Rheumatology I 02 Seronegative Spondylarthropathies

Rheumatic Diseases
Seronegative Spondylarthropathies
With Kartik Rangaraj MD
Wen Jie Lau, j.wenjie93@hotmail.com

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Spondyloarthropathies

Seronegative Spondyloarthropathies
Spondyloarthropathies consist of group of diseases that have key features in common.
These diseases are:

• Ankylosing spondylitis
• Reactive arthritis (Reiter's syndrome)
• Psoriatic arthritis
• Enteropathic arthritis (Crohn’s and ulcerative colitis)

Seronegative Spondyloarthropathies
Common features
Extra-articular manifestations
• Periarticular: enthesitis, tendinitis, dactylitis
• Ocular: uveitis, conjunctivitis
• Gastrointestinal: painless oral ulcerations, colitis
• Genitourinary: urethritis, vaginitis, balanitis
• Cardiac: aortitis, valvular insufficiency, heart block
• Cutaneous: keratoderma blennorrhagicum (characteristic rash on the sole of the foot),

psoriasis
• Ulcerative colitis and Crohn’s disease: erythema nodosum and pyoderma gangrenosum

Ankylosing Spondylitis
Seronegative spondyloarthropathy characterized by inflammation of

the axial skeleton.
Definition
• B27-positivity seen in 90–95 % of Caucasian pts

• Only 50 % of African Americans
• Thought to be male-predominant, but newer data suggests equal

distribution among genders
• Females believed to have less severe disease
Pathogenesis • Onset of disease usually in 20–30’s

• Patients present with progressive low back pain and stiffness

(insidious onset and before age 30).
• Patients have morning stiffness that improves with exercise.

• Similarly to rheumatoid arthritis and unlike
mechanical back pain
Signs & symptoms

• Patients eventually
develop limitation in the
ability to flex the spine.
• Physical exam findings:

loss of lumbar lordosis,
limited spinal motion
demonstrated by
Schober’s test, and
decreased chest
1947 1957 1967 1972 1973
expansion on deep
Signs & symptoms inspiration
© by Lecturio
• X-rays of the sacroiliac joints demonstrate sacroiliitis.
• X-rays of L-spine demonstrate characteristic “bamboo spine” and

squaring of vertebra
• Seronegativity
Diagnosis
• NSAIDs, followed by DMARDs
• Anti-TNF therapy for severe disease
• Physical therapy
• Smoking cessation in those with chest wall restriction

Treatment • Steroids not part of therapy

Sacroiliitis Bamboo spine

William Herring, Learning Radiology, 3rd Edition, 2016, p. 263, Figure 25-19, p. 264, Fig. 25-20, Saunders (Elsevier)
Reactive & Psoriatic Arthritis

Reactive Arthritis
• Seronegative spondyloarthropathy which presents as an acute,
predominantly lower extremity polyarticular, inflammatory,
asymmetric arthritis 1–3 weeks after infection
• Reiter’s syndrome: triad of nongonococcal urethritis,
conjunctivitis, and arthritis after diarrhea or GU infection,
Definition typically chlamydia
• Usually triggered by urethritis, cervicitis, or dysenteric infection

• Some of the associated infectious organisms are the following:
Chlamydia trachomatis, less likely pneumoniae, shigella flexneri,

salmonella typhimurium, yersinia enterocololitica, campylobacter
jejuni, ureaplasma urealyticum
• Interestingly, disease more severe in AIDS pts
Pathogenesis • B27-positivity in 75–80 % cases

Reactive Arthritis
• MSK: LE polyarthritis,
enthesopathy, dactylitis,
sacroiliitis
• GU: urethritis, prostatitis
• Ocular: conjunctivitis,
anterior uveitis
• Skin: keratoderma
blennorhagica, circinate
balanitis
Signs & symptoms
CDC/ Dr. M. F. Rein, PHIL #6950, PD

Reactive Arthritis
• CV: pericardial rubs, 1º AV

block, aortitis in severe
disease
• Male > female

• Due to cervicitis,
typically less
symptomatic than
urethritis
• Chronic symptoms after viral

syndrome; resolution
Signs & symptoms common
CDC/ Dr. M. F. Rein, PHIL #6950, PD

Reactive Arthritis
Dactylitis Conjuntivitis/uveitis Circinate balanitis
F.l.t.r.: Marks M, Mitjà O, Solomon AW et al., https://openi.nlm.nih.gov/detailedresult.php?img=PMC4350436_ldu03704&query=dactylitis&it=xg&lic=by&req

=4&npos=11, cropped, CC BY 4.0; P33tr, PD; Thomas P. Habif, Clinical Dermatology, 6th Edition, 2016, p. 272, Fig. 8-16, Saunders, (Elsevier)
Reactive Arthritis
• Look for temporal correlation between infection and

onset of symptoms!
• DDx includes: gonococcal arthritis, lyme disease, RA,
gout/pseudogout
Diagnosis
• NSAIDs, PT
• DMARDs, if above fail
• Doxycycline for at least 3 months in case of chlamydial arthritis

for eradication of infection
Treatment

Psoriatic Arthritis
Seronegative spondyloarthropathy which presents as an

inflammatory, acute, polyarticular arthritis in the setting of psoriatic
skin disease
• Appears like RA, but joint involvement different
• Can be symmetrical or asymmetrical

