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Seronegative Spondyloarthropathes

  1. Feature
    1. Onset usually before 40 years age
    2. Inflammatory arthritis of spine & / or large peripheral joints
    3. Absence of autoantiboides (eg rheumatoid factor) in serum i.e. known as seronegative
    4. HL B-27 positive
    5. Presence of uveitis
  2. Include

Reiter’s syndrome (Conjunctivitis, Urethritis, Polyarthritie)

Ankylosing spondylitis

Psoriatic arthritis

Enteropathic arthritis

Reactive arthritis (yersenia, gonococcal, salmonella)

SAPHO syndrome (Synovitis, Acne, Pustulosis,palmoplantar, Hyperostosis, and Osteitis)

Ankylosing Spondylitis (AS)

It is a seronegative spondyloarthropathy a genetically determined generalized chronic inflammatory disease that primarily affects the axial skeleton (sacroiliac joint & spine) with variable involvement of root joints (shoulder & hip) and more rarely the peripheral joints.

Etiology & Pathogenesis
  1. >90% of AS patients are HLA B27 positive whereas only 10% of normal population is HLA B27 positive. 1 - 6% of adults inheriting B27 have been found to have AS.
  2. The enthesitis, the site of ligamentous attachment to bone is primary site of pathology in AS particularly in pelvis & spine. It is associated with prominent edema of adjacent bone marrow and is characterized by erosive lesions that eventually undergo ossification.
    1. Sacroilitis is the earliest manifestation with features of both enthesitis and synovitis
    2. Peripheral arthritis of AS can show synovial hyperplasia lymphoid infiltration & pannus but lacks exuberant synovial villi, fibrin deposits, ulcers, & accumulation of plasma cells seen in rheumatoid arthritis. Central cartilagenous erosion, caused by proliferation of subchondral granulation tissue are common in AS but rare in RA.
  1. TNF- α & cytokine play central role in pathogenesis. There is autoimmunity to cartilage proteoglycan aggrecan. ​ 

Musculoskeletal system

  1. Enthesopathy Inflammation of tendon & ligament attachment to bone
  2. Synovitis of diarthroidal joints
    1. Sacroiliac joint
    2. Facet joint of spine
    3. Costovertebral joints
  3. Inflammation of fibroosseous junction of syndesmotic joints
    1. SI joint ligaments
    2. Manubriosternal joint
    3. Pubic symphysis
    4. Intervertebral disc
  4. Uveal tract Uveitis
  5. Aorta Conductive defect
  6. Gastro intestinal tract Inflammatory bowel disease.

Clinical Presentation

  1. Males are affected more frequently than females (2 : 1 to 10 : 1)
  2. Age of onset is between 15 — 25 years (late adolescence & early adulthood)
  3. The initial symptom is usually dull pain, insidious in onset, felt deep in lower lumbar or gluteal region, accompanied by low back morning stiffness of upto few hour duration that improves with activity and returns following period of inactivity
    1. Bony tenderness (enthesitis) occur at costochondral junction, spinous process, iliac crests, greater trochanter, ischeal tuberosity, tibial tubercles, and heels
    2. Arthritis in the hips & shoulders (root joints) occur in 25- 35%
    3. Arthritis of peripheral joints other than hips and shoulders, usually asymmetrical, occur in upto 30% of patients
    4. Peripheral joints (usually shoulder, hips & knees) are involved in one third of patients
    5. Question mark (?) posture is d/t hyper kyphosis of thoracic spine and loss of lumbar lardosis. Cervical spine involvement is usually late.
    6. Most serious complication of spinal disease is spinal fracture with even minor trauma.
    7. The most common extraarticular manifestation is acute anterior uveitis (iridocyclitis) occurring in 30%. Cataract & secondary glucoma are not uncommon sequale.
    8. Upto 60% of patients have inflammation of colon or ileum (mostly asymptomatic, only 5- 10% develop IBD) AR, 3rd degree heart block, cardiac dysfunction, restrictive lung disease. IgA nephropathy, prostatitis & retroperitoneal fibrosis are other manifestations and may shorten life span.

Diagnostic Criteria –Modified New York criterion

  1. Essential criteria is definite radiographic sacroilitis
  2. Supporting criteria: one of these three
    1. H/o inflammatory back pain
    2. Limited chest expansion (<5 cm at 4th ICS)
    3. Limited lumbar spine motion in both saggital & frontal plane (Schober test <4 cm)


  1. Hematological - HLA B27, Normocytic, normochronic anemia, increased ESR, CRP, S. alkaline P04 & IgA
  2. Radiological features in chronological order

SI Joint (more on iliac side of joint)

  1. Blurring of cortical margins
  2. Juxtaarticular osteopenia & marginal sclerosis
  3. Erosion
  4. Obliteration of join


  1. Loss of lumbar lordosis (Straightening)
  2. Sclerosis of anterior corners of vertebral body
  3. Erosions of anterior corners of vertebral body - squarring of vertebral body Delicate syndesmophyte with vertical orientation bridging vertebral bodies (horizontal in degenerative spine disease)
  4. Bamboo spine is due to syndesmophytes, & paravertebral ossification.


  1. Phenylbutazone is most effective drug but causes aplastic anemia so reserved for non-responsive cases.
  2. Indomethacin is most commonly used NSAID. Sulfasalazine & folic acid antagonist (Mtx) is used for peripheral joints
  3. Anti TNF - a therapy eg, infliximab or etanercept heralded a revolution in managment of AS.

Schobers test


Reiter’s disease –

Classic triad: Conjunctivitis, Arthritis



Keratoderma blennorrhagicum(Pustular dermatitis of the feet) & circinate balanitis

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