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Seronegative Spondyloarthropathies & Ankylosing Spondylitis (AS)

by Carlo Raj, MD
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    00:01 In this section, we’ll take a look at seronegative spondylarthropathies under rheumatology.

    00:07 Things that you wanna keep in mind as we move forward here are the following.

    00:11 Seronegative refers to the fact that well, rheumatoid factor is negative in these conditions we’ll take a look at.

    00:18 Next, there’s a particular type of seronegative, it’s spondyloarthropathy known as, well, you probably have heard of Reiter's syndrome, but now we call it reactive arthritis more clinically.

    00:31 And you’ll be comparing this to septic arthritis that we had a discussion prior.

    00:36 Under seronegative spondyloarthropathy, the common feature that we’re going to find in all of these include the fact that you’ll have bone issues in the vertebrae, you have back pain.

    00:49 The differentials will include ankylosing spondylitis, we’ll have a young male most commonly who will then have vertebral issues.

    00:59 Reactive arthritis, formerly called Reiter's syndrome.

    01:04 This is the one perhaps that you’ve come to know as being can’t see, can’t pee, and can’t climb a tree, and I’ll tell you what those mean as we move forward.

    01:16 Psoriatic arthritis, some of your patients, maybe about 15 to 30% of them when they have the salmon colored plaques on the skin and they also have vertebral issues and I’ll show you an x-ray of the hand, you would then call that psoriatic arthritis.

    01:35 These are seronegative.

    01:37 All of these patients, these four classification or differentials will have HLA-B27 to be positive but the rheumatoid factor will come back to be negative.

    01:48 And then enteropathic.

    01:50 When you talk about enteropathic type of arthritis, then you’re thinking about inflammatory bowel disease.

    01:56 What are the two major inflammatory bowel diseases that you know of? Crohn and ulcerative colitis.

    02:03 I’ll mention it here, really won’t have much of a discussion.

    02:06 But please know that these four will then make up your seronegative spondyloarthropathies.

    02:11 Before we walk into the details, let’s first take a look at common extra-articular manifestations that are important that you wanna be able to identify.

    02:20 Around the join periarticular, the insertion sites of the tendon may then undergo inflammation.

    02:29 This is called enthesitis.

    02:32 If the tendon itself undergoes inflammation, tendonitis.

    02:37 And if the fingers are then undergoing pain called dactylitis.

    02:41 Remember dactylitis could also be seen - what if there was a patient that was a young African American boy says, “Doc.” Or the mother tells you that her son after going out playing has pain in the hand.

    02:55 That’s sickle cell disease, right? With something called micro-occlusive crisis or dactylitis.

    03:01 When’s the last time you’ve seen that? Keep that in mind.

    03:04 Ocular, there might be uveitis or conjunctivitis.

    03:09 Please picture the uvea and the uvea in which is usually going to be the space or as you come around the sclera and the iris, and the window known as a cornea, you might find inflammation in that area called uvea or uveitis of anterior or posterior.

    03:31 We’ll talk about that moving forward.

    03:33 In the GI, painless oral ulcerations or maybe colitis.

    03:38 Genitourinary, urethritis.

    03:40 Now, one second here.

    03:42 With urethritis, now in gonococcal, alright.

    03:47 These will not be referring to gonococcal type of infection.

    03:50 Remember, the common features include the following again, seronegative, rheumatoid factor’s negative, HLA-B27, correct? And you’re looking for bone issues, vaginitis, or maybe perhaps balanitis, involvement of the penis.

    04:04 Cardiac, aortitis, valvular insufficiency, heart block.

    04:09 Cutaneous, something called blennorrhagicum.

    04:14 And blennorrhagicum would mean a typical or a presentation that you would find and I’ll show you a picture of a rash that you would find on the sole of the foot of your patient.

    04:25 Ulcerative colitis and Crohn’s disease could be part of our constellation of the four that I talked to you about.

    04:32 With ankylosing spondylitis may begin with telling you who your patient is.

    04:39 Most likely, they’re going to be a young male and normally you and I, when we bend over to reach something, we’ll have this vertebral curvature, correct? Well, what then happens in this patient is that ankylosing in medicine obviously means fusion.

    04:57 So there’ll be fusion taking place of the vertebrae in this young patient.

    05:02 So therefore, when this young male is bending over, there’ll be a lack of the vertebral curvature, look for that.

    05:10 So this is seronegative spondyloarthropathy characterized by inflammation of the axial skeleton.

    05:17 It’s HLA-B27, 90-95% of your patients will be Caucasian.

    05:24 Only about 50% could be African American.

    05:27 It is male predominant however, we’re beginning to see that maybe more women could also be affected, keep that in mind.

    05:36 Onset, early.

    05:39 I give you a young male when trying to bend over, doesn’t have a proper vertebral curvature.

    05:45 Signs and symptoms, patient presents with progressive, low back pain.

    05:54 Remember, one of the common features of all seronegative spondyloarthropathies is the back pain but here, you’re looking at a young patient, most likely a male but as I told you, it could be a lady as well.

    06:07 Patients may have morning stiffness but this time, you find that there is improvement with exercise.

