Spondylarthropathies

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Gabriella Griffin
5 years ago
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1 Spondylarthropathies

2 Spondylarthropathies Undifferentiated Ankylosis spondylitis Psoriatic arthritis Enteropathic arthritis Reactive arthritis (and Reiter syndrome)

3 Spondylarthropathies HLA B27 antigen associated Rheumatoid factor negative Inflammation leading to ankylosis Spine (Spondylitis) Sacroiliitis Arthritis Enthesistis

5 Presumed structure of HLA-B27 modeled after the structure of HLA-A2. Highlighted are the amino acids that are thought to be involved in binding of antigenic peptides.

7 Risk of developing Spondylarthropathy if HLA B27 + Ankylosing Spondylitis: <0.1% general Caucasian population (1/1000) 2% if HLA B27 + and no family history (20/1000) 20% if HLA B27+ and family history of AS (200/1000) Reactive arthritis after enteric infection 1-4 % general population 50-98% if HLA B27 + Psoriatic arthritis : less clear associations Enteropathic arthritis: less clear associations

8 Inflammatory enthesopathy of a tendon attachment. The invagination of the tendon fiber into bone in a normal patient contrasts with the inflammation and erosion noted in an inflammatory enthesopathy.

9 Noted in this macerated specimen are typical degenerative enthesophytes of the greater trochanter.

10 Ossification of the supraspinous ligament resulting from healing of zones involved by earlier inflammation.

11 Changes at the vertebral rim in AS. An inflammatory enthesopathy destroys the attachment region of the outer annulus and a syndesmophyte results from healing by ossification.

12 Low-power microscopy of a syndesmophyte replacing the outer layers of the anterior annulus and uniting the vertebral bodies. Note that the disc is otherwise normal in appearance.

13 Portion of macerated lumbar spine showing the characteristic bamboo spine formed by bony encirclement of the discs resulting from fusion of upper and lower syndesmophytes.

14 Progressive ossification. Initially, inflammatory changes are noted at attachments to bone (1). This progresses to bone erosions (2). Capsular ossification leads to peripheral bone ankylosis (3). The central articular cartilage then is replaced by endochondral ossification leading to intra-articular ankylosis of bone (4).

15 Macerated specimen of ankylosed hip joint showing: ossification of the capsule (left) and extensive bridges of bone (arrow) across the joint with retention of the joint space (right).

16 Macerated portion of lower spine showing marked central, and patchy peripheral, bridging across the lumbar discs with retention of the normal disc height.

18 Ankylosing Spondylitis

22 Posture in advanced longterm ankylosing spondylitis. Progressive flattening of lumbar spine and forward stooping of the thoracic and cervical spine, along with prominence of the abdomen, mild flexion contracture of the hip joints, and diminution of vertical height after many years of the disease process.

23 This woman with AS was misdiagnosed due to her ability to touch her toes (a). Thorough examination reveals her full range of extension (b) and side flexion (c) to be virtually nil. More accurate observation and the performance of a Schober test revealed that her forward flexion took place almost entirely from her hips.

24 Application of direct pressure by thumbs over the SI joints to elicit tenderness. The figure also illustrates the patient s inability to touch the floor. The decrease in spinal mobility is often more readilly recognized on hyperextension (dorsiflexion) or lateral flexion of the spine.

26 Macrae s modification of Schober s test. The lumbosacral junction is identified between the dimples of Venus, and measurement made 5cm below and 10cm above.

27 Macrae s modification of Schober s test. The distraction of these marks (b) is proportional to true lumbar flexion: in this case the patient has AS and skin distraction is limited.

28 Two procedures that may cause pain in the sacroiliac area in patients with sacroiliitis. Application of direct pressure on the anterior superior iliac spines, along with attempts to force the iliac spines laterally apart (1); and forced flexion of one hip maximally towards the opposite shoulder, with hyperextension of the contralateral hip joint (2).

29 Two procedures that may cause pain in the sacroiliac area in patients with sacroiliitis. Application of downward pressure on the flexed knee, with hip flexed, abducted and externally rotated (1); and compression of the pelvis with the patient lying on one side (2).

31 Measurement of wall tragus distance.

32 Relatively subtle limitation of motion of the shoulder joint. In individuals with the normal range of motion of the shoulder joints, these reaches overlap, but in patients with limited range of motion there is a gap between these reaches.

33 Fixed flexion deformity of the hip joint can be revealed as the contralateral hip joint is maximally flexed to obliterate the exaggerated compensatory lumbar lordosis.

34 Chest expansion in AS patients and normal controls. Although patients with AS have significantly less chest expansion than normal controls, the overlap is considerable.

35 Untreated acute anterior uveitis. Note the circumcorneal congestion, the edematous and discolored iris and the small pupil.

