Seronegative arthritis: Clinical

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Seronegative arthritis: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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A 26-year-old woman comes to the clinic for chronic pain and redness in her right eye for the past year. She reports that she has to wear very dark sunglasses when she goes out during the day due to sensitivity to bright light and that her pain is not significantly changed with eye movements. She denies any ocular swelling or discharge. Her temperature is 37.0°C (98.6°F), pulse is 68/min, respirations are 12/min, and blood pressure is 120/80 mm Hg. Medical history is noncontributory, but family history is significant for a mother with psoriatic arthritis. Slit-lamp examination of the eye shows "cells and flare" in the anterior chamber. An image of her eye is shown below. What is the most likely diagnosis?


Seronegative arthritis refers to a group of four chronic diseases - ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and enteropathic arthritis.

All of them are negative for rheumatoid factor, they’re all positive for HLA-B27, and they typically all run in families.

Another feature they share is that they usually affect the bones in the spine and nearby joints. That’s why they’re sometimes called seronegative spondyloarthritides, where spondylo means vertebra.

Other features include inflammatory back pain that causes morning stiffness which improves after 30 minutes of movement.

These diseases also cause peripheral arthritis that’s generally asymmetric, and axial arthritis like sacroiliitis and spondylitis, affecting the sacroiliac and vertebral joints, respectively.

Individuals also present enthesitis – meaning inflammation at the sites where tendons or ligaments insert into the bone and dactylitis, also known as sausage fingers.

They also cause extra-articular symptoms like involvement of the eyes with anterior uveitis, skin with psoriasis, the heart with aortic regurgitation or pericarditis, genitourinary involvement due to nerve compression at the spinal cord, and gastrointestinal involvement with inflammatory bowel disease - both Crohn's disease or ulcerative colitis.

Seronegative spondyloarthritides typically have a good response to NSAIDs and an elevated CRP in blood tests.

To meet the diagnostic criteria for seronegative spondyloarthritis, an individual has to have evidence of sacroiliitis on imaging plus one of these spondyloarthritis features, or HLA-B27 positivity plus two additional spondyloarthritis features.



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