SERONEGATIVE SPONDYLOARTHROPATHY

1. Dr Nihal Ahmed
Apollo Cancer Centre
Teynampet, Chennai

2.  Spondyloarthropathies (SpA), are a group of
musculoskeletal syndromes linked by common clinical
features and immunopathologic mechanisms.
 Diagnostic criteria:
1) Absence of RF
2) Sacroiliitis with/without AS
3) Peripheral arthropathy
4) Clinical overlap including 2 or more of following:-
 Psoriatic skin or nail lesion
 Conjuctivitis/GUT infection
 Ulceration of mouth, intestine or genitals
 Eryhtema nodosum

3.  Five subgroups of spondyloarthritis are
distinguished:
 Ankylosing spondylitis: ~90% HLAB27 positive
 Psoriatic arthritis: ~60%
 Reactive arthritis: ~85%
 Enteropathic arthritis (i.e. extraintestinal
manifestation of IBD)
 Undifferentiated spondyloarthritis

4.  A chronic, progressive inflammatory disease resulting in fusion
(ankylosis) of the spine and sacroiliac (SI) joints.
 Mostly affects young adults(3rd decade), Male predilection of
3:1.
 The axial skeleton is predominantly affected, although in
~20% of cases the peripheral joints are also involved.
 Associations
 Anterior uveitis (25-40%)
 Cardiovascular disease, Aortic valve disease
 Apical/upper lobe predominant interstitial lung disease with small
cystic spaces (in ~1% of patients)
 Arachnoiditis

6. SACRUM
Sacroiliitis is usually the first manifestation
– Bilateral, symmetrical
 Subchondral demineralization - equivalent of
subchondral bone marrow hyperintensity seen on MRI.
 Subchondral erosions, sclerosis (>5mm) on the iliac side
of the SI joints.
 At end-stage, total ankylosis/complete obliteration of joint
space.

8. SPINE
 Begins in the thoracolumbar spine and progresses cranially.
 Small erosions at the corners of vertebral bodies with reactive
sclerosis: Romanus lesions (shiny corner sign)
 Vertebral body squaring
 Noninfectious spondylodiscitis: Andersson lesion
 Diffuse syndesmophytic ankylosis -Bamboo spine (Lat)
 Interspinous ligament ossification - Dagger spine (AP)
 Ossification of facet joint – Tram track sign
 Enthesophyte
 Complications – carrot stick fractures

11. Hips
 Bilateral and symmetric, uniform joint space narrowing, axial
migration of the femoral head, protrusio acetabuli, and a collar
of osteophytes at the femoral head-neck junction.
Pelvis
 Whiskering of the pelvic bones primarily affects the ischial
tuberosities/iliac crest.
 Bridging or fusion of the pubic symphysis.
Knees
 Knees demonstrate uniform joint space narrowing with bony
proliferation.
Shoulders
 Large erosion of the anterolateral aspect of the humeral head
- 'hatchet' deformity, glenohumeral joint involvement is not
uncommon

14.  Inflammatory arthritis seen in ~30% of patients with
psoriasis.
 In contrast to many other arthropathies, there is no
gender predilection, mean age: 20-40 years.
 Dermatological features of psoriasis precede arthritis in
70-75% of cases.
 Strong association with nail involvement, particularly for
distal interphalangeal joint arthritis.
 Pathogenesis – Chronic synovitis – joint destruction

15. Five subtypes :
Symmetric polyarthritis (similar in
appearance to RA)
Asymmetric mono- or oligoarthritis
Spinal column involvement (spondylitis)
Distal interphalangeal arthritis of the hands
and feet
Arthritis mutilans

16.  The hallmark of psoriatic arthritis is the combination of bone erosions
with bone proliferation and predominantly distal distribution.
(e.g. interphalangeal more than metacarpophalangeal joints).
 Enthesitic and marginal bone erosions; “Pencil in cup” deformities
are common, but not pathognomonic for PsA.
 Joint subluxation, joint space - preserved.
 Periostitis
 Dactylitis: Soft tissue swelling of a whole digit- “Sausage digit”;
underlying synovitis and tenosynovitis
 Acro-osteolysis
 Arthritis mutilans: osteolysis and articular collapse-"telescoping
fingers"
 Ivory phalanx: Classically involving the distal phalanx of the great toe

19.  Sacroiliitis: often
asymmetrical
 Spondylitis:
 Osteophytes – coarse,
asymmetric, non marginal
 Parasyndesmophytes

20.  Sterile inflammatory monoarticular or
oligoarticular arthritis that follows an infection
at a different site, commonly enteric or
urogenital.
 Reiter syndrome -Urethritis, arthritis and
conjunctivitis.
 Similar appearance to psoriatic arthritis -
ill-defined erosions, enthesopathy, bone
proliferation and fusiform soft tissue
swelling.

21.  Lower extremity involvement - MTP joint, DIP
rarely involved*
 Enthesitis -Calcaneus at the sites of Achilles
tendon and plantar fascia attachment.
 Large bulky paravertebral ossification
"floating osteophyte"
 Sacroiliitis -usually unilateral,asymmetric
 Knee > Ankle > Sacroiliac joint) is more
prevalent than upper extremity.

23. Enteropathic arthritis (EA) is a form of
chronic, inflammatory arthritis associated
with IBD(Crohns,UC), Whipples disease.
Location – 3 patterns
1) Peripheral joint arthritis
2) Sacroiliitis
3) Spondylitis identical to AS – can precede
bowel disease*

25. Non-specific mono or polyarthropathy.
Early presentation of a more well-known
form of arthritis.
A specific diagnosis is usually reached
within three months – commonly RA
(30%), AS
HLA B-27 positive in ~75% cases