    06:14 In general, whenever you deal with other than osteoarthritis, remember, osteoarthritis, that patient, the morning stiffness might have lasted approximately 30 minutes.

    06:25 Osteoarthritis, the mechanical wear and tear of the joints.

    06:30 But keep in mind that with osteoarthritis when the patient over the period of time, it’s the wear, right, that caused the tear, so therefore, any type of activity would worsen the pain in osteoarthritis.

    06:43 Here, the patient feels better.

    06:46 So this is then similar to not osteoarthritis, but then, it would be similar to rheumatoid arthritis.

    06:53 In rheumatoid arthritis, remember, many of your patients will be rheumatoid factor positive.

    06:58 By definition, when we say seronegative, these conditions, the patient is rheumatoid factor negative and a patient with rheumatoid might be positive, keep that in mind.

    07:10 And then discussion rheumatoid arthritis, completely different from what we’re seeing here.

    07:14 What you’ll notice here is that as the patient gets older.

    07:20 For example, from year 1947 to 1973, you’ll notice that the patient is becoming more and more, and more debilitated.

    07:27 Patients eventually develop limitation of the flexion of the spine.

    07:32 Physical exam finding, you’re going to - well, this condition at the lower back, you’re going to refer to it as being lumbar lordosis, limited spinal motion demonstrated by a test that we call Schober's test.

    07:47 Now, because of the lack of vertebral curvature, guess who is having a hard time properly functioning physiologically? The lungs.

    07:56 So with lumbar lordosis as you see here as the patient’s getting older, that the lungs will be compromised, resulting in a type of restrictive lung disease, and for issues as such and it’s also important as we then go on to management.

    08:14 Diagnosis, on x-ray, I’m going to show you that ankylosing.

    08:20 What does ankylosing mean? It means fusion.

    08:23 Where is the fusion that you’re focusing upon? It most likely is going to be in the vertebrae or in the sacroiliac joints.

    08:31 These are the two places that you’re going to expect to find fusion on x-ray.

    08:36 In the vertebrae, when there’s fusion taking place, please picture what a bamboo stick looks like or a plantation of bamboo.

    08:45 It’s going to be a fused stick.

    08:49 So therefore, the vertebrae is oftentimes referred to as being bamboo spine.

    08:56 And seronegative obviously referring to RF negative.

    09:00 Management, anti-inflammatories, NSAIDs is where you begin conservatively.

    09:09 And then maybe, you use the same drugs that you would be using for rheumatoid arthritis.

    09:13 So these would be the drugs for modifying antirheumatoid type of drugs.

    09:19 So these are disease modifying, DM, antirheumatologic drugs, DMARDs.

    09:26 Anti-TNF therapy, physical therapy, and remember, a patient with ankylosing spondylitis in the long run is gonna develop what kind of lung disease? Restrictive.

    09:39 Now, for the patient at the same time, that’s a lot of stress and there’s every possibility that your patient might be a smoker.

    09:45 So therefore, this is what I was telling you earlier.

    09:49 You’re gonna use that information about restrictive lung disease, and if the patient is a smoker, you wanna make sure that you maintain proper lung function, hence, smoking cessation programs.

    10:01 Steroids are really not part of the therapy here because this is not a true inflammatory type of issue.

    10:08 You need to have modulators.

    10:10 The picture on the left that you’re seeing here is of the sacroiliac joint and you’re noticing that there’s fusion taking place.

    10:20 This is your black areas if you see.

    10:23 The pictures on the right represent the spine being in the shape of a bamboo.

    10:29 In other words, there’s ankylosing taking place, in other words, fusion.

    10:33 So therefore, this young male who is trying to bend over doesn’t have a proper, proper vertebral curvature.


    About the Lecture

    The lecture Seronegative Spondyloarthropathies & Ankylosing Spondylitis (AS) by Carlo Raj, MD is from the course Seronegative Spondylarthropathies. It contains the following chapters:

    • Introduction to Seronegative Spondylarthropathies
    • Ankylosing Spondylitis
    • Psoriatic Arthritis

    Included Quiz Questions

    1. Osteoarthritis
    2. Ankylosing spondylitis
    3. Psoriatic arthritis
    4. Enteropathic arthritis
    5. Reactive arthritis
    1. Rheumatoid factor
    2. Back pain
    3. Uveitis
    4. Aortitis
    5. Tendinitis
    1. Old age
    2. HLA-B27 positive
    3. Young age
    4. Male gender
    5. Caucasian population
    1. Inflammation of the insertion site of tendons.
    2. Inflammation of the tendon.
    3. Inflammation of the phalanges.
    4. Inflammation of joint capsule.
    5. Inflammation of cartilage.
    1. Ankylosing spondylitis
    2. Reiter's syndrome
    3. Reactive arthritis
    4. Psoriatic arthritis
    5. Enteropathic arthritis
    1. Keratoderma Blennorhagicum
    2. Dermatosis Papulosa Nigra
    3. Reactional Keratosis
    4. Necrobiotic Xanthogranuloma
    5. Hyperkeratosis Lenticularis Perstans

    Author of lecture Seronegative Spondyloarthropathies & Ankylosing Spondylitis (AS)

     Carlo Raj, MD

    Carlo Raj, MD


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