A Complete Review of Seronegative Spondyloarthritis: Causes, Diagnosis and Treatment

From this article you will learn: seronegative spondyloarthritis - what it is, what types of this pathology exist. Causes and factors predisposing to the onset of the disease. Characteristic signs of seronegative spondyloarthritis, symptoms and diagnostic methods. Treatment methods, in which cases patients are given a disability group, prognosis for the disease.

Author of the article: Victoria Stoyanova, category 2 doctor, head of the laboratory at the diagnostic and treatment center (2015–2016).

Article publication date: 05/04/2019

Article updated date: 01/19/2020

Seronegative spondyloarthritis is the general name for a group of diseases of the spine and joints in which destruction of the bone and cartilage tissue of the spine occurs due to a chronic inflammatory process. Different types of spondyloarthritis have similar causes, symptoms and development mechanisms.

Seronegative spondyloarthritis is a systemic disease, that is, affecting the entire body. Pathogens that enter the body (chlamydia, yersinia, salmonella) cause acute intestinal or urogenital infections. In the process of pathology, the immune system produces antibodies to bacterial antigens and at the same time attacks its own cartilage tissue. The result is metabolic disorders, chronic inflammation and degenerative changes in joint tissue (loosening, swelling, loss of elasticity and strength, cracking).

Another name for these diseases is spondyloarthropathy; previously they were classified as rheumatoid arthritis, but later they were separated into a separate group. Characteristic features that distinguish them from rheumatoid (usually seropositive) polyarthritis and other inflammatory diseases of the spine and joints:

• absence of rheumatoid factor (RF) in the patient’s blood or, in other words, seronegativity (negative result), there are no characteristic rheumatoid nodules under the skin;
• asymmetrical joint damage;
• hereditary predisposition (close relatives are more likely to suffer from such diseases);
• radiographic signs - bilateral inflammation of the sacroiliac joint (sacroiliitis) and ankylosing spondylitis (changes in the vertebrae leading to their fusion);
• the presence of the marker antigen HLA-B27 in 95% of patients (the structure coincides with the antigens of some pathogens).

Sacroiliitis is a characteristic sign of seronegative spondyloarthritis.
Click on the photo to enlarge Seronegative spondyloarthritis (spondyloarthropathy) must be distinguished from:

• spondyloarthrosis (the cause of degenerative-dystrophic spiky growths of bone tissue is age-related metabolic disorders, trauma or stress on the spine; other joints and organs are not involved in the process);
• spondylitis (a large group of inflammatory diseases of the spine, which begin with the destruction of bone tissue of the vertebrae; the causes may be infections or an autoimmune inflammatory process).

Spondyloarthropathy is a dangerous pathology that constantly progresses, despite the measures taken. The result is fusion and complete immobility of the spine, deformation of the joints involved, incapacity and disability.

The disease can be stopped, but it cannot be completely eliminated. Treatment is carried out by rheumatologists.

Types of pathology

According to general characteristics, the group of diseases includes the following spondyloarthritis:

1. Reactive (Reiter's disease).
2. Psoriatic.
3. Juvenile (children's, teenage forms).
4. Enteropathic (causes: Crohn's disease and ulcerative colitis).
5. Ankylosing (Bechterew's disease).
6. Undifferentiated.

Ankylosing spondylitis is a type of spondyloarthritis. Click on photo to enlarge

Some time ago (in 2002), due to non-compliance with certain diagnostic criteria, the following were excluded from the list:

• Behcet's syndrome (in most patients the marker antigen HLA-B27 is not detected, there is no characteristic lesion of the spine);
• juvenile chronic (various diseases, which in most cases progress to rheumatoid arthritis);
• spondyloarthritis due to Whipple's disease (rarely accompanied by spondylitis and sacroiliitis).

Whipple's disease
All other inflammatory lesions of the spine and joints that do not have characteristic diagnostic signs (marker antigen, sacroiliitis, RF seronegativity) are classified not as other spondyloarthritis, but as other groups of diseases (reactive arthritis, rheumatoid polyarthritis, etc.).

