Polyarthritis Chronic

Seronegative Spondyloarthropathies

- Family history and the associated HLA-B27 haplotype

- Predilection for the sacroiliac joints and spine

- Common association with dermatitis

- Rheumatoid factor negative.

  • Physical examination: -

      - Asymmetric polyarthritis, especially involving the DIP joints, feet, including the heels, and often a gradually progressive involvement of the spine, with decreased spinal range of motion, decreased chest expansion, and pain in the buttocks.

      - Skin may demonstrate psoriasis or psoriatic-like lesions, mucus membrane inflammation, nail pitting and dystrophic changes.

      - May also have conjunctivitis, urethritis, balanitis, and aortitis.

  • Laboratory tests: -

      - Radiologic evidence of sacroiliitis, spinal involvement with syndesmophytes, peripheral enthesopathy with calcifications of tendons and ligaments, destructive bone lesions at DIP joints.

      - Negative rheumatoid factor, positive HLA-B27 antigen.

      - Synovial fluid is often very inflammatory with > 25,000 leukocytes and may even appear purulent.

  • Clinical course and treatment:Often responds well to various NSAIDS. Trend now is to treat earlier and more aggressively with multiple agents. NSAIDS are still often tried first.

  • Recent therapeutic regimes: -

      -Methotrexate, 5-20mgs po once per week is the most effective second-line agent.

      -Oral minocycline (200 mg/day) recently appears safe and effective in reducing clinical and laboratory indexes of disease activity (Tilley et al, 1995)

      -Hydroxychloroquine, 400 mg/d, and sulfasalazine, 1-3 g/d, are other popular choices.

      -Cyclosporine and azathioprine may be helpful.

      -Prednisolone, 7.5 mg daily for 2 years combined with other treatments reduces the rate of progression of rheumatoid arthritis (Kirwan et al, 1995). Low dose corticosteroids are most helpful with acute flares.