انت هنا الان : شبكة جامعة بابل > موقع الكلية > نظام التعليم الالكتروني > مشاهدة المحاضرة

SERONEGATIVE ARTHROPATIHY ANKYLOSING SPONDYLITIS

    Include a group of diseases with considerable overlapping of articular and extra-articular features with obvious genetic association with HLA-B27.

This group of diseases includes:

·       Ankylosing spondylitis (AS).

·       Reactive arthritis including Reitr’s disease.

·       Psoriatic arthritis.

·       Arthropathy associated with inflammatory bowel disease (crohn’s and ulcerative colitis).

Seronegative spondarthropathy most likely are caused by the interplay between genetic and environmental factors.

The association of HLA-B27 in seronegative arthropathy mainly in AS more than 95% and Reiter’s disease up to 90% might lead to the suggestion that the pathogenesis is due to an aberrant response to environmental factors “infection” in genetically predisposed patients. The triggering organisms can be identified , as in reactive arthritis but in others the environmental events or triggers remain unclear.

Ankylosing spondylitis(AS)

It is a chronic inflammatory disease characterized by progressive stiffness and fusion of the axial skeleton, also affects the peripheral joints and characteristic extra articular structures involvement. It is considered a prototype of seronegative spondarthritis with predilection for sacroiliac joint and spine.

A.S is more common in men with male/female approximately 3/1, with peak onset in the second and third decades. More than 95% associated with HLA-B27.

·       The pathogenesis of AS is incompletely understood but is almost certainly immune mediated. The dramatic response of all aspects of the disease to therapeutic blockade of tumor necrosis factor ?(TNF- ?) indicates that this cytokine plays a central role in the immuno pathogenesis of AS.

·       Although specific event or exogenous agent that trigger the onset of the disease has not been identified, chronic prostatitis is common, but it is not infective in nature. There may increase the fecal carriage of Kleb. Aerogenes in patient with AS, but this could be relate to exacerbation of joint and eye involvement.

·       The enthesis, the site of ligamentous attachment to bone, is though to be the primary site of pathology in AS, often characterized by erosion and eventually undergo ossification.

Clinical features:

·       The onset is insidious, patient usually presented over several months, with low backache and marked stiffness which worsen by such inactivity as overnight rest and improved by exercise.

·       Sacroiliitis, is the most common initial features, causes pain in the buttock, that some time radiate down ward the thighs and is often misdiagnosed as sciatica. Within a few months the pain has usually become persistent and bilateral. Nocturnal exacerbation of pain that forces the patient to rise and move around may be frequent.

·       The disease tends to ascend the spine slowly and after several years the whole spine, become affected, as the spine progressively ankylosed,  spinal rigidity and secondary osteoporosis occur, which predispose to spinal fracture. Secondary spinal cord compression is a rare complication.

·       Costovertebral joint involvement, causing “pleuritic” like pain which aggravated by breathing, later on restriction (bilateral) of chest expansion.       

·       Enthesitis, the central feature of AS, appear in form plantar fasciatis, achilis tendonitis, tenderness over bony prominence such as iliac crest, greater trochanter, sternal/costal cartilage tenderness.

·       Fatigue is a common and troublesome symptoms, and impaired sleep due to pain and stiffness, is a major contributor to this fatigue.

·       Peripheral arthritis occur up to 40%, firstly are oligoarticular asymmetrical mainly involved hips, knee, ankles, shoulder.

Peripheral joint involvement may antedate the spinal symptoms in 10% of cases. In further 10% it present as pauciarticular in JIA.

Physical signs:

·       Failure to obliterate lumber lordosis on forward flexion with positive Schobber test, restriction of spinal movement in  all direction.

·       Pain on sacroiliac compression.

·       As disease progress all spine become restricted, with restriction of chest expansion.

·       In some severe cases, marked kyphosis of dorsal and cervical spine which may interfere with forward vision.

·        Local tenderness at the site of active enthesitis.

Extra-articular features:

·       Acute anterior uveitis up to 25% which sometimes precedes the joint disease. Conjunctivitis (20%).

·       Prostatitis 80% of men, usually asymptomatic.

·       Aortic incompetence, mitral incompetence, cardiac conductive defect, pericarditis.

·       Amyloidosis.

·       Atypical upper pulmonary fibrosis (1%).

“Despite the persistence of the disease, most patient well employed. Anyhow the shortening of life span may attributed to spinal trauma, aortic insufficiency, respiratory failure, amyloid nephropathy or complication of therapy such as gastrointestinal hemorrhage”.

Investigation:

ESR and CRP are usually raised in active disease and with synovitis, but it could be normal. Rheumatoid factors are largely absent . ( or occasionally present in low titre ).

Radiographic changes: In well established cases have a strong evidence of the disease but may take years to develop.

·          Sacroiliitis is the 1^st affected with pseudo widening and loss of cortical margins with irregularity, then sclerosis, narrowing and fusion.

·       Thoraco-lumbar spine lateral views shows sequaring of vertebrae.

·       Bridging syndesmophytes are fine and symmetrical, that follow the outermost fibers of annulus fibrosis.

·       Ossification of longitudinal ligaments, with fusion of facetal joints. The combination of above features gives later on the typical appearance of “bamboo” spine.

·       Erosive changes at entheses sites, and peripheral joints in persistent synovitis.

·       Osteoporosis and atlanto-axial subluxation could be seen.

Management:

1.    It is important to establish the diagnosis of early AS before the development of irreversible deformity.

2.    The main aims of management are pain and stiffness reliefment, prevent deformity and preserve mobility as can as possible.

3.    Patient education and theraputical exercises are the corner stone in management. Patient should perform regular back extension exercises, pacing of prolonged period of inactivity with regular breaks for warming - up exercises.

Poor posture, poor chair posture, high pillows should be avoided. Swimming exercises, considered ideal mode of exercises especially when hips are involved.

4.    NSAID, used for symptoms relievment , and to lessen morning stiffness, but they are not alter the course of the disease.

5.    DMARD therapy as sulfasalazine, methotrixate, azathioprine are indicated in progressive peripheral synovitis, but they have no or marginal affect on axial progression.

6.    Last years patients with AS treated with anti-TNF-? therapy have shown rapid, profound and sustained reduction in all clinical and laboratory measures of disease activity.

7.    Local corticosteroid injection for persistent enthesitis.

8.    Any patient developing any eye problems requires urgent specialist ophthalmologic examination to diagnose or to exclude uveitis which need urgent treatment.

Surgery sometimes is needed in severe peripheral joint restriction, especially in form total hip replacement.

A small number of patients may benefit from surgical correction of extreme flexion deformities of the spine or of atlanto-axial subluxation.