seronegetive spondyloarthropathy

SERONEGATIVE SERONEGATIVE SPONDYLOARTHROPATHSPONDYLOARTHROPATH

YY

DR. KRISHNA MADHUKAR. DDR. KRISHNA MADHUKAR. D

BHARATI HOSPITALBHARATI HOSPITAL

INCLUSIONSINCLUSIONS Ankylosing SpondylitisAnkylosing Spondylitis

Reiter’s DiseaseReiter’s Disease

Psoriatic ArthritisPsoriatic Arthritis

Arthritis Of Inflammatory Bowel DiseaseArthritis Of Inflammatory Bowel Disease

Whipple’s DiseaseWhipple’s Disease

Behcet’s DiseaseBehcet’s Disease

COMMON FEATURESCOMMON FEATURES Negative Rheumatoid FactorNegative Rheumatoid Factor

Familial ClusteringFamilial Clustering

Association with HLA – B27Association with HLA – B27

Asymmetrical Peripheral ArthritisAsymmetrical Peripheral Arthritis

X-ray Evidence Of Sacroiliitis With Or X-ray Evidence Of Sacroiliitis With Or Without SpondylitisWithout Spondylitis

HLA – B27 ANTIGENHLA – B27 ANTIGEN

Present in 6-7% of white Present in 6-7% of white populationpopulation

4% of Afro-American 4% of Afro-American populationpopulation

Absent in black AfricansAbsent in black Africans

Associated with Associated with seronegative seronegative spondyloarthropathyspondyloarthropathy

FREQUENCY OF HLA – B27 FREQUENCY OF HLA – B27 AMONG SERONEGATIVE AMONG SERONEGATIVE

SPONDYLOARTHROPATIESSPONDYLOARTHROPATIESDISEASEDISEASE HLA – B27 POSITIVE (%)HLA – B27 POSITIVE (%)

Ankylosing spondylitisAnkylosing spondylitis 90%90%

Reiter’s DiseaseReiter’s Disease 95%95%

IBD with spondylitisIBD with spondylitis 70%70%

Psoriasis and peripheral Psoriasis and peripheral arthritisarthritis

25%25%

Psoriasis and spondylitisPsoriasis and spondylitis 35%35%

ANKYLOSING SPONDYLITISANKYLOSING SPONDYLITISMARIE-STRUMPELL DISEASEMARIE-STRUMPELL DISEASE

ANKYLOSING SPONDYLITISANKYLOSING SPONDYLITIS Generalized chronic inflammatory diseaseGeneralized chronic inflammatory disease

Mainly in the spine and sacroiliac jointMainly in the spine and sacroiliac joint

Characteristic pain and stiffness of the backCharacteristic pain and stiffness of the back

Variable involvement – hips & shouldersVariable involvement – hips & shoulders

Males > Females (10:1)Males > Females (10:1)

Age of onset ( 15 – 25 Yrs)Age of onset ( 15 – 25 Yrs)

CAUSESCAUSES

Genetically determined Genetically determined immunopathological disorder.immunopathological disorder.

Associated with HLA - B27 (90%)Associated with HLA - B27 (90%)

Strong tendency of familial aggregation.Strong tendency of familial aggregation.

PATHOLOGYPATHOLOGY

Two basic lesionsTwo basic lesions

A) Synovitis of diarthrodial joints.A) Synovitis of diarthrodial joints.

B) Inflammation of the fibro-osseus B) Inflammation of the fibro-osseus

junction of syndesmotic joints. junction of syndesmotic joints.

Synovitis effects Synovitis effects the sacroiliac joint the sacroiliac joint and the vertebral and the vertebral facet joints.facet joints.

Inflammation of the fibro-osseus Inflammation of the fibro-osseus junction is seen injunction is seen in

A) Intervertebral discsA) Intervertebral discs

B) Sacroiliac ligamentB) Sacroiliac ligament

C) Symphysis pubisC) Symphysis pubis

D) Manubrium sterniD) Manubrium sterni

E) Bony insertions of large tendonsE) Bony insertions of large tendons

PATHOLOGICAL CHANGES - PATHOLOGICAL CHANGES - 3 STAGES3 STAGES

Inflammation - Inflammation - i) round cell i) round cell infiltrationinfiltration ii) granulation tissueii) granulation tissue formationformation iii) bone erosioniii) bone erosion

Granulation tissueGranulation tissue fibrous tissuefibrous tissue

Ossification of fibrous Ossification of fibrous tissue tissue

ankylosis of the ankylosis of the jointjoint..

