restricted ROM, worse in morning
Late stage arthritis mutilans

14

Criteria for clinical presentation of rheumatoid arthritis

1) morning stiffness
2) arthritis of three or more joint areas
3) arthritis of hand joints
4) symmetric arthritis
5) rheumatoid nodules
6) serum rheumatoid factor
7) radiographic changes
*1-4 must be present for at least 6 weeks

15

Radiologic features of rheumatoid arthritis

Early:
Bilateral and symmetrical involvement
Periarticular soft tissue swelling
Uniform loss of joint space
Later:
Marginal erosions
Juxtaarticular osteoporosis
Large pseudocysts
Joint deformity

16

Cervical spine involvement on rheumatoid arthritis

The clinical features of cervical spine dislocation can be parasthesia, weakness, numbness, sensory impairment, spastic paralysis, paraplegia, tetraplegia, syncope, loss of bladder control, fecal incontinence and sudden death.
RA involves the cervical spine in 50-80% of all cases

17

Constitutional manifestations of rheumatoid arthritis

Fatigue, fever, weight loss, malaise
Rheumatoid nodules, vasculitis, haematologic abnormalities, visceral involvement
Cardiac, pulmonary, renal, ocular, and neurological or hepatic involvement

18

What is psoriasis

Common skin disorder associated with joint disease and characterized by peripheral joint destruction and deformity, sacroiliitis and non-marginal syndesmophyte formation.

19

Extra articular features of psoriatic arthritis

20 to 50 years,♂=♀.
Skin lesions characteristically located on extensor surfaces (knees, elbows, back), also scalp, abdomen, and genital region.
Lesions are well-defined, dry, raised, red and silvery, scaly patches.
Presence of nail changes seen in 80% of arthritis patients.

20

Clinical features of psoriatic arthritis

Arthritis usually affects the peripheral joints, especially DIP joints.
Sausage digits are common.
Rarely results in severe arthritis mutilans.

21

Lab test results for psoriatic arthritis

- ESR normal (except in acute phase),
- negative RA profile ,
- positive HLA-B27 in 75% of patients with sacroiliac involvement and
30% in

22

Pathological features of psoriatic arthritis

Similar to rheumatoid arthritis
No subcutaneous nodules
RA factor negative.

23

Clinical features of Osteitis Condensans Ilii

Women 20-40yo 9:1, multi parlours
Asymptomatic or can have chronic LBP and leg pain
Usually self limiting

24

Radiographic features of Osteitis Condensans Ilii

Bilateral, dense, triangle shaped iliac subchondral sclerosis involving the lower half of the joint margin
Joint space and joint margins are normal

25

Clinical presentation of Gout

Initially monarthritic, polyarthritic
1st MTP mc, in steps, heels, ankles, fingers, wrist and elbows

26

What are the modifiable risk factors for Gout

Alcohol consumption
Obesity
Hypertension
Occupational and environmental exposure to lead
Ingesting large amounts if protein and purine-rich foods

27

Topheous Gout

Nodular masses of monosodium urate crystals deposited in the soft tissues
Late complication of hyperuricemia
Complication- ST damage, and deformity, joint destruction and nerve compression (carpal tunnel)

28

Laboratory tests for Gout

Lab tests should include:
Full blood cell count
Urinalysis
Serum creatinine
Blood urea nitrogen
Serum uric acid

29

Clinical manifestations of Systemic Lupus Erythematosus

Mixture of constitutional symptoms, with skin, musculoskeletal, and hematologic (mild) involvement
Some patients present with predominantly hematologic, renal or neuropsychiatric manifestations