Seronegative Spondyloarthritis:

Ø  Ankylosing spondylitis

Ø  Reactive arthritis (Reiter’s syndrome)

Ø  Psoriatic arthritis

Ø  Enteropathic arthritis (associated with inflammatory Bowel disease such as Ulcerative Colitis and Crohn’s disease)

Clinical features common to Seronegative Spondyloarthropathy:

Ø  Asymmetrical inflammatory oligoarthritis (lower > upper limb)

Ø  Enthesitis

Ø  Sacroiliitis and spondylitis

Ø  Familial

Ø  Extra – articular features:

o   Conjunctivitis

o   Buccal ulceration

o   Urethritis

o   Prostatitis

o   Bowel ulcers

o   Pustular skin lesions

o   Anrerior uveitis

o   Aortic root fibrosis (causing aortic regurgidation, heart blocks)

Ankylosing spondylitis

It is chronic inflammatory seronegative arthritis especially affecting sacroiliac joints and spine and characterized by stiffening and fusion of the axial skeleton.

Incidence:

o   Age: 25 – 35 years

o   Male to female ratio 3:1

o   More than 90 % of affected persons carry the histocompatibility antigen HLA – B27

Clinical features:

o   Chronic low back pain

o   Morning stiffness < 1 hour

o   Relieves with exercise

o   Other are same as for Seronegative Spondyloarthropathy

Investigations:

o   ESR and CRP often raised

o   RA factor absent

o   HLA – B27 in 90 % cases

o   X – ray:

§  Sacroiliitis

§  Syndesmophytes

§  Fusion of vertebrae (Bamboo spine)

Management:

NSAIDs

Physiotherapy

DMARDs:

o    Methotrexate

o    Sulfasalazine

Biological Response Mediator (BRM):

Anti – TNF therapy:

o    Inflixemab

o    Etanercept

Surgery:

Joint replacement

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Osteoarthritis:

A degenerative disease of joints resulting from wear of the articular cartilage , which may lead to secondary changes in the underlying bone.

Etiology:

Primary: Unknown

Secondary:

·         Trauma

·         Occupational overuse of a joint

·         Metabolic diseases:

·         Hyperparathyroidism

·         Ochronosis alcaptonuria

·         Neurological disease:

·         Tabes dorsalis

·         Obesity

Pathophysiology:

·         Degeneration of cartilage

·         Hypertrophy of the bone

·         Thickening of synovial membrane

·         Reduction of the joint cavity (not obliterated)

Clinical features:

·         Onset : Insidious (slow)

·         Morning stiffness not more than 15 min

·         Pain:

Worse on activity

Relieved by rest

·         Asymmetrical joint involvement

·         Limited range of movement

·         Distal interphalangeal joint involvement as compared to rheumatoid arthritis

·         Number of joint involve is less as compared to rheumatoid arthritis

Investigations:

·         ESR will be normal because of no inflammation

·         X – ray:

·         Narrowing of joint space due to loss of cartilage

·         Formation of osteophytes at the margin of the joints

·         Cyst formation

Management:

General measures

·         Weight reduction

·         Rest

·         Joint protection

Physical therapy:

·         Heat therapy

·         Hydrotherapy

·         Proper exercises

Drug treatment:

·         Acetaminophen (Ponston)

·         NSAIDs

·         Inj. Triamcinolone

Surgery:

Joint replacement

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Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.

Incidence:

·         Female to male ratio 3: 1

·         Peak age incidence between 20 – 40 years

·         25 % of RA patients need large joint replacement.

Etiology:

The cause of rheumatoid arthritis is unknown. The following are the risk factors.

·         Genetic factors because it is usually associated with HLA – DR4 in whites and DR1 in Indo – Pak.

·         Female gender is a risk factor and this susceptibility is increased post – partum and by breast feeding.

·         Cigarette smoking is also a risk factor.

Pathophysiology:

There are three main pathological characteristics.

      i.        Chronic inflammation

     ii.        Granuloma formation

    iii.        Joint destruction

RA is disease of synovial membrane. There is swelling and congestion of synovial membrane and the underlying connective tissues, followed by infiltration by lymphocytes (especially CD4 T cells), plasma cells and macrophages. The synovial membrane then proliferates and grows out over the surface of cartilage, which causes the erosion and destruction of the cartilage.

Clinical features:

·         Joint pain

·         Morning stiffness

·         General symptoms: Fatigue and malaise

·         Deformities: In advance stage of RA.

Deformities of hand and forearm:

Swan neck deformity: Characterized by hyperextension at the proximal interphalangeal joints and fixed flexion at the distal interphalangeal joints.

Boutonniere or Button hole deformity: Characterized by fixed flexion of the proximal interphalangeal joint and extension of the distal interphalangeal joint.

Z deformity of thumb: Characterized by hyperextension of the first interphalangeal joint and flexion of the firs metacarpophalangeal joint with a consequent loss of thumb mobility.

Ulnar deviation

Deformities of foot and knee:

Cock up deformity: Dorsal sublaxation of metatarsophalangeal joint.

Baker’s cyst: Cyst (extension of inflamed synovium) in popliteal space. High pressure generated by flexion of knee can cause rupture of cyst into calf leading to calf pain, swelling and tenderness.

Criteria for the diagnosis of RA:

Diagnosis of RA is made with four or more of the following.

      i.        Morning stiffness (> 1 hour)

     ii.        Arthritis of 3 or more joints

    iii.        Arthritis of hand joints

    iv.        Symmetrical arthritis

     v.        Rheumatoid nodules

    vi.        Rheumatoid factor

   vii.        Radiological changes

  viii.        Duration of symptoms ≥ 6 weeks

Extra –articular features:

Lungs:

o    Pleural effusion

CNS:

o    Cervical cord compression

o    Peripheral neuopathy

Ocular:

o    Scleritis

o    Keratoconjunctivitis

Musculoskeletal:

o    Muscle wasting

o    Tenosynovitis

o    Bursitis

Cardiac:

o    Pericarditis

o    Myocarditis

o    Endocarditis

Lymphatic:

o    Spleenomegaly

o    Feltey’s syndrome

Investigations:

o    ↑ ESR

o    ↑ C – reactive protein

o    RA factor is present in about 70% of cases.

o    X – Ray to establish diagnosis and monitor disease damage.

Management:

General measures:

·         Educate the patient

·         Control pain: Paracetamol 1 g TDS

·         Exercise

·         Joint protection: If obese then weight loss

Specific treatment:

DMARDs (Disease Modifying Anti-Rheumatic Drugs): 

o    Methotrexate

o    Sulfasalazine

o    Azathioprine

o    Hydroxychloroquine

o    Leflunamide

o    Gold

o    Penicillamine

Biological DMARDS:

Anti – TNF therapy:

o    Inflixemab

o    Adalimumab

o    Etanercept

Steroids:

Low dose

Surgery:

o    Synovectomy

o    Arthrodesis

• Arthroplasties

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