36 Diagnosis Blood tests HLA B27 ESR/CRP Radiology Bone scan

37 Enthesopathy at the heel. Erosive lesion at the insertion of the Achilles tendon and the beginning of bone apposition at the insertion of the plantar fascia

38 Spur formation at the insertions of the Achilles tendon and the plantar fascia.

39 Early radiographic changes of sacroiliitis in AS consist of bony erosions ( postage stamp serrations ) and adjacent bony sclerosis. These changes are typically seen first, and tend to be more prominent, on the iliac side of the SI joints.

40 Inflammatory enthesopathy may occur at fibrous articulations (syndesmoses). This is demonstrated in a specimen radiograph of the upper fibrous portion of the sacroiliac joint in this patient with ankylosing spondylitis. Irregular bone formation is present. The synovial aspect of this joint is also affected with superficial bone erosions.

41 Evolution of syndesmophytes, lateral view of the spine. Osteitis of the corners of the vertebral bodies anteriorly, causing reactive sclerosis ( shiny corners ) leads to subsequent erosions and resultant squared vertebral bodies. This is followed by vertical bony bridges (syndesmophytes) between vertebral bodies, resulting from ossification of the superficial layers of the annulus fibrosus.

42 Bamboo spine.

43 Ankylosing spondylitis. A radiograph of a macerated specimen demonstrate a typical syndesmophyte bridging the intervertebral disc space. It is thin, vertically oriented and orginates from the margins of vertebral bodies.

44 Technetium scan showing pauciarticular asymmetrical joint involvement in a spondyloarthritic patient. There is increased uptake at the left wrist, left first metacarpophalangeal joint, left ankle, left tarsus, left first metatarsophalangeal joint and the sacroiliac joints.

45 Medical NSAID s Sulphasalazine Exercise Home Hydrotherapy Management Aids and appliances Pain relief: TENS, Radiotherapy Surgical

46 A home exercise regime. This must be individually devised taking into account the patient s social circumstances and the severity of the disease.

47 Hydrotherapy is valuable in restoring and maintaining movement. This can include spinal movements, hip, trunk and shoulder movements. The therapist is often able to gain considerably more movement by stretching in the pool than is possible on dry land.

48 Local application of ultrasound over the sacroiliac joint.

49 Pre- and postcervical fusion. The atlanto-axial subluxation seen preoperatively was accompanied by severe pain and numbness over the occiput. The symptoms were completely relieved by cervical fusion.

50 Psoriatic Arthritis

53 Monoarthropathy associated with psoriasis vulgaris.

54 Flexural psoriasis in the natal cleft.

55 Guttate psoriasis with widespread small red scaly papules.

56 Keratoderma blenorrhagicum.

57 Koebner phenomenon. Development of psoriasis at site of trauma around surgical incision.

58 Nail involvement with psoriasis. Note pitting, onycholysis (a) and hyperkeratosis (b).

61 Distal interphalangeal joint involvement.

62 Symmetrical psoriatic polyarthritis resembling rheumatoid arthritis.

63 Arthritis mutilans.

64 Telescoping in psoriatic arthritis.

65 Dactylitis of the toe.

66 Dactylitis of the index finger

67 Achilles insertional tendinitis.

68 Bony changes observed in degenerative disc disease (osteophytes), AS (syndesmophytes), and psoriatic spondylitis (nonmarginal syndesmophytes and paraspinal ossification).

69 Asymmetrical sacroiliitis.

70 Asymmetrical syndesmophytes and large other-than-marginal syndesmophytes.

71 Whiskering in the terminal interphalangeal joint of the great toe.

72 Whittling.

73 Osteolysis.

74 Pencil-in-cup appearance.

75 Erosion and new bone formation on calcaneum.

88 Enteropathic Arthritis

89 Enteropathic arthritis Ulcerative colitis Crohn s disease Whipple disease Coeliac disease Intestinal bypass surgery

90 Reactive Arthritis

91 Reactive arthritis Acute arthritis that develops soon after/during an infection elsewhere (urogenital/gastro-intestinal) No viable organisms are present in joint

92 Common organisms Chlamydia Yersinia Shigella Salmonella Campylobacter

95 Reiter syndrome Arthritis Urethritis Conjunctivitis

96 Reactive arthritis of the knee.

97 Circinate balanitis in a man with reactive arthritis.

98 Keratoderma blenorrhagicum of the palm in a patient with reactive arthritis.

100

Seronegative Spondyloarthropathies (SpA)

Seronegative Spondyloarthropathies (SpA) Objectives: Introduction SpA disease information Pathogenesis Clinical features Team Members: Ameera Niazi - Lulwah AlShiha - Qaiss Almuhaideb - Abdullah Hashem