Seronegative Arthritis

Spondyloarthopathies Current classification  Axial Spondyloarthritis With radiographic sacroileitis Without radiographic sacroiletis  MRI positive  HLA B27 positive  Peripheral sondyloarthritis  With Psoriasis  With IBD With preceding infection Without IBD, Psoriasis, or Preceding infection  4 Major Groups (classic classification)  Reactive Arthritis  Ankylosing Spondylitis  Psoriatic Arthritis  Enteropathic Arthritis (IBD associated)   Ankylosing Spondylitis and Axial Spondyloarthritis NEJM 2016 Common C/F Both Axial or Peripheral Arthritis can occur Enthesitis Dactylitis Ankylosing Spondylitis and Axial Spondyloarthritis NEJM 2016 Ankylosing Spondylitis and Axial Spondyloarthritis NEJM 2016 Ankylosing Spondylitis and Axial Spondyloarthritis NEJM 2016 Ankylosing Spondylitis and Axial Spondyloarthritis NEJM 2016 1. Reactive Arthritis  Skin Manifestations:  Keratoderma Blenorrhagica 2. Ankylosing Spondylitis  3. Psoriatic Arthritis  Pathogenesis:  Mechanisms of Disease Psoriasis NEJM 2009 Mechanisms of Disease Psoriasis NEJM 2009 Mechanisms of Disease Psoriasis NEJM 2009 Mechanisms of Disease Psoriasis NEJM 2009 Clinical Features  Psoriatic Patients are at risk of  Gout (due to increase turn over of skin) Skin : When PsA is suspected examine the skin around extensor surfaces, scalp posterior auricular area, gluteal cleft, umbilicus (15 % of patients will eventually develop Psoriasis)  OA PsA: 30% of patients with Posriasis develop PsA; 5 Patterns of joint involvement Asymmetric Oligoarthritis (m/c type of PsA, 30  - 50%) Psoriatic Arthritis: Asymmetric Synovitis, Knees ACR Symmetric Polyarthritis (3rd m/c manifestation; Like RA) DIP (3rd m/c manifestation, 10-15%) Nail changes are common: Examine for 4 types of nail manifestations Pitting Psoriatic Arthritis: Nail Pitting ACR Onycholysis Psoriatic Arthritis: Telescoping Fingers ACR Psoriatic Arthritis: Hands ACR Subungal Keratosese Oil drop like staining Psoriasis and Psoriatic Arthritis: Pre and Post-Treatment, Hands Psoriatic Arthritis, Hand ACR Spondylitis Arthritis Mutilans (osteolysis of digits with significant deformity) Psoriatic Arthritis: Arthritis Mutilans, Feet ACR Psoriatic Arthritis: Hands, Arthritis Mutilans ACR Note: Enthesisits is seen as Dactilytis (sausage digit) Psoriatic Arthritis: ”Sausage" Digits and Rash ACR Psoriatic Arthritis: Enthesitis, Ankle ACR Lab: RF and Anti-CCP ab can be present in around 10 of these patients Xray: Pencil in Cup  Treatment: Anti-TNF  5 FDA approved Anti-TNF medications for Psoriasis  Monoclonal ab against IL-12/23: Ustekinumab (Stelara) Medscape 2015 IL-12 leads to Th1 pathway  IL-23 leads to Th17 pathway  Ustekinumab (UST), an mAb directed against the p40 subunit of IL-12 and IL-23 PDE-4 (Phosphodiesterase 4) Inhibitor: Apremilast  Downstream in the TNF pathway Increases expression of IL-10  IL - 17A: Secukinumab (Cosentyx™) - monoclonal antibody against 17 A 2 other drugs are in Phase II/III that inhibit 17A and / or 17 F References: The Latest on Treating Psoriatic Arthritis Medscape 2015 Apremilast New Oral Option for Psoriatic Arthritis Medscape 2015 Treating to Target in Psoriatic Arthritis Medscape 2015 New Treatment Paradigms in Psoriatic Arthritis Medscape 2015 4. Enteropathic Arthritis (IBD associated)