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SERONEGATIVE ARTHRITIS
• A group of inflammatory conditions causing
arthritis of the spine and peripheral joints, often
associated with HLA B27, but without a positive
rheumatoid factor, hence "seronegative".
• The joint involvement is more limited than in
rheumatoid arthritis, and has different
distribution - the lumbo-sacral spine, distal
interphalangeal joints, depending on the subtype.
• Enthesopathy (ligament/ tendon to bone junction
inflammation) is more common.
• Share similar pathogenesis with RA
• Seronegative arthritis are more common in
Males than in Females
Types:
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3.
4.
Ankylosing spondylitis
Reiter’s syndrome
Psoriatic Arthropathy
Arthropathy associated with IBD
Ankylosing Spondylitis
• It is a chronic, inflammatory arthritis
• It affects joints in the spine and the sacroiliac
joints in the pelvis, causing eventual fusion of the
spine.
• Complete fusion results in a complete rigidity of
the spine, a condition known as bamboo spine
• The typical patient is young aged 18-30 years
• Associated with HLA-B27(98%)
• Men are affected more than women by a ratio
about of 3:1.
• In 40% of cases, Ankylosing Spondylitis is
associated with an inflammation of the eye
(iridocyclitis), causing eye pain and photophobia.
Clinical features:
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Recurrent low back pain
Stiffness in back
Early morning worsening of symptoms
Pain is often severe on rest, and improves with physical activity.
Chest pain: Aggravated by breathing results from involvement of the
costovertebral joints
• Another common symptom is generalized fatigue.
• May affect other joints: Ankle, Knee, Elbow
• When Ankylosing Spondylosis occurs before 18 years It causes pain and
swelling of large limb joints, particularly the knee, the spine may be
affected later on.
Clinical features:
• Failure to obliterate the lumbar lordosis on
forward flexion
• Pain on sacroiliac compression
• Tenderness over bony prominence such as
iliac crest, ischial tuberosity and greater
trochanter
• Restrictions of movements of lumbar spine in
all directions
• As the disease progresses, stiffness increases
throughout the spine
• Schober's test- Positive
Schober's test
• The examiner makes a mark
approximately at the level of L5.
• The examiner then places one
finger 5 cm below this mark, and
another, second, finger, 10 cm
above this mark.
• The patient is asked to touch
his/her toes.
• By doing so, the distance
between the two fingers of the
examiner increases.
• However, a restriction in the
lumbar flexion of the patient
reduces this distance
• If the distance increases less than
5 cm, then there is an indication
that the flexion of the lower back
is limited.
Extra-articular features of Ankylosing spondylitis
• Anterior uveitis
• Conjunctivitis
• Cardiovascular diseases
– Aortic incompetence
– Mitral incompetence
– Cardiac conduction defects
– Pericarditis
• Amyloidosis
• Atypical upper lobe pulmonary fibrosis
Investigations
• Rheumatoid factor  Negative/ Low titre positive
• ESR,CRP Elevated/ Normal
• X-Ray spine/ SI joint
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Sacroilitis
Irregularity/ Loss of cortical Margins
Widening of Joint spaces
Marginal Sclerosis
Narrowing
Fusion
• Lateral views of Thoracolumbar spine
– Anterior Squaring of vertebrae
• Due to  Erosion+ Sclerosis of anterior corners with periostitis
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Bridging syndesmophytes
Ossification of Anterior longitudinal ligament
Facet joint fusion
 Fusion of two vertebral bodies giving typical Bamboo Spine.
• HLA-B 27/ HLA-B7/B*2705 heterozygotes Highest risk
NOTE
• The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), is an
index designed to detect the inflammatory burden of active disease.
• The BASDAI can help to establish a diagnosis of AS in the presence of
other factors such as
– HLA-B27 positivity
– Persistent buttock pain which resolves with exercise, and
– X-ray or MRI evident involvement of the sacroiliac joints.
• Assesses a patient's need for additional therapy
• A patient with a score of 4 out of a possible 10 points while on adequate
NSAID therapy is usually considered a good candidate for biologic therapy.
• The Bath Ankylosing Spondylitis Functional Index (BASFI) is a functional
index which can accurately assess a patient's functional impairment due to
the disease as well as improvements following therapy.
