Seronegative rheumatoid arthritis is different from seronegative spondylitides

is a 40-year-old Hispanic gentleman and is a dedicated long distance runner. He had a 1-year history of right ankle arthralgias and a 2-month history of right knee arthralgias. Then, during a meeting he was attending in Plymouth, he developed right thigh, calf & foot swelling, and a right knee effusion.

History - "Dandruff" x 3 months , Mild Low back pain and buttock pain in the past 3 months

Examination -Scaling plaque right occiput -Dactylitis right 3rd toe

Right 4th and 5th fingernails - isolated "pitting"

Chronic seronegative inflammatory arthritis associated with psoriasis.

30% of pts with psoriasis have arthropathy HLA-B27 associated

common in white population than in other races. Men are more commonly affected by the spondylitic subtype, with higher incidence of the 'rheumatoid' pattern of disease among women. It is most common in middle age (35-55) but may be seen in patients of any age.

Asymmetric large joint oligoarthritis Axial arthritis Asymmetrical sacroiliitis Peripheral small joints, DIPS Pain and stiffness Enthesitis: Achilles tendonitis, tennis elbow, golfers elbow, plantar fasciitis Dactylitis Psoriasis

Anterior uvetis Conjuctivitis (30%)

Nails become loose and separate from bed

GALS Examine particular joint (the one with current problem) Skin examination (if no time, look at elbows, knees, under hair at the back of the neck and ears. Then say you would do a full one) Nail examination (focus on them in hands and feet) if not mentioned in GALS screen or seen properly

Hands and feet are affected initially with enthesopathy causing dactylitis ('sausage fingers'). Usually up to 5 joints are involved.

This is more common in men. There is morning stiffness and limitation of back movement. There may not be much in the way of symptoms, and it may be only noted radiologically. Unlike AS, the vertebrae are usually affected asymmetrically. The atlantoaxial joint may be involved, with destruction of odontoid peg and danger of subluxation.

This is more common in women. Wrists, hands, feet and ankles are usually affected. DIP rather than MCP helping to distinguish it from RA, along with absence of skin nodules and a negative RF test.

The nail can also be involved Usually seen in men.

relatively rare variation of DIP disease. Resorption of the terminal phalanx, giving a 'telescopic digit' appearance. It gives the classical 'pencil in cup' radiographic appearance. 'Opera-glass hand' (flexion deformity of DIP joints) seen mainly in men with earlyonset arthritis.

1/5of childhood arthritis usually starts as a monoarthritis, but DIP pattern may be seen. Tenosynovitis affects up to a third and nail changes are present in about two-thirds. Epiphyseal involvement can affect growth. Sacroiliitis may occur. Simultaneous onset of rash and arthritis is more common than in adults.

The major differential of nail changes is fungal nail infection. RA. Reactive arthritis/Reiter's syndrome. Ankylosing spondylitis. Enteropathic arthropathy. Gout (particularly foot monoarthritis). Septic arthritis. Juvenile chronic arthritis and other causes of childhood arthritis.

Bloods: FBC (anaemia), ESR, CRP (both raised), RhF (-ve), ANA (-ve) Synovial fluid Aspiration: -ve crystals, could have high WBC (neutrophils) Xray CT/MRI: subtle signs MRI (useful for imaging the sacroiliac joint to detect inflammation/deformity)

 Mild bony erosion at edge of cartilage. Asymmetric erosive changes in the small joints of

hands and feet. DIP or PIP involvement - more common than MTP or MCP changes. DIP cases may have erosion and deformity with bony ankylosis of the joint and subluxation. Erosion of the distal tuft of the distal phalanx.

MDT Skin and joint treatment Conservative, Medical and Surgical

Regualr Physiotherapy Occupational Therapy Physical exercise helps to maintain mobility and reduce stiffness

Methotrexate, retinoids and PUVA appear most effective at treating skin and joints together. NSAIDS DMARDS: methotrexate and sulfasalazine Phototherapy Biologics

Etanercept, infliximab and adalimumab should be offered as an option for treating adults with psoriatic arthritis when: The person has arthritis with 3 or more tender joints and 3 or more swollen joints. At least 2 other DMARDs, given on their own or together, haven't worked.

 Joint

replacement : knee or Hip

worse prognosis and more severe disease: Arthritis mutilans and symmetric polyarthritis. Young age at onset. Severe skin involvement. Gender (higher risk in females). Family history of arthritis. HLA markers (HLA-B39 and HLA-B27 in the presence of HLA-DR7 are more likely to experience disease progression).

Significantly increased mortality is associated with:

ESR of greater than 15 mm/hour. Medication use before the first clinical visit. Radiological evidence of joint damage. Absence of nail lesions.