Polyarthritis Chronic

Seronegative Spondyloarthropathies

General Features of Seronegative Spondyloarthropathies :

  • Sex:Men 3X > women
  • Age:20-50
  • General health:Good
  • Antecedent events:IBD, psoriasis, non-gonococcal urethritis, dysentery.
  • Prior arthritis:No
  • Most common joints:Sacroiliac joints, spine, feet, heels, knees

  • These chronic polyarthritides share a number of features: -
      - 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: -

    - Etanercept acts by inhibition of tumor necrosis factor-alpha and has provided rapid, significant, and sustained improvement in patients with ankylosing spondylitis (Gorman, 2002).
    Other traditional therapies :
    - 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.

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