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RH24 Rheumatology
Seronegative Rheumatic Disease
Toronto Notes 2019
Table 29. CASPAR Criteria for PsA*
Criterion
1. Evidence of psoriasis 2. Psoriatic nail dystrophy 3. Negative results for RF 4. Dactylitis
5. Radiological evidence
Description
Current, past, or family history Onycholysis, pitting, hyperkeratosis
Current or past history
Juxta-articular bone formation on hand or foot x-rays
Clinical Triad of Reactive Arthritis
• Arthritis
• Conjunctivitis/uveitis • Urethritis/cervicitis
“Can’t See, Can’t Pee, Can’t Climb a Tree”
Triad of conjunctivitis, urethritis, and arthritis is 99% specific (but 51% sensitive) for ReA
* To meet the CASPAR (ClASsification criteria for Psoriatic ARthritis) criteria, a patient must have inflammatory articular disease (joint, spine, or entheseal) with ≥3 points from the above 5 categories
Arthritis Rheum 2006 Aug;54(8):2665-73. Classification criteria for PsA: development
Reactive Arthritis
Definition
• oneoftheseronegativespondyloarthropathiesinwhichpatientshaveaperipheralarthritis(≥1mo duration) accompanied by one or more extra-articular manifestations that appears shortly after certain infections of the GI or GU tracts
• thistermshouldnotbeconfusedwithrheumaticfeverorviralarthritides
Etiology
• onsetfollowinganinfectiousepisodeeitherinvolvingtheGIorGUtract
■ GI: Shigella, Salmonella, Campylobacter, Yersinia, C. Difficile species
■ GU: Chlamydia (isolated in 16-44% of ReA cases), Mycoplasma species
• acuteclinicalcourse
■ 1-4 wk post-infection
■ lasts weeks to years
■ oftenrecurring
■ spinal involvement persists
Epidemiology
• inHLA-B27patients,axial>peripheralinvolvement • M>F
Signs and Symptoms
• musculoskeletal
■ peripheral arthritis, asymmetric pattern, spondylitis, Achilles tendinitis, plantar fasciitis, dactylitis
• ophthalmic
■ iritis (anterior uveitis), conjunctivitis
• dermatologic
■ keratoderma blennorrhagicum (hyperkeratotic skin lesions on palms and soles) and balanitis
circinata (small, shallow, painless ulcers of glans penis and urethral meatus) are diagnostic • gastrointestinal
■ oral ulcers, diarrhea
• genitourinary
■ urethritis; cervicitis; sterile pyuria; presence not related to site of initiating infection
Investigations
• diagnosisisclinicalpluslaboratory
• bloodwork:normocytic,normochromicanemia,andleukocytosis • sterilecultures
• serology:HLA-B27positive
Treatment
• antibioticsfornon-articularinfections • NSAIDs, physical therapy, exercise
• localtherapy
■ IAsteroidinjection
■ topical steroid for ocular involvement • systemictherapy
■ corticosteroids, sulfasalazine, MTX (for peripheral joint involvement only) ■ TNF-α inhibitors for spinal inflammation
Prognosis
• self-limited,typically3-5mo,variesbasedonpathogenandpatient’sgeneticbackground • chronicin15-20%ofcases
• 1st MTP = podagra • Ankle
• Knee
Figure 13. Common sites of involvement of gout (asymmetric joint involvement)
© Jerry Won, after Linda Colati