THE SERONEGATIVE SPONDYLOARTHROPATHIES - Clinical features, Investigations

This title describes a group of conditions (Table 7.7) that share certain clinical features:

■ A predilection for axial (spinal and sacroiliac) inflammation

■ Asymmetrical peripheral arthritis

■ Absence of rheumatoid factor, hence ‘seronegative'

■ Inflammation of the enthesis (Fig. 7.1)

■ A strong association with HLa-B27, but its aetiological relevance is unclear.

Ankylosing spondylitis

This is an inflammatory disorder of the spine, affecting mainly young adults. It is both more common and more severe in men than women.

Clinical features

The typical patient is a young man (late teens, early 20s) who presents with increasing pain and prolonged morning stiffness in the lower back and but-tocks. Pain and stiffness improve with exercise but not with rest. There is a progressive loss of spinal movement. Inspection of the spine reveals two characteristic abnormalities:

■ Loss of lumbar lordosis and increased kyphosis (Fig. 7.4).

■ Limitation of lumbar spine mobility in both sagittal and frontal planes. Reduced spinal flexion is demonstrated by the Schober test. A mark is made at the fifth lumbar spinous process and 10 cm above, with the patient in the erect position. On bending forward, the distance should increase to >15 cm in normal individuals.

Other features include Achilles tendinitis and plantar fasciitis (enthesitis) and tenderness around the pelvis and chest wall. Reduction in chest expansion (<2.5 cm on deep inspiration measured at the fourth intercostal space) is due

Table 7.7 Seronegative spondyloarthropathies
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis (sexually acquired, Reiter’s disease)
Post-dysenteric reactive arthritis
Enteropathic arthritis (ulcerative colitis/Crohn’s disease)

Ankylosing spondylitis – the typical posture in advanced cases

Fig. 7.4 Ankylosing spondylitis - the typical posture in advanced cases compared to normal posture.

to costovertebral joint involvement. Non-articular features include anterior uveitis (p. 711) and, rarely, aortic incompetence, cardiac conduction defects and apical lung fibrosis.

Investigations

■ ESR and CRP are often raised.

■ X-rays may be normal or show erosion and sclerosis of the margins of the sacroiliac joints, proceeding to ankylosis (immobility and consolida-tion of the joint). In the spinal column, blurring of the upper or lower vertebral rims at the thoracolumbar junction is caused by an enthesitis at the insertion of the intervertebral ligaments. This heals with new bone formation resulting in bony spurs (syndesmophytes). Progressive calcifi-cation of the interspinous ligaments and syndesmophytes eventually produce the ‘bamboo spine' (Fig. 7.5).

■ MRI shows sacroiliitis before it is seen on plain X-ray.

■ HLa-B27 testing is not usually performed.

Management

Early diagnosis and treatment is essential to prevent irreversible syndes-mophyte formation and Progressive calcification. With effective treatment most patients are able to lead a normal active life and remain at work.

■ Morning exercises to maintain posture and spinal mobility.

■ Slow-release NSAIDs taken at night are particularly effective in relieving night pain and morning stiffness. Methotrexate helps the peripheral arthritis but not spinal disease. TNF-a-blocking drugs (see RA) are highly effective in active inflammatory disease and improve both spinal and peripheral joint inflammation.

X-ray of bamboo spine in ankylosing spondylitis

Fig. 7.5 X-ray of bamboo spine in ankylosing spondylitis. In advanced disease there is calcification of the interspinous ligaments and fusion of the facet joints as well as syndesmophytes at all levels. The sacroiliac joints fuse.

Psoriatic arthritis

Arthritis occurs in 20% of patients with psoriasis, particularly in those with nail disease (p. 807) and may precede the skin disease.

Clinical features

There are several types:

■ Asymmetrical involvement of the small joints of the hand, including the distal interphalangeal joints

■ Symmetrical seronegative polyarthrms resembling RA

■ Arthritis mutilans, a severe form with destruction of the small bones in the hands and feet

■ Sacroiliitis - unilateral or bilateral.

Investigations

■ Routine blood tests are unhelpful in the diagnosis. The ESR is often normal.

■ X-rays may show a ‘pencil in cup' deformity in the IPJs (bone erosions creates a pointed appearance and the articulating bone is concave).

Treatment

This is with analgesia and NSAIDs. Local synovitis responds to intra-articular corticosteroid injections. In severe cases methotrexate or TNF-blocking drugs (p. 287) control both the arthritis and the skin lesions.

Reactive arthritis

Reactive arthritis is a sterile synovitis, which occurs following:

■ Gastrointestinal infection with Shigella, Salmonella, Yersinia or Campylobacter

■ Sexually acquired infection - non-specific urethritis in the male or cervi-citis in the female due to infection with Chlamydia trachomatis or Urea-plasma urealyticum.

Persistent bacterial antigen in the inflamed synovium of affected joints is thought to drive the inflammatory process.

Clinical features

The typical case is a young man who presents with an acute arthritis shortly (within 4 weeks) after an enteric or sexually acquired infection, which may have been mild or asymptomatic. The joints of the lower limbs are particularly affected in an asymmetrical pattern; the knees, ankles and feet are the most common sites.

The skin lesions resemble psoriasis. Circinate balanitis causes superficial ulcers around the penile meatus, which harden to a crust in the circumcised male. Red plaques and pustules that resemble pustular psoriasis (kerato-derma blenorrhagica) are found on the palms and soles of the feet. Nail dystrophy may also occur.

Additional features are acute anterior uveitis, enthesitis (plantar fasciitis, Achilles tendonitis) and the classic triad of Reiter's syndrome (urethritis, reactive arthritis and conjunctivitis). A few patients develop sacroiliitis and spondylitis.

Investigations

The diagnosis is clinical. The ESR is raised in the acute stage. Aspirated synovial fluid is sterile, with a high neutrophil count.

Management

The acute joint inflammation responds well to NSAIDs and local corticosteroid injections. Any persisting infection is treated with antibiotics. Most patients have a single attack; relapsing cases are treated with sulfasalazine or methotrexate and TNF-blocking drugs (p. 287) in severe cases.

Enteropathic arthritis

Enteropathic arthritis is a large-joint mono- or asymmetrical oligoarthritis occurring in 10-15% of patients with ulcerative colitis or Crohn's disease. It usually parallels the activity of the inflammatory bowel disease and conse-quently improves as bowel symptoms improve. An HLa-B27 sacroiliitis or spondylitis occurs in 5% of patients with inflammatory bowel disease which is not related to disease activity.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology

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