Seronegative spondyloarthritis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

"Seronegative" refers to the fact that these diseases are negative for Rheumatoid factor and CCP in the serum.

Classification

Algorithm showing classification of seronegative spondyloarthritis

Seronegative Spondyloarthritis (SpA)

Axial SpA including Ankylosing spondylitis

Peripheral SpA

Psoriatic arthritis

Reactive arthritis

Inflammatory bowel disease related arthritis

Juvenile spondyloarthritis

Classification Criteria

ASAS classification criteria for axial spondyloarthritis (axial SpA)

The Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (axial SpA) include:

• Patient with back pain ≥ 3 months and age of onset <45 years should fulfill either of the two criteria:
  1. Sacroiliitis on imaging^* plus ≥ 1 feature of SpA^**
  2. HLA-B27 plus ≥ 2 feature of SpA^**

^*Sacroiliitis on imaging:

• Active (acute) inflammation on MRI highly suggestive of sacroiliitis associated with SpA

OR

• Definite radiographic sacroillitis accorging to modified New York criteria

^**SpA features:

• Inflammatroy back pain
• Arthritis
• Enthesotos (heel)
• Uveitis
• Dactylitis
• Psoriasis
• Crohn's disease or ulcerative colitis
• Good response to NSAIDs
• Family history for SpA
• HLA-B27
• Elevated CRP

ASAS classification criteria for peripheral spondyloarthritis

• The Assessment of SpondyloArthritis international Society classification criteria for peripheral spondyloarthritis (peripheral SpA) include:

Arthritis or Enthesitis or Dactylitis

PLUS ≥ 1 of:

• Psoriasis
• Inflammatory bowel disease
• Preceding infection
• HLA-B27
• Uveitis
• Sacroiliitis on imaging (radiograph or MRI)

PLUS ≥ 2 of:

• Arthritis
• Entheistis
• Dactylitis
• Inflammatory back pain in the past
• Positive family history of SpA

Differential

Arthritis Type	Clinical Features						Body Distribution				Key Signs				Laboratory Abnormalities
	History	Symmetric joint involvement	Asymmetric joint involvement	Enthesopathy	Dactylitis	Nail Dystrophy	Upper extremity-hands	Lower extremity	Sacroiliac joints	Spine	Osteopenia	Joint Space	Ankylosis	Periostitis	Soft tissue swelling	ESR	Rheumatoid factor (RF)	HLA-B27
Psoriatic arthritis		+	++	+	+	+	+++ (DIP/PIP)	+++	++ (Unilateral)	++	-	++ (Widening)	++	+++ (Fluffy)	++	+	-	30-75%
Rheumatoid arthritis		++	+	-	-	-	+++ (MCP/wrist)	+++	+ (Unilateral)	++(Cervical)	+++	+++ (Narrowing)	+	+ (Linear)	+++	+++	+++	6-8%
Ankylosing spondylitis		+++	-	+	-	-	+	+	+++ (Bilateral)	+++	+++	++ (Narrowing)	+++	+++ (Fluffy)	+	+++	-	90%
Reactive arthritis (Reiter's syndrome)		+++	-	+	+	-	++	+++	++ (Unilateral)	+	+	+ (Narrowing)	-	+++ (Fluffy)	++	++	-	75%

Key:+ : Infrequently present, ++ : Frequently present, +++ : Always present, - : Absent

Diagnosis

History and Symptoms

• Onset of symptoms typically occurs in early adulthood.
• Presenting symptom is typically dull pain over the buttock and lower lumbar area associated with morning stiffness, which is relieved by exercise and aggravates with inactivity.
• Other symptoms include:
  • Frank arthritis (involve large joints, asymmetrical fashion)
  • Enthesopathy
  • Dactylitis
  • Recurrent acute anterior uveitis
  • Cardiovascular manifestations
    • Aortic insufficiency
    • Congestive heart failure
    • Aortitis
    • Angina
    • Pericarditis
    • Cardiac conduction abnormalities
  • Pulmonary manifestations (due to pulmonary fibrosis)
    • Dyspnoea
    • Cough
    • Hemoptysis
  • Genitourinary manifestations (Present in reactive arthritis)
    • Urethritis
    • Cervicitis
    • Vulvovaginitis
    • Salpingitis
    • Prostatitis
• Specific manifestations:
  • Psoriasis
  • Inflammatory bowel disease
  • Oral ulcers
  • Erythema nodosum
  • Conjunctivitis