205. Beware of PEAR - An Approach to Seronegative Spondyloarthritides
Sep 3, 2023
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This podcast discusses the pathophysiology, clinical presentation, associated diseases, and treatment of seronegative spondyloarthritides. It explores the historical origins of these disorders, the approach to assessing severe peripheral oligoarthritis, the importance of combining clinical and radiological findings for diagnosis, and the goals and options for treatment.
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Quick takeaways
Seronegative spondyloarthritides are a group of inflammatory disorders involving joint inflammation, axial skeleton, and anthocitis, with negative rheumatoid factor and anti-CCP.
Assessing for features of inflammatory arthritis, extra-articular manifestations, family history, and functional limitations is crucial when evaluating a patient suspected of seronegative spondyloarthritides.
Deep dives
Overview of seronegative spondyloarthritidies
Seronegative spondyloarthritidies belong to a family of disorders that include ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis, and reactive arthritis. These conditions are characterized by joint inflammation, involvement of the spine or axial skeleton, and the presence of anthocitis. Although patients with seronegative spondyloarthritidies test negative for rheumatoid factor and anti-CCP, they are distinct from those with clinical rheumatoid arthritis. The exact pathophysiology of these conditions is not fully understood, but genetic and environmental factors play a role, and cytokines such as tumor necrosis factor and interleukin-17 are implicated in the inflammatory cascade.
Approaching a patient with seronegative spondyloarthritidies
When assessing a patient with suspected seronegative spondyloarthritidies, it is important to ask about features of inflammatory arthritis, such as asymmetric oligoarthritis and morning stiffness. Inflammatory back pain, characterized by lower back pain that improves with exercise and worsens with inactivity, is a cardinal feature of these conditions. Assessing for extra-articular manifestations, including psoriasis, ocular symptoms, and gastrointestinal symptoms, is crucial. Family history of arthritis, inflammatory bowel disease, or psoriasis should also be obtained, as well as evaluating the patient's functional limitations.
Diagnosis and treatment of seronegative spondyloarthritidies
Diagnosing seronegative spondyloarthritidies requires a combination of clinical, laboratory, and radiological findings. While there is no single test to confirm the diagnosis, elevated ESR and CRP, along with negative rheumatoid factor, anti-CCP, and ANA, may be present. Genetic testing for HLAB27 can provide additional support. Radiographs of the lumbar spine and sacroiliac joints can be helpful in making a diagnosis, with evidence of sacroiliitis being a key finding. Treatment goals for seronegative spondyloarthritidies include symptom reduction, functional improvement, and preventing complications. NSAIDs are often used for acute peripheral arthritis, along with glucocorticoids if infection is ruled out. Antibiotics may be necessary for reactive arthritis, while demarts and biologics are options for persistent disease, considering the different subtypes within seronegative spondyloarthritidies.
In this episode, we review the pathophysiology, clinical presentation, associated diseases, investigations and treatment for the seronegative spondyloarthritides. These include psoriatic arthritis, enteropathic or IBD-associated arthritis, ankylosing spondylitis and reactive arthritis - or PEAR!
Written by: Dr. Steven Cho (Internal Medicine Resident) Reviewed by: Dr. Lori Albert (Rheumatologist) and Dr. Vanessa Zannella (General Internist) Recorded and Produced by: Dr. Alison Lai