Ossification across Ossification across surfaces of the disc surfaces of the disc gives rise to small gives rise to small bony bridges or bony bridges or ‘SYNDEMOPHYTES‘SYNDEMOPHYTES’ ’

CLINICAL SYMPTOMSCLINICAL SYMPTOMS Insidious onsetInsidious onset

Complaints of back ache Complaints of back ache and stiffness – worse in the and stiffness – worse in the early morning and after early morning and after inactivity.inactivity.

Generalized fatigueGeneralized fatigue

Pain and swelling of jointsPain and swelling of joints

Intercostal painIntercostal pain

CLINICAL SIGNSCLINICAL SIGNS

Flattening of lower back.Flattening of lower back.

Diminished spine movements in all Diminished spine movements in all directions – extension is earliest and most directions – extension is earliest and most severe disability.severe disability.

Tenderness over spine and SI joint.Tenderness over spine and SI joint.

Diminished chest expansion.Diminished chest expansion.

CLINICAL SIGNSCLINICAL SIGNS TYPICAL POSTURETYPICAL POSTURE

Loss of lumbar lordosis.Loss of lumbar lordosis.

Increased thorasic Increased thorasic khyphosis.khyphosis.

Forward thrust of the neck.Forward thrust of the neck.

Upright posture and Upright posture and balance maintained by balance maintained by slight hip and knee flexion. slight hip and knee flexion.

Sometimes spine is Sometimes spine is completely ankylosed completely ankylosed from occiput to from occiput to sacrum.sacrum.

Marked loss of cervical Marked loss of cervical extension.extension.

Line of vision Line of vision restricted to few restricted to few paces.paces.

EXTRA SKELETAL EXTRA SKELETAL MANIFESTATIONSMANIFESTATIONS

Generalized fatigue.Generalized fatigue.

Loss of weight.Loss of weight.

Acute anterior uveitis (28%)Acute anterior uveitis (28%)

Aortic valve disease (rare)Aortic valve disease (rare)

Carditis (rare)Carditis (rare)

Pulmonary fibrosis (rare)Pulmonary fibrosis (rare)

X-RAY FINDINGSX-RAY FINDINGS

Earliest sign – erosion Earliest sign – erosion of the SI jointsof the SI joints

Later – periarticular Later – periarticular sclerosis on the iliac sclerosis on the iliac side of the jointside of the joint

Finally – bony Finally – bony ankylosisankylosis

X-RAY FINDINGSX-RAY FINDINGS VERTEBRAL CHANGESVERTEBRAL CHANGES

- Earliest sign – Earliest sign – squaring of vertebral squaring of vertebral bodiesbodies

- Ossification around Ossification around the intervertebral the intervertebral discs and ligaments. discs and ligaments. ‘syndesmophytes’‘syndesmophytes’


Bridging at several Bridging at several levels give a levels give a typical appearance typical appearance ofof

‘ ‘ BAMBOO SPINE’BAMBOO SPINE’

SPECIAL INVESTIGATIONSSPECIAL INVESTIGATIONS

ESR in active ESR in active phase.phase.

HLA – B27 present HLA – B27 present (90%)(90%)

Rheumatoid factor Rheumatoid factor - negative- negative

TREATMENTTREATMENT Maintain satisfactory posture and preserve Maintain satisfactory posture and preserve

movement with spinal extension exercises.movement with spinal extension exercises.

Anti – Inflammatory drugs to counter act pain and Anti – Inflammatory drugs to counter act pain and stiffness.stiffness.

Deformity correction – surgical means.Deformity correction – surgical means.

Breathing exercises.Breathing exercises.

Physiotherapy to other joints.Physiotherapy to other joints.

COMPLICATIONSCOMPLICATIONS Spinal fractures – commonest site C5 Spinal fractures – commonest site C5

– 7.– 7.

Hyperkhyphosis.Hyperkhyphosis.

Spinal cord compression.Spinal cord compression.

Lumbar nerve root compression.Lumbar nerve root compression.

DIFFUSE IDIOPATHIC SKELETAL DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS ( DISH )HYPEROSTOSIS ( DISH )

FORESTIER’S DISEASEFORESTIER’S DISEASE

Symptoms resemble AS.Symptoms resemble AS.