Clinical picture

The symptoms that are provoked by seronegative spondyloarthritis are usually grouped into separate complexes. Let's look at each of them in more detail.

Joint syndrome

As a rule, problems with joints come first in the clinical picture of absolutely all forms and varieties of spondyloarthritis. Patients suffer from bilateral sacroiliitis. There is severe pain in the spinal column.

Posture changes due to the fact that severe stiffness and general discomfort are felt in the musculoskeletal system.

Organs of vision

Damage to the visual organs manifests itself through extra-articular SSAP syndrome. Most often, patients suffer from symptoms that cause the following pathologies:

• Uveitis (usually anterior);
• Iritis;
• Iridocyclitis.

Soon the condition will only worsen. Among the most common complications are cataracts, total corneal dystrophy, and glaucoma.

The optic nerve can also be severely damaged. Because of this, visual function sharply decreases. In some cases, irreversible blindness occurs.

Damage to the dermal tissue

The dermal tissue and the structure of the nail plates are affected differently by SSAP. It all depends on what type of disease provokes destructive changes.

The most common clinical signs:

• Psoriatic plaques;
• Psoriatic pustules;
• Erythema nodosum;
• Psoriatic destruction of nail plates;
• Ulcerative processes on the mucous membranes;
• Keratoderma.

There are situations when there are no such changes at all. In other cases, patients have several symptoms from the list presented above.

Pathological processes in the intestines

Inflammatory pathologies in the intestines accompany SSAP in approximately 20% of all cases. The ailments are characterized by an exclusively chronic nature. It has been noted that the activation of inflammatory processes in articular tissues coincides with the intensification of unfavorable changes in the intestinal mucous membranes.

Often, foci of inflammation in the structures of the digestive tract are minor. Due to their subclinical form, they almost never cause significant symptoms. The problem is known at the stage of a comprehensive study of the body, in particular during endoscopic instrumental procedures.

Heart

Frequent cardiac “companions” of seronegative spondyloarthritis are aortitis and AV conduction disorders. Exacerbation of cardiac pathologies is in no way associated with the activation of abnormal processes in the joints. Cases have been recorded where a patient complained of pain in the heart, and at the same time signs of SSAP were identified.

Kidney structures

Kidney problems occur in every fifth patient suffering from seronegative spondyloarthritis. The main pathological phenomena that occur against the background of inflammatory and destructive processes in the spinal column are nephrotic syndrome, microhematuria, proteinuria, and renal failure.

Causes

The causes of seronegative spondyloarthritis are unknown; official medicine puts forward a polyetiological (that is, a combination of several factors) version of the origin of inflammatory damage to the spine and joints.

Currently, any seronegative spondyloarthritis is associated with:

• genitourinary and intestinal infections (salmonellosis, dysentery, chlamydia, yersiniosis, etc.);
• genetic predisposition, evidence of which is the presence of the marker antigen HLA-B27;
• inheritance of spondyloarthropathy by close relatives.

Urogenital and intestinal infections (view under a microscope). Click on photo to enlarge

Factors that, according to experts, can influence the occurrence of pathology are more numerous:

1. Pathological displacement of the spinal axis (spondylolisthesis).
2. Congenital and acquired degenerative changes in intervertebral cartilage, necrosis of cartilage tissue.
3. Microdamage to joints.
4. Spinal fractures and injuries.
5. Cracks and damage to the vertebral processes.
6. Deposition of calcium salts in articular cartilage (chondrocalcinosis).
7. Epiphyseal dysplasia (deformation, flattening, abnormal development of bone articular surfaces).
8. Infectious diseases affecting the joints.

Click on photo to enlarge

In women, seronegative spondyloarthritis appears less frequently.

By age, the peak incidence occurs between 15 and 45 years.

