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Spondylo - Arthrosis (AIIMS Nov 12)

It is a group of disease which include. 
  1. Ankylosing spondylitis
  2. Reiter’s disease
  3. Reactive Arthritis
  4. Psoriatic arthritis
  5. Juvenile rheumatoid arthritis (JRA)
  6. Inflammatory bowel disease
  1. Seronegativity (rheumatoid factor –ve) 
  2. HLA B27 associated (AIIMS Nov 12)
  3. Axial arthritis: Pathology in spine and sacroiliitis.
  4. Asymmetrical large-joint oligoarthritis (i.e <5 joints) or monoarthritis.
  5. Enthesitis: Inflammation of the site of insertion of tendon or ligament into bone, eg. Plantar fasciitis, Achillis tendonitis, costochondritis. 
  6. Extra-articular manifestations eg anterior uveitis, aortic regurgitation
Table 325-1 ASAS Criteria for Classification of Axial Spondylarthritis (to Be Applied for Patients with Back Pain 3 Months and Age of Onset <45 Years) (Ref. Hari. 18th ed., Pg -  2777, Table 325-1)
Sacroiliitis on imaging plus 1 SpA feature or HLA-B27 plus 2 other SpA features
Sacroiliitis on imaging SpA features
1. Active (acute) inflammation on MRI highly suggestive of SpA-associated sacroiliitis
2. Definite radiographic sacroiliitis
1. Inflammatory back pain
2. Arthritis
3. Enthesitis
4. Anterior uveitis
5. Dactylitis
6. Psoriasis
7. Crohn's disease or ulcerative colitis
8. Good response to NSAIDs
9. Family history of SpA
10. HLA-B27
11. Elevated CRP

ASAS = Assessment of Spondylarthritis International Society, SpA = Juvenile onset spondylarthritis

Ankylosing Spondylitis (AS)

  1. AS is an inflammatory disorder of unknown cause that primary affects the axial skeletonQ.
  2. Usually begins in the second or thirdQ decade of life.
  3. Men >> women.
  4. HLA – B27 Q positive.
Clinical Features
  1. Sacroiliitis is usually one of the earliest manifestation of AS.
  2. The initial symptom is usually a dull pain, insidious in onset, felt deep in the lower lumbar or gluteal region, accompanied by low – back morning stiffness. 
  3. Enthesopathy
  4. Arthritis in the hips and shoulders may occur.
  5. Acute anterior uveitis, can antedate the spondylitis. 
  6. Loss of spinal mobility, with limitation of anterior flexion, lateral flexion, and extension of the lumbar spine, is seen.
  7. The Schober Test-
  8. It is a useful measure of forward flexion of the lumbar spine. It is ↓ in A.S
  9. Pulmonary involvement, is characterized by slowly progressive upper lobe fibrosis. There is limitation of chest expansion. Recurrent chest infection is the most common cause of the death.
  10. Aortic insufficiency or cardiac conduction disturbances.
  11. Prostatitis occurs with increased frequency in men. 
  12. The most serious complication of the spinal disease is spinal fracture, which can occur with even minor trauma to the rigid, osteoporotic spine. (Ref. Hari. 18th ed., pg - 2775)
  13. The most common extraarticular manifestation is acute anterior uveitis, 
  14. Mortality attributable to AS is largely the result of spinal trauma, aortic insufficiency, respiratory failure, amyloid nephropathy, or complications of therapy such as upper gastrointestinal hemorrhage.
Radiographic Findings
  1. The earliest changes in the sacroiliac joints demonstrable by pain x-ray shows erosions and sclerosis. 
  2. Progression of the erosions leads to ‘pseudo widening’ of the joint space and bony ankylosis. 
  3. X-ray spine reveals bamboo spine appearance.
  1. There is no definite treatment for ankylosing spondylitis. 
  2. The mainstay of therapy in all seronegative spondyloarthropathies are NSAIDs. Indomethacin is a drug of choice.
  3. Patients with AS treated with either infliximab, etanercept, or adalimumab or golimumab have shown rapid, profound, and sustained reductions in all clinical and laboratory measures of disease activity. (Ref. Hari. 18th ed., Pg - 2777)

Reiter’s Disease (FAQ)

Definition - It is characterised by a triad of
  1. Seronegative oligoarthritisQ,
  2. Conjunctivitis
  3. Nonspecific urethritis, 1 – 3 weeks following bacterial dysentery or exposure to sexually transmitted disease.
Arthritis occurring alone following sexual exposure or enteric infection is known as reactive arthritis.