Not an inflammatory disease.Not an inflammatory disease.

Older men affected.Older men affected.

Calcification of ALL , PLL and Calcification of ALL , PLL and interspinous ligament seeninterspinous ligament seen

Discs, hip, SI joints are spared.Discs, hip, SI joints are spared.

Spinal pain and stiffness not Spinal pain and stiffness not severesevere

ESR normal.ESR normal.

PSORATIC ARTHRITISPSORATIC ARTHRITIS Inflammatory erosive arthritis.Inflammatory erosive arthritis.

Oligoarticular or polyarticular predominantly Oligoarticular or polyarticular predominantly effecting small joints of the hand and feet in an effecting small joints of the hand and feet in an asymmetrical fashion.asymmetrical fashion.

Seen in 5% -10% cases of cutaneous psoriasis.Seen in 5% -10% cases of cutaneous psoriasis.

In pure cutaneous psoriasis (without arthritis) In pure cutaneous psoriasis (without arthritis) HLA-B27 is absentHLA-B27 is absent

PATHOLOGYPATHOLOGY Chronic inflammation Chronic inflammation edema & round cells edema & round cells fibrous replacement.fibrous replacement.

Erosion of cortex & articular Erosion of cortex & articular cartilage exposes cancellous cartilage exposes cancellous bone.bone.

Finally leads to fibrous Finally leads to fibrous ankylosis with subluxation ankylosis with subluxation and dislocation.and dislocation.

CLINICAL PICTURECLINICAL PICTURE

Skin changes Skin changes usually precede usually precede arthritic changes.arthritic changes.

Careful search Careful search reveals hidden reveals hidden areas of psoriasis areas of psoriasis in the scalp, axilla in the scalp, axilla and navel.and navel.


The nail plate The nail plate crumbles in yellowish crumbles in yellowish patches patches (onychodystrophy), (onychodystrophy), probably due to probably due to psoriatic involvement psoriatic involvement in the nail matrixin the nail matrix. .


Onset may be insidious & arthritis mild or Onset may be insidious & arthritis mild or acute where the fingers & toes swell up acute where the fingers & toes swell up within few hours.within few hours.

Evolves in exacerbations and remissions.Evolves in exacerbations and remissions.

Later residual damage is apparent with Later residual damage is apparent with deformity and limitation of motion.deformity and limitation of motion.


In the hand , the In the hand , the DIP joints and PIP DIP joints and PIP joints are affected .joints are affected .

Rarely MCP joints Rarely MCP joints are affected.are affected.


Tenosynovial effusion Tenosynovial effusion may cause may cause generalized swelling generalized swelling of the finger producing of the finger producing a typical a typical

‘‘SAUSAGE LIKE DIGIT’SAUSAGE LIKE DIGIT’


Boutonniere Boutonniere deformity and deformity and swan neck swan neck deformity typical of deformity typical of rheumatoid rheumatoid arthritis are arthritis are uncommon but uncommon but may be present.may be present.

CLINICAL GROUPSCLINICAL GROUPS

CLASSICAL CLASSICAL PSORIATIC PSORIATIC ARTHROPATHY ARTHROPATHY (5%)(5%)

- Predominantly - Predominantly affects the DIP affects the DIP jointsjoints

CLINICAL GROUPSCLINICAL GROUPS ARTHRITIS MUTILANS ARTHRITIS MUTILANS

(5%)(5%)

- Severe osteolysis Severe osteolysis affects the DIP, PIP and affects the DIP, PIP and MCP joints.MCP joints.

- Produces marked Produces marked digital telescoping or digital telescoping or

‘‘doigt en doigt en lorgnette’lorgnette’

deformitydeformity


SYMMETRICAL SYMMETRICAL POLYARTHRITIS (15%)POLYARTHRITIS (15%)

- Similar to rheumatoid - Similar to rheumatoid arthritis but arthritis but rheumatoid nodules rheumatoid nodules and serology are and serology are absent.absent.


ASYMMETRICAL ASYMMETRICAL OLIGOARTICULAR OR OLIGOARTICULAR OR MONOARTICULAR MONOARTICULAR ARTHRITIS (70%)ARTHRITIS (70%)

- Affects scattered - Affects scattered DIP, PIP & MCP joints. DIP, PIP & MCP joints.


ANKYLOSING ANKYLOSING SPONDYLITIS or SPONDYLITIS or SACROILIITIS SACROILIITIS (70%).(70%).