Uveitis is one of the characteristic signs of seronegative spondyloarthritis

About possible complications

Many patients wonder whether right-sided spondyloarthritis or other types of SSAP can be cured. Unfortunately, the answer is no. Destructive-degenerative processes destroy cartilage and bones irreversibly.

The pathological process can be stopped; specialists can eliminate inflammatory processes and minimize the discomfort that causes the disease.

If help is not provided in a timely manner, the person faces a number of serious complications:

• Total degenerative changes in joints in the structural units of the spinal column;
• Violation of circulatory processes;
• Development of severe heart defects (usually aortic);
• Reduced visual acuity up to blindness;
• Severe lesions of the dermal tissue;
• Kidney failure.

Symptoms

The initial stages of some seronegative spondyloarthritis are almost asymptomatic (or the signs of the disease are very weak).

Others begin with severe pain (which lasts more than 3 months) and stiffness in the spine in the morning.

Gradually, the symptoms increase, intensify and lead to the development of ankylosis (intervertebral adhesions), complete immobility and disability of the patient.

A characteristic feature of some seronegative arthritis is deformation of the spinal column in the form of a “proud posture” or “petitioner” (a very straight or hunched back, corresponding position of the neck and head).

The supplicant pose for ankylosing spondylitis

General symptoms (for all forms of pathology):

• slow, gradual development;
• pain in the spine (starts with morning stiffness, lasts more than 3 months) and in the buttocks (subsides and returns);
• asymmetric inflammation (arthritis) of the leg joints;
• impaired mobility of joints and spine;
• X-ray confirmed inflammation of the sacroiliac joint;
• pain at the attachment points of tendons and ligaments;
• extra-articular symptoms (diarrhea, cervicitis, urethritis, psoriasis, balanitis, uveitis).

Click on photo to enlarge

Possible progression and consequences of the disease

The pathology develops and gradually leads to the appearance of:

• deformations of articular surfaces;
• fusion of the vertebrae and complete immobility of the spine;
• aortitis (inflammation of the walls of the aorta);
• amyloidosis (metabolic disorders);
• carditis (inflammation of the membranes of the heart);
• pulmonary fibrosis (replacement of functional tissue).

Characteristic differences of seronegative spondyloarthritis

Seronegative spondyloarthritis is characterized by a number of signs by which they are distinguished from other inflammatory-degenerative polyarthritis with damage to the spine:

1. Unilateral or bilateral inflammation of the iliosacral joint (sacroiliitis).
2. Inflammatory lesion of the spinal column (spondylitis).
3. Degenerative-inflammatory process and ossification of ligaments, joint capsules and tendons at their attachment points (enthesopathy).
4. Asymmetrical damage to peripheral joints (usually arthritis of the lower extremities).
5. Absence of rheumatoid factor in the patient’s blood (seronegativity).
6. The presence of the HLA-B27 marker in 95% of patients.
7. Extra-articular manifestations of pathology with damage to the skin (psoriasis), eyes (uveitis), lungs (fibrosis), heart (carditis), gastrointestinal tract, oral mucosa, genitourinary system (urethritis, cervicitis).
8. Cases of seronegative spondyloarthritis in close relatives.
9. The presence of cross forms (pathologies are manifested by symptoms belonging to different diseases of the group).

Prevention

In order to avoid the appearance of one of the varieties of this disease, you should be careful about personal hygiene. Before eating, be sure to wash your hands, and eat only fresh and properly processed food. Avoid private and questionable sexual relations. Hypothermia, excessive stress on the body and reduced immune resistance can also be a provoking factor.

If any symptoms or signs of a developing inflammatory process occur, you should immediately contact a medical facility.

Diagnostics

Differential diagnosis is carried out by excluding diseases with similar manifestations: rheumatoid polyarthritis, rheumatoid arthritis, hydroxyapatite arthropathy and some others.

