PSORIATC ARTHRITIS

REACTIVE ARTHRITIS
ENTEROPATHIC ARTHRITIS

DR : ADNAN SADKHAN
Psoriatic Arthritis
• a member of the spondyloarthropathy family
• an inflammatory arthritis in the presence of
psoriasis
with a usual absence of rheumatoid factor .
• It occurs in 7-20% of pts with psoriasis .
• The onset is usually between 25 and 40 years of
age.
• Most patients ( 70% ) have pre-existing psoriasis
but in 20% the arthritis predates the psoriasis .
• Occasionally, the arthritis and psoriasis develop
synchronously .
• It affects 0.6% of the general population .
Clinical features
1- Asymmetrical inflammatory oligoarthritis (40%) :
presents abruptly with a synovitis and adjacent
periarticular inflammation, in hands and feet
( finger or toe ) with tenosynovitis, enthesitis and
inflammation of intervening tissue to give a ‘sausage
digit’ or dactylitis . Large joints, such as knee and
ankle, may also be involved.
2- Symmetrical polyarthritis (25%) : mainly in
women, resemble RA, less extensive and more
benign .
3- Predominant distal interphalangeal joint (15%) :
uncommon, mainly affect men, accompanying nail
dystrophy .
4- Psoriatic spondylitis (15) : presents a similar
clinical picture to AS but with less severe . Occur
alone or with others, unilateral or asymmetric in
severity .
5- Arthritis mutilans (5%) is a deforming erosive
arthritis targeting the fingers and toes .
• Nail changes include pitting , onycholysis
, subungual hyperkeratosis and horizontal
ridging, occur in 85% with PsA and 30% of those
with uncomplicated psoriasis .
• The characteristic rash of psoriasis may be
widespread, or confined to the scalp, natal cleft, and
umbilicus .
• Conjunctivitis .
• Uveitis mainly in HLA-B27 positive individuals
with sacroiliitis and spondylitis .
Investigation
• ESR and CRP may be raised in active disease .
• Autoantibodies are generally negative .
• X-rays may be normal or show erosive change
with joint space narrowing .
• Proliferative erosions with marked new bone
formation, absence of periarticular osteoporosis and
osteosclerosis, in addition to the characteristic
distribution, distinguish PsA from RA .
• The changes in axial skeleton resemble those of
chronic reactive arthritis .
Management
• NSAID .
• Intra-articular steroid in severe synovitis .
• DMARDs used in persistent synovitis
to conservative treatment . unresponsive
• Methotraxate is first choice drug since it also help
skin psoriasis .
• Other DMARDs including sulfasalazine, ciclosporin
and leflunomide, may be effective .
• Hydroxychloroquine avoided, as it can cause
exfoliative skin reactions .
• The retinoid acitretin used for skin lesions and
arthritis, avoided in young women due to
teratogenicity, mucocutaneaus side-effects,
hyperlipidaemia , myalgias and extra spinal
calcification .
• Photo chemotherapy with methoxysoralen and long
wave ultraviolet light ( psoralen + UVA, PUVA)
used fore skin disease & inflammatory arthritis .
Reactive arthritis
• Inflammatory arthritis a predominantly affects young
men in aged 16-35 but may occur at any age .
• It may present with triad ( Non - specific urethritis,
arthritis, conjunctivitis ) or with arthritis only .
• 1-2 % of pts with non – specific urethritis have
reactive arthritis .
• 20% of HLA-B21 positive men developed reactive
arthritis following shigella dysentery .
Clinical features
• Acute onset, with an inflammatory oligoarthritis
asymmetrical & targets lower limb joints, such as
knees, ankles, midtarsal and MTP joints .
• It may present with single joint involvement with no
history of an infections trigger .
• Fever, wt loss, achillous tendinitis or planter fascitis
.
• 1st attack is self-limiting, & recurrent or chronic
arthritis develops in more than 60% of pts .
• Low back pain & stiffness .
• Sacroiliatis ( 15-20% ) .
• Spondylitis, chronic erosive arthritis, recurrent acute
arthritis & uveitis .
• Extra-articular features .
• Circinate balanitis ( 20-50% ) .
• Keratoderma blennorrhagica ( 15% ) .
• Nail dystrophy with subungual hyperkeratosis .
 • Mouth nlcer (10%), shallow red painless patches
on tongue, palate, buccal mucosa and lips .
• Conjunctivitis .
• Rare complications
• Uveitis
• Aortic incompetence, conduction defects,
pleuropericarditis .
• Peripheral neuropathy, seizures & meningoence-
phalitis .
Investigations
• Joint aspiration to exclude crystal arthritis &septic
arthritis .
• Sterile & inflammatory synovitis .
• ESR & CRP are raised during an acute attack .
• RF, ACPA & ANA are negative .
• Urine culture ( chlamydia )
• Stool culture ( salmonella, yersinia, shigella
& campylobacter )
• High vaginal swab
• Radiological
• periarticular osteoporosis, joint space narrowing
& proliferative erosions
• periostitis of metatarsals, phalanges & pelvis, &
large, ‘fluffy’ calcaneal spurs .
• Sacroilitis is asymmetrical & unilateral, &
syndesmophytes are coarse & asymmetrical .
• X-ray changes in the peripheal joints and spine are
identical to those in psoriasis .
Treatment
• rest
• Oral NSAIDS & analgesics .
• Intra-articular steroids in severe synovitis
• Non-specific chlamydial urethritis is treated with a
short course of doxycyline or a single dose of
azithromycin .
• DMARDs indicated for persistent severe symptoms,
recurrent arthritis or severe keratoderma
blennorrhagica .
• Anterior uveitis is a medial emergency treated by
topical, subconjuctival or systemic corticosteroids .
Enteropathic arthritis
• acute inflammatory oligoarthritis occurs in 10% of
ulcerative colitis & 20% of crohn’s disease pts.
• affects large lower limb joints( knees, ankles, hips)&
less often wrist & small hand & feet joints.
• arthritis coincides with exacerbations of the
underlying bowel disease.
• aphthous mouth ulcers ,iritis and
erythema nodosum .
• It improves with effective treatment of
the bowel disease .
• IBD pts develop sacroiliitis ( 16% )&AS ( 6%)
which are clinically & radiologically identical to
classic AS .
• These can predate or follow the onset of bowel
disease & there is no correlation between activity of
spondylitis & bowel disease .
• DMARD & biological treatment may be required .
• NSAID may exacerbate ulcerative colitis .
• Systemic steroid may flare crohn’s disease .