- Similar to - Similar to idiopathic idiopathic ankylosing ankylosing spondylitis.spondylitis.


Erosion and narrowing of Erosion and narrowing of small finger and toe joints.small finger and toe joints.

Ankylosis of various small Ankylosis of various small joints of hands and feet.joints of hands and feet.

Predilection for DIP & PIP Predilection for DIP & PIP joints with relative sparing joints with relative sparing of MCP joints.of MCP joints.


Dissolution of terminal Dissolution of terminal phalangeal tufts phalangeal tufts

(acro –osteolysis).(acro –osteolysis).

Cupping of proximal ends of Cupping of proximal ends of phalanges, metacarpals and phalanges, metacarpals and metatarsals.metatarsals.

End of a whittled bone End of a whittled bone articulates with cup shaped articulates with cup shaped erosion of distal bone forming erosion of distal bone forming a typicala typical

‘ ‘PENCIL – IN – CUP’ PENCIL – IN – CUP’ deformitydeformity

LABORATORY FINDINGSLABORATORY FINDINGS

Associated with Associated with HLA – B27.HLA – B27.

ESR ESR

RA Factor -veRA Factor -ve

AnemiaAnemia

TREATMENTTREATMENT Early arthritis – simple analgesics and NSAIDS.Early arthritis – simple analgesics and NSAIDS.

Indomethacin produces serious side affects - Indomethacin produces serious side affects - AvoidedAvoided

Small dose of corticosteroid given at night ( 2.5 – Small dose of corticosteroid given at night ( 2.5 – 5mg prednisolone)5mg prednisolone)

Clinical remission can be achieved with large Clinical remission can be achieved with large doses of prednisolone (40 – 60mg) or ACTH ( 40 – doses of prednisolone (40 – 60mg) or ACTH ( 40 – 50 units) daily.50 units) daily.

TREATMENTTREATMENT Then dose is reduced for maintainance.Then dose is reduced for maintainance.

After 6 – 10 wks the drug is gradually withdrawn.After 6 – 10 wks the drug is gradually withdrawn.

For long term control antimetabolites like For long term control antimetabolites like methotrexate, methotrexate,

6 – mercaptopurine, azathioprine and azaribine 6 – mercaptopurine, azathioprine and azaribine can be usedcan be used

REITER’S DISEASEREITER’S DISEASE

Idiopathic syndrome.Idiopathic syndrome.

Characterized Characterized pathologically by pathologically by asymmetric arthritis.asymmetric arthritis.

Clinically by a Clinically by a characteristic tetrad of characteristic tetrad of abacterial urethritis, abacterial urethritis, conjuctivitis, arthritis & conjuctivitis, arthritis & mucocutaneous lesionsmucocutaneous lesions

ETIOLOGYETIOLOGY Exciting cause is unknown.Exciting cause is unknown.

Affects men > women (50:1)Affects men > women (50:1)

Syndrome follows outbreaks of desentry caused Syndrome follows outbreaks of desentry caused by by shigellashigella, , yersiniayersinia and and salmonellasalmonella..

Associated with HLA – B27.Associated with HLA – B27.

Occurs between 20 – 40 Yrs of age.Occurs between 20 – 40 Yrs of age.

CLINICAL FEATURESCLINICAL FEATURES

An attack averages about 3 months, An attack averages about 3 months, ranging from 2 wks to 1 year.ranging from 2 wks to 1 year.

Recurrence occurs in approximately half Recurrence occurs in approximately half the patients.the patients.

There is complete remission following first There is complete remission following first attack in the remaining.attack in the remaining.


The first symptoms The first symptoms are urethritis, cystitis are urethritis, cystitis with dysuria, with dysuria, increased frequency & increased frequency & mucoid or mucoid or mucopurulent mucopurulent discharge.discharge.

Acute prostatitis –Acute prostatitis –prostatic secretions prostatic secretions contain large number contain large number of neutrophils.of neutrophils.


Within a few days, Within a few days, mild catarrhal mild catarrhal conjunctivitis conjunctivitis (lacrimation, (lacrimation, photophobia and photophobia and discharge) discharge) develops. develops.


Within 2 wks, acute Within 2 wks, acute polyarthritis develops with polyarthritis develops with slight elevation of slight elevation of temperature.temperature.

Weight bearing joints Weight bearing joints particularly knees, ankles particularly knees, ankles and small joints of the feet and small joints of the feet are involved commonly.are involved commonly.

