by Hope Starkman , MD
There are many forms of arthritis which fit into the inflammatory category but which do not have labs tests that specifically identify them. For example, patients with Rheumatoid Arthritis (RA) may have positive Rheumatoid Factors or CCP antibodies in their blood and patients with Systemic Lupus Erythematosus often have positive Antinuclear antibodies. Very often patients show up at the rheumatologist’s office with arthritis that clinically looks like rheumatoid arthritis but their blood tests are repetitively negative. They may have elevated sed rates/ESR’s, swollen, tender joints, anemia, fatigue and even sometimes the same joint pattern of involvement at patients with rheumatoid arthritis.
About 20 percent of patients with rheumatoid arthritis are seronegative but they still meet criteria for RA. We call those patients seronegative RA. There is a larger group of patients that do not meet criteria for RA and who are seronegative but they still have a form of inflammatory arthritis. It is often difficult to make diagnoses on these patients and they are often misdiagnosed and treated late
The hallmark of inflammatory arthritis and inflammatory disease in general is the presence of post rest or morning stiffness lasting more than 30-60 minutes. Most patients with RA or other inflammatory diseases will have a very difficult time starting up their day due to this stiffness. Some patients have hours or morning or post rest stiffness and some will be stiff the entire day. One way to monitor disease activity and response to treatment is by following the amount of post rest or morning stiffness.
Some types of seronegative inflammatory arthropathies include but are not limited to the following:
Psoriatic arthritis (the arthritis associated with psoriasis) also to be referred to as PSA. The difficult part of making this diagnosis occurs when the arthritis precedes the psoriasis or when the psoriasis is hidden I.e. in the scalp, inverse psoriasis, nail psoriasis or minimal. Patients with PSA may initially look like they have PMR ( polymyalgia rheumatic)because initial PSA presentation may start with inflammation where the tendons attach to bone-a condition called enthesopathy ) so that there is more muscle pain than joint pain at the onset of the disease.
Chrons or Inflammatory Bowel Disease Associated Inflammatory Arthritis: Again the actual bowel disease and the arthritis do not have to be present at the same time though they often are. Some patients with this form of arthritis may have had only one or few flares of their bowel condition in the distant past and they may not even remember. These patients may have also had flares of ocular/eye inflammation i.e. Iritis or Uveiitis Reactive Arthritis or a variation of Reiter’s Syndrome: This is a form of arthritis following some type of exposure usually to a bacterial infection ie a diarrheal infection with Salmonella, Shigella or Yersinia or to a STD related infection like Chlamydia. The start of this form of arthritis is generally related to the development of the infection within days or week. The triad of Iritis/Conjuntivitis/Uveiitis(ocular inflammation), urethritis or urinary tract inflammation, and arthritis is referred to as Reiter’s, however, it is not uncommon to develop incomplete Reiter’s syndrome with some of the above elements missing. There is possibly a genetic propensity to develop reactive arthritis after exposure to pieces of bacterial protein DNA
Anklyosing Spondylitis(AS): This is an inflammatory condition of the spine (cervical thru lumbar) Again marked by post res stiffness and adaptive posture. The spine becomes rigid and many of the patients with AS lose the ability to even turn their head. On X ray their spine becomes fused at consecutive levels and appears like a “Bamboo” spine. Eighty percent of these patients have a gene called HLAB27. Men are more often affected by AS, though women can certainly be affected. Since women are less often affected by AS, they are often diagnosed later or even misdiagnosed. Many also develop arthritis in joints outside of their spine, particularly larger joints like the hips, knees, elbows but also small joints as well. With this disease the lumbar spine becomes straight rather than curved and mobility is severely restricted. Knees often remain flexed and bent so posture is stooped. Other organ systems can become involves like the heart and lungs in AS.
The most difficult part of treating patients with some of these conditions is identifying them. There is a lot of overlap between the above conditions and patients often “Do not read the textbook” In other words, they may present in an atypical fashion. Formal diagnoses probably should not be made unless criteria are met and present for at least 6 weeks. Some forms of viral arthropathies can look the same as more chronic forms of arthritis described above but viral related arthropathies usually resolve within weeks to months.
More often than not, the various forms of seronegative arthropathies are treated just like RA. Often treating the accompanying symptoms like the psoriasis or colitis does not treat the arthritis unless the causative pathway for all parts of the condition are being addressed like with the use of anti tumour necrosis factor agents(Enbrel-Etanercept, Humira-Adalimumab, Remicaide-Imfliximab, Cimzia-Certolizimab, Simponi-Golimumab, Orencia-Abetacept, Rituximab Tocilizumab-Actemra. On the other hand, treating the arthritis with anti TNF agents may improve the other conditions accompanying the arthritis. Risks and benefits, potential drug interactions, prior patient experiences must always be weighed out and tailored to each specific patient. Patient goals in terms of treatment outcomes may differ widely between patients due to age, expectations, functional ability, employment issues, financial concerns, insurance formularies and even ability to self administer injectables.
The current available medications makes most of the above conditions liveable and may even prevent progression of permanent deformities