• The BASFI is not usually used as a diagnostic tool but rather as a tool to
establish a patient's current baseline and subsequent response to therapy.
Treatment:
MEDICAL:
• NSAIDS ibuprofen, phenylbutazone, indomethacin, naproxen and COX-2
inhibitors
• Opiate analgesics (extended-release formulations)
• DMARDs cyclosporin, methotrexate, sulfasalazine, and corticosteroids
• TNFα blockers such as etanercept, infliximab and adalimumab (also known as
biologics)helps by slowing the progress of AS
SURGICAL:
• Joint replacements, particularly in the knees and hips (Severe cases)
• Surgical correction for those with severe flexion deformities
PHYSICAL THERAPIES:
• Movements that normally have great benefits to one's health may harm a patient
with AS. So, all physical therapies must be approved in advance by a
rheumatologist
• Physical therapy/physiotherapy
• Swimming, one of the preferred exercises since it involves all muscles and joints in
a low-impact
• Slow movement muscle extending exercises like stretching, yoga, climbing, tai chi,
Pilates method, etc.
REACTIVE ARTHRITIS/REITER’S SYNDROME
• Reactive arthritis is an autoimmune condition
that develops in response to an infection in
another part of the body.
• Coming into contact with bacteria and
developing an infection can trigger reactive
arthritis
• A type of seronegative spondyloarthropathy
• “A patient with Reiter’s syndrome can't see, can't
pee and can't bend the knee/can't climb a tree".
• Male: Female=20:1
COMMON TRIGGERS:
– HLAB-27
– Sexually acquired Chlamydial/ Neisseria gonococcal
infection(STD)
– Intestinal infections : Salmonella,Shigella and
Campylobacter jejuni
– HIV
Clinical Triad of
1. Inflammatory arthritis of large joints
including commonly the knee and the back
(due to involvement of the sacroiliac joint)
2. Inflammation of the eyes in the form of
(conjunctivitis or uveitis), and
3. Urethritis in men or cervicitis in women.
Clinical features:
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It is an inflammatory arthritis of large joints
Inflammation of the eyes (conjunctivitis and uveitis), and
Non-specific Urethritis
Inflammatory arthritis
Conjunctivitis or uveitis
Urethritis in men or cervicitis in women
Patients can also present with
Mucocutaneous leisons, as well psoriasis-like skin lesions such as
– Circinate balanitis (Serpiginous annular dermatitis of the glans penis)
– Keratoderma blennorrhagica (Skin lesions commonly found on the palms
and soles but which may spread to the scrotum, scalp and trunk also, and
which resemble psoriasis)
• Enthesitis can involve the Achille's tendon resulting in heel pain.
Systemic features:
-Fever and weight loss are common
-Carditis and aortic regurgitation may occur
• First episode: Self limiting
• >60% Patients: Recurrent/Chronic arthritis develops
• HLAB27 gene: In 90% patients positive
Treatment:
• NSAIDS
• Steroids
• Treat infections
• Severe case not responding to other medicines:
Immunosuppresives
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PSORIATIC ARTHROPATHY
Seen in Patients with Psoriasis
Arthritis develops in around 7-10% of patients with posriasis
Age of onset: 25-50 years
Oligoarthritis=Small joints of hands and feet
Symmetric Polyarthritis= May mimic RA
Arthritis involves DIP joint and usually associated with nail changes:
Characteristic
• Spondylitis
• Arthritis mutilans
• Intermittent exacerbations
• Presence of other features of Psoriasis
--Scaling lesions typically over extensor surfaces
--Nail changes: Pitting and onycholysis
--Eye :Iritis
Treatment:
• NSAIDS
• Joint injections with corticosteroids - this is
only practical if a few joints are affected
• Methotrexate, Sulfasalazine, Azathioprine
• Splints and prolonged rest are avoided
because of increased tendency to fibrous and
bony ankylosis
• TNF Alpha (Infiximab)
• PUVA—May improve skin and joint disease
ARTHRITIS ASSOCIATED WITH IBD
• Seronegative arthritis associated with Crohn’s
disease and ulcerative colitis
• Oligoarthritis= Large joints in lower limb
• Symptoms coincide with exacerbation of
underlying bowel disease
• Spondylitis
• Enthesitis
• Sometimes it may be associated with mouth
ulcers,iritis and erythema nodosum
INFECTIVE ARTHRITIS
SEPTIC ARTHRITIS
• Septic arthritis is an acute onset bacterial
inflammation, usually involving single
joint(>90%).