Reiter disease can occur in epidemic form (FAQ)

Bacteria causing Reactive Arthritis (AIIMS Nov 2010)
  1. Salmonella
  2. Shigella
  3. Campylobacter
  4. Yersinia
  5. Chlamydia.

Note: Shigella is the most common organism causing Reiter’s disease following diarrhea.
(Ref. Hari. 18th ed., Pg- 2778)


Chlamydia Trachomatis is the most common cause of reactive arthritis following urethritis.


Ureaplasma and mycoplasma are rare causes.

Clinical Features
  1. It presents with monoarthritis of a knee or an asymmetrical inflammatory arthritis of interphalangeal joints.
  2. Patient can have heel pain, Achilles tendinitis or plantar fasciitis with presence of circinate balanitis. (AIPG 2010)
  3. The presence of rash of keratoderma blennorrhagica (LQ 2012) (AIIMS Nov 2010) is diagnostic of Reiter’s disease in the absence of classical triad.
  4. Ocular involvement (mild bilateral conjunctivitis)
  5. Dactylitis, or "sausage digit," a diffuse swelling of a solitary finger or toe, is a distinctive feature of ReA and other peripheral spondylarthritides but can be seen in polyarticular gout and sarcoidosis.
  6. Oral ulcers can be there.
Important Points

Subcutaneus nodules is not a feature

  1. Analgesics
  2. Local corticosteroids are useful in the case of iritis
  3. The nonspecific urethritis is treated with a short course of Tetracycline.

Psoriatic Arthritis

Definition - It is a seronegative inflammatory arthritis and associated with characteristic changes in the nails (pitting and transverse ridges).

Clinical Features
  1. Asymmetrical oligoarthritis (70%) (DIP involvement is a characteristic feature). (FAQ)
  2. Sacroiliitis/spondylitis (40%)
  3. Symmetrical seronegative arthritis (15%)
  4. Distal interphalangeal joint arthritis (15%)
  5. Arthritis mutilans. (AIPG 2010) On X-ray pencil in cup appearance is seen.
    Hand Joints involved in Psoriases = PIP + DIP + MCP + Wrist
Important Points

Articular Features

  1. Scaly skin lesions are seen over extensor surfaces (scalp, natal cleft and umbilicus)
  2. The nail changes are pitting, onycholysis, sub – ungual hyperkeratosis and horizontal ridging.

  1. Analgesics (NSAIDs)
  2. Sulphasalazine and gold are used in persistent symptomatic cases without exacerbation
  3. Chloroquine and hydroxychloroquine are used
  4. Retinoid etretinate 30mg/day is effective for both arthritis and skin lesions
  5. Photochemotherapy with methoxy psoralen and long wave ultra violet light (PUVA) are used for severe skin lesions
  6. Methotrexate can also given.

Juvenile Chronic Arthritis (JRA)

  1. It is non infective inflammatory joint disease of more than 3 months duration in children <16 years of age.
  2. Aetiopathology is similar to RA but with less marked cartilage erosion, and joint instability and absent rheumatoid factor.
  3. Clinical presentation may be
    1. Still’s disease/Systemic JRA (15%)
      1. Usually seen below 3years age equally in boys & girls.
      2. Fever, rash, skin nodule lymphadenopathy & hepato splenomegaly.
      3. Arthritis usually occurs some weeks or months after the onset
    2. Pauciarticular JRA (60%)
      1. Commonest form, below age of 6 years, more commonly in girls.
      2. One to few joint involvement (knee, ankle, elbow, wrist) without systemic illness.
      3. RF test is negative & chronic iridocyclitis occur in about 50% case.
    3. Juvenile RA/Polyarticular JRA (10%)
      1. Involvement of temporo mandibular joint & cervical spine, hands & wrist.
      2. Usually seen in older children mainly girls.
    4. Seronegative spondylarthritis Juvenile AS (5%)
      1. In older children, usually boys
      2. HLA B27 positive
      3. Sacroiliitis, spondylitis, hip & knee involvement
Important Points

Raynaud's phenomenon is not a feature of JRA.

Adult rheumatoid arthritis is DW4/DR4

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