Definition
• Unknown
• B27-positivity seen with sacroiliitis
Pathogenesis

Psoriatic Arthritis
Most develop skin lesions before arthritis,

but ~15 % appear the other way around.
Signs & symptoms
Thomas P. Habif, Clinical Dermatology, 6th Edition, 2016, p. 276, Fig. 8-26, Saunders, (Elsevier)
Psoriatic Arthritis
5 patterns of arthritis:
1. DIP arthritis: associated with

onycholysis and pitting, resembles
severe OA,
“pencil-in-cup”
2. Asymmetrical oligoarthritis:
dactylitis common
Signs & symptoms 3. Symmetrical polyarthritis:
very similar to RA
4. Arthritis mutilans: telescoping

digits, widespread joint ankylosis
5. Sacroiliitis
William Herring, Learning Radiology, 3rd Edition, 2016, p. 263, Fig. 25-18, Saunders (Elsevier)
Psoriatic Arthritis
• NSAIDs
• DMARDs or anti-TNF therapy for aggressive disease
Treatment

Enteropathic Arthopathies
IBD-associated arthritis
• Arthritis manifests with IBD flare
• Ulcerative colitis
• Crohn’s disease

This document is a property of: Wen Jie Lau
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Rheumatic Diseases

With Kartik Rangaraj MD

Wen Jie Lau, j.wenjie93@hotmail.com

Wen Jie Lau, j.wenjie93@hotmail.com

Spondyloarthropathies consist of group of diseases that have key features in common.

These diseases are:

• Reactive arthritis (Reiter's syndrome)

• Enteropathic arthritis (Crohn’s and ulcerative colitis)

Wen Jie Lau, j.wenjie93@hotmail.com

• Ocular: uveitis, conjunctivitis

• Gastrointestinal: painless oral ulcerations, colitis

• Genitourinary: urethritis, vaginitis, balanitis

• Cardiac: aortitis, valvular insufficiency, heart block

• Cutaneous: keratoderma blennorrhagicum (characteristic rash on the sole of the foot),

Wen Jie Lau, j.wenjie93@hotmail.com

Seronegative spondyloarthropathy characterized by inflammation of

• B27-positivity seen in 90–95 % of Caucasian pts

• Thought to be male-predominant, but newer data suggests equal

Wen Jie Lau, j.wenjie93@hotmail.com

• Patients present with progressive low back pain and stiffness

• Patients have morning stiffness that improves with exercise.

Wen Jie Lau, j.wenjie93@hotmail.com

• Physical exam findings:

• X-rays of the sacroiliac joints demonstrate sacroiliitis.

• X-rays of L-spine demonstrate characteristic “bamboo spine” and

• NSAIDs, followed by DMARDs

• Anti-TNF therapy for severe disease

• Smoking cessation in those with chest wall restriction

Wen Jie Lau, j.wenjie93@hotmail.com

Sacroiliitis Bamboo spine

Wen Jie Lau, j.wenjie93@hotmail.com

• Usually triggered by urethritis, cervicitis, or dysenteric infection

Chlamydia trachomatis, less likely pneumoniae, shigella flexneri,

Wen Jie Lau, j.wenjie93@hotmail.com

• GU: urethritis, prostatitis

CDC/ Dr. M. F. Rein, PHIL #6950, PD

• CV: pericardial rubs, 1º AV

• Male > female

• Chronic symptoms after viral

CDC/ Dr. M. F. Rein, PHIL #6950, PD

Dactylitis Conjuntivitis/uveitis Circinate balanitis

F.l.t.r.: Marks M, Mitjà O, Solomon AW et al., https://openi.nlm.nih.gov/detailedresult.php?img=PMC4350436_ldu03704&query=dactylitis&it=xg&lic=by&req

• Look for temporal correlation between infection and

• Doxycycline for at least 3 months in case of chlamydial arthritis

Wen Jie Lau, j.wenjie93@hotmail.com

Seronegative spondyloarthropathy which presents as an

• Can be symmetrical or asymmetrical

• B27-positivity seen with sacroiliitis

Wen Jie Lau, j.wenjie93@hotmail.com

Most develop skin lesions before arthritis,

Signs & symptoms

1. DIP arthritis: associated with

4. Arthritis mutilans: telescoping

• DMARDs or anti-TNF therapy for aggressive disease

Wen Jie Lau, j.wenjie93@hotmail.com

• Arthritis manifests with IBD flare

Wen Jie Lau, j.wenjie93@hotmail.com

Wen Jie Lau, j.wenjie93@hotmail.com

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