SPONDILO ARTHROPATY SERONEGATIP

(SPONDILO ARTRITIS)
SPONDYLOS = BACK BONE
ARTROPATI = JOINT INVOLVEMENT
SERONEGATIP = Rheumatoid Factor
A group polyarthritis with clinical symptoms:
Rheumatoid Fakctor (-)
1. periphery asymmetric polyartrhrtis
2. Sacroilitis
3. Familial Agregation
4. HLA-B27
Family of Spondyloarthropathies
2
AS
Undifferentiated
Spondylo-
arthropathy
Juvenile
Spondylo-
arthropathy
IBD
Associated
Arthritis
Psoriatic
Arthritis
Reactive
Arthritis
Ankylosing Spondilitis
Primarily affects: spine, axial skleleton and
large proximal joint of the body
Distinctive feature :fibrosis, secondary
ossification and ankylosing of involved joints
Men >Women ( 30-40 year old )
Ankylosing Spondilitis is strongly associated
with HLA B-27
3
Prevalence
USA 1.29 per 1,000 person
A positive family history ( 15-20% cases )
The risk development of AS in HLA-27 (20%)
Genetic aspects
Schlosstein and Brewerton (73) : a strong
association B-27 with AS
: = 3:1

4
KRITERIA NEW YORK 1984
UNTUK DX. S.A.
Kriteria Klinis
1. Nyeri pinggang minimal 3 bulan, tak berkurang dg istirahat,
membaik dengan gerak
2. Pembatasan gerak lumbal pada bidang sagital dan frontal
3. Pengembangan dada menurun

Kriteria Radiologis
1. Bilateral Sacroiliitis Grade 2 4, atau
2. Unilateral Sacroiliitis Grade 3 4

S.A. Definitif :
1 (satu) kriteria klinis + Radiologis

KRITERIA DIAGNOSIS SAS
( European Spondyloarthropathy Study Group th. 1991)
Nyeri inflamasi sendi vertebra 3 bulan
Atau
Sinovitis : Asimetrik atau terutama pada tungkai bawah
Dan
Salah satu manifestasi dibawah ini :

Riwayat Keluarga SA, psoriasis, uveitis akut, artritis reaktif, penyakit
inflamasi usus
Psoriasis
Penyakit inflamasi usus (IBD)
Uretritis non gonococcal, cervicitis, diare akut dalam 1 bulan
sebelum artritis
Nyeri daerah pantat hilang timbul
Tendinitis achilles atau fasciitis plantaris
Sacroiliitis pada radiografis
Pathology
Skeletal sites
Axial skeleton( intervetebral disk, sacroiliac
joints,costovetebral joints )
Anterior central joints ( manubriosternal
joints,sternoclavicular joint and sympisis pubis )
Large Prox joint ( hip, knee, shoulders)
7
Extra skeletal sites:
Eye: uveal tract
Aortic root wall, apical lung parenchyma and heart
valves
Fibro cartilage inflammation, subchondral
bone
Annulus fibrosus, perispinal ligaments
(enthesitis),periosteum
Synovial membrane (synovitis )
8
Clinical Presentation
Classic: young man:15-40 years old
Low back pain and stiffness
worse in the mourning hours and after
prolong rest, relieved physical activity
Chest pain and stiffness
Peripheral arthritis ( asymmetric ):hip, shoulder,
heel
9
Extra skeletal manifestations :
aortic valve regurgitation Iritis of one site ( unilateral )
Pulmonary involvement:
-Restrictive thoracic cage
-Apical lobe fibrosis
Vetebral fracture (eg:minmal trauma )
Cauda equina syndrome (nerve root compression )
10
Sacroiliac joints:
Lateral compression of the pelvis
Gaenslens sign
Spine :
Loss of spinal motion(lateral,flexi and extension)
Schober test (+),occiput wall test, tragus wall test
Costovetebral involvement:chest expansion

HLA B-27 (45%)
ESR
A mild normocytic anemia
Pulmonary function test ( thorax involvement )

11
Sacroiliac joint:punche out erosion
pseudo whitening
Adjacent sclerosis
Bony bridging of the joint (complete loss of joint space )
Spine:squarring of vetebra,syndesmophytes or bamboo
spine
Romanus sign: an erosion surounded by sclerosis at
veterbra body margin
Ligamentous bony junctions (enthesitis )
12
Four or more of following features are present:
Age of onset <40 years
Insidious onset
LBP lasting longer than 3 months
Associatiom with morning stiffness and
improvement with exercise
Lumbar strain (lumbosacral disk disease
Other seronegative spondyloarthropaties
Degerative joint disease ( OA )
Diffuse Idiopathic Skeletal Hyperosthosis ( DISH )
13
Control pain
Maintain maximum skeletal mobility
Prevent deformity
Sulfasalazine:Early
:Active disease

14
Inflammatory Bowel Disease:
Ulcerative colitis and Crohns disease
No association with HLA-B27
Peripheral arthritis
acute, migratory, transient, asymmetric /
oligo articular
pattern
Usually follow: bowel symptom
Extra intestinal manifestations:
erythema nodusum,enthesitis,Aphtous
oral ulceration,uveitis
Axial involvement: (sacroilitis and spondylitis)
15
Slight anemia, ESR
Synovial fluid ~ inflammatory
arthritis (4 000-40.000 leucocytes),
culture sterile
Rheumatic fever
Acute mono arthritis
(septic arthritis )
Gout
Pseudo gout
16
Therapy should be directed primarily at the intestinal
Inflammation
Sulfazalazine only effective for peripheral arthritis
NSAIDs should be used with caution
Colectomy cures peripheral arthritis in ulcerative colitis,
but does not alter the course of spondylitis
17
Celiac disease (Gluten induced enteropathy )
Small intestine
Therapy: gluten free diet
Henoch Schnlein Purpura
SLE
Syndrome associated with vasculitis(involvement
mesentery arteries )
18
Cutaneus or nail lesion
Arthritis
Dactylitis ( sausage digities )
RF (-)
CRP
Serum uric acid
ESR
Destructive lesions: DIP joint of finger
PIP joint of toe
Bony ankylosis DIP joint
Pencil in cup
Physical Examinations
Radiographic Features
Laboratory Studies
19
Reyters Syndrome
Gout
RA
NSAIDs
DMARDs
Gold salt (aurothiomalate) sequential weekly
IM of 10,25 and then 50 mg until a total dose
of 1,000 mg has been archieved
Anti malarial therapy: hidroxy chloroquin 200
mg/day
Sulfa salazine
MTX ( low dose )
PUVA (methoxy psoralen and long wave ultra
violet A light )
Therapy
DD
20
Male predominance ( young adults)
Reyter syndrome: arthritis, conjunctivitis, urethritis
Strong association with HLA-27
Caused by:
Molecular mimicry
Altered cellular immune response
Altered microbial host cell interactions
Reyters Syndrome and Reactive Arthtritis
Yersenia, Clamydia, Salmonella, Shigella,
Campilobacter
Hypothesis
21
History : diarrhea illness, sexually transmitted pathogen
Low back pain
Recurrent tendinitis

Low grade fever (38 C)
Asymmetric arthritis/oligoarthritis
Enthesitis
Genitourinary symptoms
Ocular symptoms( conjunctivitis, uveitis)
Mucocutan lesions:
circinate balanitis
keratoderma blenarrhagicum
mucous ulcer
Cardiac and neurologic feature:
heart block, pericarditis,Aorta insufiency
myelopathy, cranial nerve lesion