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Toronto Notes 2019 Seronegative Rheumatic Disease
Rheumatology RH21
Seronegative Rheumatic Disease
ReA
Table 25. A Comparison of the Spondyloarthropathies*
Feature
M:F
Age of Onset Peripheral Arthritis Distribution Sacroiliitis Dactylitis Enthesitis
Skin Lesions
Uveitis Urethritis HLA-B27
LE = lower extremities
Ankylosing Spondylitis (AS)
3:1
20s
25%
Axial, LE 100% Uncommon Common Rare
Common Rare 90-95%
Psoriatic Arthritis (PsA)
1:1
35-45
96%
Any
40%
Common
Common
100%
Psoriasis eventually 70% at onset of arthritis
Occasional Uncommon 40%
Reactive Arthritis (ReA)
8:1
20s
90%
LE
80%
Occasional
Common
Occasional Keratoderma blennorrhagica
20% Common 80%
Enteropathic Arthritis (EA)
1:1
Any
Common
LE
20% Uncommon Less Common
Occasional Pyoderma, erythema nodosum
Rare Rare 30%
AS PsA
EA U-SpA
*Spondylarthropathy: inflammatory joint disease of the vertebral column
Figure 10. Spondyloarthropathy subsets
AS shares some features with the other three types of seronegative spondyloarthopathies such as ReA, EA, PsA and undifferentiated spondyloarthropathy (U-PSA)
Enthesitis: inflammation of tendon or ligament at site of attachment to bone
Consider AS in the differential for causes of aortic regurgitation
Rule of 2s
AS occurs in
0.2% of the general population
2% of HLA-B27 positive individuals
20% of HLA-B27 positive individuals with
affected family member
Ankylosing Spondylitis
Definition
• chronicinflammatoryarthritisinvolvingthesacroiliacjointsandvertebrae • enthesitisisamajorfeature(e.g.Achillestendonitis,plantarfasciitis)
• prototypicalspondyloarthropathy
Table 26. ASAS Classification Criteria for Axial Spondyloarthritis*
Sacroiliitis on Imaging plus ≥1 AS Feature or HLA-B27 Positive plus ≥2 AS Features
AS Features
HLA-B27 positive Inflammatory back pain Arthritis
Enthesitis (heel) Uveitis
Dactylitis
Psoriasis
Crohn’s disease/colitis Good response to NSAIDs Family history of AS Elevated CRP
Sacroiliitis on Imaging
Active (acute) inflammation on MRI highly suggestive of sacroiliitis associated with AS Definite radiographic sacroiliitis ≥ grade 2 bilaterally or grade 3-4 unilaterally
*For patients with ≥3 mo back pain and age at onset <45 yr Etiology and Pathophysiology
• inflammation→osteopenia→erosion→ossification→osteoproliferation(syndesmophytes)
Epidemiology
• M:F=3:1;femaleshavemilderdiseasewhichmaybeunder-recognizedandmoreperipheralarthritis and upper spine spondylitis
• 90-95% of patients have HLA-B27 (9% HLA-B27 positive in general population)
• SI
• Spondylitis • Hip
• Shoulder
Figure 11. Common sites of involvement of AS
The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is a self-reported scoring system that focuses on fatigue, axial pain, peripheral pain, enthesitis, and morning stiffness
© Linda Colati