• Most often knee joint and wrists are involved.
• In IV drug abusers infection of spine and
sacroiliac joints is more common
Etiology:
• Staphylococcus aureus
• Streptococci
• Gram negative Bacilli such as E-coli and
Pseudomonas
Predisposing Factors:
1. Hematogenous spread:
 Microorganisms reach the joint by hematogenous
spread following bacteremia, so it is important to
look for evidence of :
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Septic skin lesion, Abrasions
Endocarditis
Iv drug abuse
Throat or urinary tract infection
2. Direct entry in the joint:
• Following penetrating wounds
• Local osteomyletis or Joint injection.
Clinical features:
• Sudden onset
• Typical presentation is single painful joint,
often knee
• Other joints are wrist, hip, shoulder and ankle
• The joints are red, warm and swollen with a
demonstrable effusion
• Marked limitation of movement
• Fever with chills in 80%
Diagnosis:
• Blood culture: Positive in 50% cases
• Aspiration of joint:
 Synovial fluid is purulent with neutrophil
dominant, Increased WBC often>100,000/μL
• Gram stain of synovial fluid is positive in 75% of
cases.
• C/S of fluid
D/D:
 Trauma
 Gout and Pseudogout
 Reactive arthritis
Treatment:
• Joint immobilization/elevation of joint
• Antiobiotics:
It is given according to culture and sensitivity.
Intravenous antiobiotics for 2-3 weeks, followed by
9-10 weeks of oral antibiotics
Empirical treatment:
1. IV Ceftriaxone 1-2 gm once daily plus Cloxacillin
1-2 gm 6 hourly
2. IV Vancomycin 1gm 12 hourly if methicillin
resistant staph is suspected
3. Aminoglycosides should be given to IV drug
absuer in which Pseudomans is suspected.
Drainage:
• Daily drainage of fluid until no further fluid is
available
• Arthroscopic drainage and lavage is required if
repeated needle aspiration fails to relive the
symptoms, failure to decrease the volume of
effusion and there is no clearance of bacteria
from smear.
GONOCOCCAL ARTHRITIS
• This is one of the most common cause of septic
arthritis in previously fit and sexually active young
adults.
• Recurrent infection should be evaluated for
congenital deficiency of complements C7 and C8
• Blood culture is positive in about 40% of cases
• Cultures is usually positive also from genital
organs, throat and rectum
• Synovial fluid gram staining is positive in 25%
Treatment:
• IV Ceftriaxone 1gm daily for 24-48 hrs then
• Ciprofloxacin 500mg 12 hourly for 7-10 days
TUBERCULOUS ARTHRITIS
• Tuberculous arthritis is invariably secondary to
pulmonary or renal TB due to hematogenous
spread of organism
Pathology:
• The synovial membrane and periarticular
tissues become inflamed and edematous
• Later there is destruction of cartilage which
may lead to fibrous ankylosis
• When spine is involved the infection may track
along the fascial plane to produce psoas
abscess
Clinical features:
• Usually single joint involvement affecting the
hip or knee(30%) or other joints(20%) and
spine(50%)
• Onset is insidious of pain and dysfunction of
the joint with swelling and synovial
proliferation and restriction of movement
• Malaise,anorexia,night sweats and weight loss
• Spinal involvement may lead to compression
of vertebrae and paraplegia
Investigations:
• Synovial fluids:Synovial fluid culture and
sensitivity
• Synovial biopsy
• X-ray:Initially normal,later narrowing of joint
space
T/T:
• Anti tuberculous drugs
MENINGOCOCCAL ARTHRITIS
• This usually occurs as a part of generalised
meningococcal septicemia
• It is a migratory polyarthritis
• Organism cannot be isolated from synovial
fluid
• Treatment is with Penicillin or Ceftriaxone
VIRAL ARTHRITIS
Organisms:
• Rubella virus
• Mumps
• Hepatitis
This is particularly a complication of the
rubella infection in young adult female
This presents as bilateral, symmetrical
Polyarthritis and resolves within few weeks
inmost of the cases