name:

Biadsi Odey
Group:M1560

SUBJECT : rheumatology ( patenit

presentation ).

Data : 31/03/2019.
 Name: iugene magurian
 Gender:female
 age:52
 Childs:3
 Birth:11/11/1967
 hometown:moldova centru
 work/retrirement/disability:service in the
school
 she have seronegative spondyloarthritis
 reason:
 patient referred to hospital by family doctor
due to pain in the joint which is symmetrical
espically in the morning (seronegative
spondyloarthritis)
 Have cahnges in his hand(dactylitis)
 Possible aMost common presenting symptoms: back and
neck pain
◦ Gradual onset of dull pain that progresses slowly
◦ Morning stiffness that improves with activity
◦ Pain is independent of positioning, also appears at night
◦ Tenderness over the sacroiliac joints
 Limited mobility of the spine (especially reduced forward
lumbar flexion)
 Inflammatory enthesitis (e.g., of the Achilles tendon, iliac
crests, tibial tuberosities): painful on palpation
 Dactylitis
 Arthritis outside the spine: hip, shoulder, and knee join
 And have symptomps of psoraitic arthritis like Nail
pitting: small, round depressions in the nail
 Oil drop sign (or salmon spot): well-
circumscribed, yellow-reddish discoloration of the nail
 Negative for rheumatoid factor
 Genetic association with HLA-B27
 Generally more commonly affects men
 Age of onset: typically between 20–40
years of age
 Non-specific symptoms (fever, fatigue,
weight loss)
 Diagnostic approach
 Physical examination, patient history, and pelvic x-ray: If results are conclusive,
no additional testing is required!
 If inconclusive → HLA-B27 testing
 If still inconclusive → pelvic MRI
 Clinical tests
 Chest expansion measurement: in full expiration and inspiration
◦ Pathological difference: < 2 cm
◦ Physiological difference: > 5 cm
 Spine mobility tests
 Examination of the hip[3]
◦ Mennell sign: tenderness to percussion and pain on displacement of the sacroiliac joints
◦ FABER test: FABER (Flexion, ABduction, and External Rotation) provokes pain in
the ipsilateral hip
 Laboratory findings
 ↑ CRP and ESR
 Auto-antibodies (e.g., rheumatoid factor, antinuclear antibodies) are negative
 HLA-B27 positive in 90–95% of cases
◦ However, < 5% of HLA-B27 positive individuals have ankylosing spondylitis.
 Imaging
 X-ray
 Can help confirm a diagnosis or evaluate the
severity of disease, but is not required for the
diagnosis
 Changes are generally more evident in later
disease
 Sacroiliac joints: signs of sacroiliitis,
including ankylosis of sacroiliac joints
 Spine
◦ Loss of lordosis with increasing abnormal
straightening of the spine
◦ Sclerosis of the vertebral ligamentous apparatus
◦ Syndesmophytes resulting in a so-called 'bamboo
spine' in anteroposterior radiograph in the later
 ◦ Ultrasound findings of the kidney and urinary
bladder include:
 Urinary obstruction, calculi, or abscess
 Diffuse corticomedullary junction
◦ Intravenous pyelogram (IVP)
◦ Retrograde cystourethrogram to
diagnose vesicoureteral reflux

 Physical therapy
◦ Consistent and rigorous physical therapy
◦ Independent exercises
 Medical therapy
◦ First choice: NSAIDs (e.g., indomethacin)
◦ Additional options
 Tumor necrosis factor-α inhibitors (e.g., etanercept) [12]
 In case of peripheral arthritis: DMARDs (especially sulfasalazine)
 In severe cases: temporary, intra-articular glucocorticoids
 Surgery: in severe cases to improve quality of life
◦ Indication:
 Severe deformity of the spinal column
 Instability of the spine
 Neurologic deficits
◦ Procedures:
 Osteotomy
 Joint replacement
 Spinal fusion
 Physical therapy is the most important treatment modality!
 Uveitis
 Aortic regurgitation
 Restrictive lung disease due to limited chest wall
expansion(costovertebral and costosternal
ankylosis