Joints are hot, swollen and Joints are hot, swollen and tender. tender.


Mucous membrane Mucous membrane ulcerations form ulcerations form within the oral within the oral cavity and on the cavity and on the glans penis.glans penis.


Hyperkeratotic Hyperkeratotic papules form over papules form over the soles and the soles and palms.palms.


Subungual Subungual brownish yellow brownish yellow hyperkeratotic hyperkeratotic lesions elevate and lesions elevate and separate the nails.separate the nails.

CLINICAL FEATURESCLINICAL FEATURES Most commonly Most commonly

associated soft tissue associated soft tissue involvementinvolvement

- Achilles tendinitis- Achilles tendinitis - Plantar fasciitis- Plantar fasciitis - Tenosynovitis of the - Tenosynovitis of the

fingersfingers - Heel spur formation- Heel spur formation


Prolonged course Prolonged course of the disease is of the disease is complicated with complicated with ankylosing disease ankylosing disease of the spine and of the spine and sacroiliac joints.sacroiliac joints.


After repeated severe After repeated severe attacks the foot attacks the foot develops a typical develops a typical deformity with lateral deformity with lateral deviation and dorsal deviation and dorsal subluxation of toes subluxation of toes and pes cavus calledand pes cavus called

‘ ‘ LAUNOIS DEFORMITY ’LAUNOIS DEFORMITY ’

X-RAY FINDINGSX-RAY FINDINGS Destructive changes in the Destructive changes in the

interphalangeal and interphalangeal and metatarsophalangeal joints metatarsophalangeal joints of the toes with lateral of the toes with lateral deviation and subluxation deviation and subluxation is seen.is seen.

Joints of the fingers and Joints of the fingers and wrist are less commonly wrist are less commonly affected.affected.

Calcaneal spur formation Calcaneal spur formation may be seen.may be seen.


Periarticular Periarticular sclerosis and bony sclerosis and bony ankylosis are seen ankylosis are seen in the Sacroiliac in the Sacroiliac jointsjoints


Tear drop shaped Tear drop shaped paravertebral paravertebral ossifications are ossifications are characteristic.characteristic.

Numerous Numerous syndesmophytes and syndesmophytes and bony ankylosis may be bony ankylosis may be seen in the lumbar seen in the lumbar spine.spine.

COMPLICATIONSCOMPLICATIONS ACUTE PHASEACUTE PHASE Meningoencephalitis.Meningoencephalitis. Acute psychosisAcute psychosis Cranial nerve lesionsCranial nerve lesions

CHRONIC PHASECHRONIC PHASE Neuropsychiatric disordersNeuropsychiatric disorders SeizuresSeizures Personality changesPersonality changes Peripheral radiculopathiesPeripheral radiculopathies

LATE SEQUELAELATE SEQUELAE Aortic insufficiencyAortic insufficiency Atrioventricular blockAtrioventricular block

LABORATORY FINDINGSLABORATORY FINDINGS

Negetive Rheumatoid factorNegetive Rheumatoid factor

Positive HLA – B27Positive HLA – B27

Normal synovial fluid complement levelsNormal synovial fluid complement levels

Positive stool culture for Positive stool culture for ShigellaShigella, , YersiniaYersinia or or SalmonellaSalmonella organisms following organisms following dysentry epidemic dysentry epidemic

TREATMENTTREATMENT Self limiting disease – no specific treatment.Self limiting disease – no specific treatment.

Acute phase – preservation of mobility and prevention of Acute phase – preservation of mobility and prevention of deformity.deformity.

Bed rest and forbidden weight bearing.Bed rest and forbidden weight bearing.

NSAIDS to relieve pain NSAIDS to relieve pain

Medical management for visceral, neurological and Medical management for visceral, neurological and ophthalmic complications.ophthalmic complications.

Prostatic massage is contraindicated as it provokes an Prostatic massage is contraindicated as it provokes an acute exacerbationacute exacerbation

ARTHRITIS OF INFLAMMATORY ARTHRITIS OF INFLAMMATORY BOWEL DISEASEBOWEL DISEASE

Seronegative Seronegative peripheral arthritisperipheral arthritis is is seen in 10 – 20 % seen in 10 – 20 % cases of ulcerative cases of ulcerative colitis and Crohn’s colitis and Crohn’s disease.disease.