In addition to the help of the treating rheumatologist, the patient receives consultations with an ophthalmologist, dermatologist, urologist (gynecologist), cardiologist, gastroenterologist (depending on the most severe symptoms).

Confirmatory diagnostic methods are:

• radiography of the joints and spine (it is used to detect sacroiliitis, intervertebral adhesions, calcification of intervertebral ligaments), intestines with barium;
• examination of intra-articular fluid obtained by puncture (this method allows us to determine the cause of arthritis);
• blood tests for rheumatoid factor (negative in seronegative spondyloarthritis), C-reactive protein and erythrocyte sedimentation rate (increased), uric acid (negative), urine tests for the presence of protein and red blood cells (increased in kidney damage);
• Ultrasound of the kidneys (if there is protein and red blood cells in the urine);
• MRI and ECG of the heart, aortography (if cardiac involvement is suspected or complaints of rhythm disturbances).

Joint puncture

Treatment

It is impossible to completely get rid of the disease; as a result of treatment of seronegative spondyloarthritis, a short-term remission (improvement) is achieved, which is never long-lasting.

The main methods used to stop the progression of the disease to complete immobility and deformation of the joints are medications and physical therapy (physical therapy, massage).

Medicines prescribed for seronegative spondyloarthritis:

1. Non-steroidal anti-inflammatory drugs (Diclofenac, Nimesulide, Indomethacin). They are combined with the prophylactic use of the drug "Omez" to prevent the development of perforated ulcers or gastric erosion.
2. Hormonal anti-inflammatory drugs (Prednisolone, Methylprednisolone).
3. Immunosuppressants (Methotrexate) suppress cellular immunity.
4. Monoclonal immunosuppressants (Infliximab) reduce the activity of autoimmune reactions and reduce the amount of antibodies against chondrocytes (cartilage tissue cells).
5. Chondroprotectors (Chondroitin, Glucosamine) help restore cartilage tissue.

Treatment of pathology is impossible without:

• diets to correct weight (if you are overweight);
• daily performance of a set of physical therapy exercises;
• massage courses;
• sleeping on a hard surface without a mattress.

To reduce the rate of spinal deformation, it is vital for the patient to go swimming, regularly visit mud baths and balneological resorts (with therapeutic radon and hydrogen sulfide baths).

Mud treatment

Is disability given for illness?

The disease may result in partial or complete loss of ability to work. In this case, the person is given a disability group:

• the third – with a long-term and persistent limitation of the range of movements (the person is capable of self-care and some types of work);
• the second – in case of disability due to irreversible changes in the joints (the patient is capable of self-care, but cannot perform other physical activities);
• the first – in case of disability with curvature of the spine and damage to the spinal nerves (the person is not capable of self-care).

Preventive actions

As soon as the inflammatory process is eliminated with medication and the patient’s condition is stabilized, it is necessary to explain to the person in great detail how he should behave further. By following your doctor's recommendations, you can prevent relapses of the disease. Here are the basic rules:

• Avoid stress and situations accompanied by severe psycho-emotional exhaustion;
• Maintain personal hygiene;
• Eat properly and balanced;
• Adhere to a certain daily routine;
• Full sleep;
• Exercise;
• Take care of your immunity;
• Promptly treats any infectious and viral diseases;
• Undergo regular preventive examinations.

These rules are not that difficult to follow. Moreover, a healthy lifestyle will help not only prevent relapses of SSAP, but also protect yourself from any other ailments.

Forecast

This disease will have to be treated throughout your life.

The prognosis worsens:

1. In men.
2. At early onset (before 19 years of age).
3. With the development of hip arthritis and limited mobility of the spine in the first years from the onset of the disease (the first 2 years).
4. If you have the HLA-B27 marker and family members suffering from the disease.
5. With concomitant peripheral arthritis and local pain at the attachment sites of tendons and ligaments.

Remissions (periods of improvement) are short-lived and unstable; the disease sooner or later results in partial or complete loss of spinal mobility and varying degrees of disability.