Erythema nodosum, Erythema nodosum, oral ulcerations and oral ulcerations and anterior uveitis are anterior uveitis are other complications other complications


Associated with mild Associated with mild oligoarticularoligoarticular arthritis.arthritis.

Knee, ankle and wrist are Knee, ankle and wrist are most often affected.most often affected.

Inflammation is mild but Inflammation is mild but infrequently severe degree infrequently severe degree involvement might occur .involvement might occur .

Radiographic changes are Radiographic changes are minor with soft tissue minor with soft tissue swelling, juxtra-articular swelling, juxtra-articular osteoporosis and small osteoporosis and small ersions.ersions.


5% - 15% of cases develop 5% - 15% of cases develop ankylosing spondylitis and ankylosing spondylitis and sacroiliitis.sacroiliitis.

HLA – B27 is usually absent HLA – B27 is usually absent in patients with IBD with in patients with IBD with peripheral arthritis and is peripheral arthritis and is present in those who present in those who develop ankylosing develop ankylosing spondylitis or uveitis. spondylitis or uveitis.

TREATMENTTREATMENT Peripheral arthritis responds to successful Peripheral arthritis responds to successful

treatment of the bowel disease including bowel treatment of the bowel disease including bowel resection.resection.

Symptomatic treatment – rest, application of hot Symptomatic treatment – rest, application of hot packs and administration of NSAIDS if tolerated.packs and administration of NSAIDS if tolerated.

A single dose of intra-articular steroid injection is A single dose of intra-articular steroid injection is effective.effective.

Irradiation is given for spondylitis and sacroiliitis.Irradiation is given for spondylitis and sacroiliitis.

WHIPPLE’S DISEASEWHIPPLE’S DISEASE

Occurs commonly in Occurs commonly in middle aged men.middle aged men.

Characterized by Characterized by gastrointestinal cramping gastrointestinal cramping pain, diarrhea, occult blood pain, diarrhea, occult blood loss (89%), loss (89%), arthralgia (65 – arthralgia (65 – 90%),90%), weight loss (60%), weight loss (60%), hypotension (63%), hypotension (63%), lymphadenopathy (52%) lymphadenopathy (52%) and spondylitis.and spondylitis.

DIAGNOSISDIAGNOSIS

Diagnosis is by Diagnosis is by finding densely finding densely packed period acid packed period acid – Schiff (PAS) – Schiff (PAS) positive positive macrophages in macrophages in small bowel biopsy.small bowel biopsy.

TREATMENTTREATMENT

The disease can be cured with The disease can be cured with antibiotics like antibiotics like Penicillin, Penicillin, Ampicillin, TetracyclineAmpicillin, Tetracycline or or

Co - trimoxazoleCo - trimoxazole for 1-2 years. for 1-2 years.

Symptomatic analgesia for joint Symptomatic analgesia for joint involvement along with hot packs.involvement along with hot packs.

BEHCET’S DISEASEBEHCET’S DISEASE Rare multisystemic disorder.Rare multisystemic disorder.

Characterized by painful oral Characterized by painful oral and genital ulcerations, and genital ulcerations, arthritis of large jointsarthritis of large joints & & gastrointestinal gastrointestinal manifestations.manifestations.

Males are commonly Males are commonly affected in 3affected in 3rdrd decade. decade.

Associated withAssociated with HLA-B51 HLA-B51..

BEHCET’S DISEASEBEHCET’S DISEASE Associated with asymmetrical Associated with asymmetrical

oligoarticular arthritis.oligoarticular arthritis.

Knee, ankle, wrist & elbow are Knee, ankle, wrist & elbow are commonly effected.commonly effected.

Associated with low grade Associated with low grade fever, malaise & erythema fever, malaise & erythema nodosum.nodosum.

Preservation of joint function Preservation of joint function with little or no deformity is with little or no deformity is good.good.

Sacroiliac and spinal Sacroiliac and spinal involvement is rare. involvement is rare.

TREATMENTTREATMENT

Steroids, cyclosporin, Steroids, cyclosporin, cyclophosphamide or azathioprine.cyclophosphamide or azathioprine.

NSAIDS for reducing pain if joints are NSAIDS for reducing pain if joints are involved.involved.

THANK YOU . . .THANK YOU . . .

‘ ‘All animals except man know that the principle of All animals except man know that the principle of life is to enjoy it’life is to enjoy it’

- Anonymous- Anonymous

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