Bone erosions by MRI in first-degree relatives of patients with RA: an exploratory study

INTRODUCTION/OBJECTIVES

First-degree relatives (FDR) of patients with rheumatoid arthritis (RA) are at increased risk of RA diagnosis. Magnetic resonance imaging (MRI) has been proposed as a useful tool to detect subclinical synovitis and bone abnormalities as predictors of progression to RA. The presence of grade ≥ 2 bone erosions in RA MRI scoring system (RAMRIS) was reported to be RA-specific. We aim to describe the prevalence and characteristics of MRI findings in RA patients and FDR.

METHODS

A cross-sectional and exploratory study of 60 individuals was performed in 38 RA patients and 22 FDR with hand arthralgia without clinical arthritis and positive rheumatoid factor or anticitrullinated protein antibodies. All patients underwent an MRI and were evaluated for synovitis, bone erosion, and bone marrow edema. We evaluated second to fifth metacarpophalangeal joints of the dominant hand according to RAMRIS.

RESULTS

Among the total population, eighteen (30%) subjects had grade ≥ 2 bone erosions, and 42 (70%) had at least one erosion of any grade. In patients with grade ≥ 2 bone erosions, 12 (31.6%) were from RA patients and 6 (27.2%) from FDR (p = 0.72). In patients with erosions of any grade, 26 (68.4%) were from RA patients and 15 (68.2%) were from FDR (p = 0.98).

CONCLUSION

A high prevalence of bone erosions was found in RA patients' FDR who had symptoms without clinical arthritis and positive serology. MRI might be helpful in this population for an early detection of RA-specific erosions. The prognosis and the treatment decisions in these subjects should be elucidated.

KEY POINTS

• First-degree relatives (FDR) of rheumatoid arthritis (RA) patients with positive serology and joint symptoms constitute a select subpopulation of individuals with an increased risk of developing RA. • Magnetic resonance imaging (MRI) of FDR shows a high prevalence of bone erosions of any grade, grade ≥ 2 erosions, and synovitis. • MRI might be helpful in FDR of RA patients to screen for the presence of RA-specific erosions or clinically undetectable synovitis.

A convolutional neural network with transfer learning for automatic discrimination between low and high-grade synovitis: a pilot study

Ultrasound-guided synovial tissue biopsy (USSB) may allow personalizing the treatment for patients with inflammatory arthritis. To this end, the quantification of tissue inflammation in synovial specimens can be crucial to adopt proper therapeutic strategies. This study aimed at investigating whether computer vision may be of aid in discriminating the grade of synovitis in patients undergoing USSB. We used a database of 150 photomicrographs of synovium from patients who underwent USSB. For each hematoxylin and eosin (H&E)-stained slide, Krenn's score was calculated. After proper data pre-processing and fine-tuning, transfer learning on a ResNet34 convolutional neural network (CNN) was employed to discriminate between low and high-grade synovitis (Krenn's score < 5 or ≥ 5). We computed test phase metrics, accuracy, precision (true positive/actual results), and recall (true positive/predicted results). The Grad-Cam algorithm was used to highlight the regions in the image used by the model for prediction. We analyzed photomicrographs of specimens from 12 patients with arthritis. The training dataset included n.90 images (n.42 with high-grade synovitis). Validation and test datasets included n.30 (n.14 high-grade synovitis) and n.30 items (n.16 with high-grade synovitis). An accuracy of 100% (precision = 1, recall = 1) was scored in the test phase. Cellularity in the synovial lining and sublining layers was the salient determinant of CNN prediction. This study provides a proof of concept that computer vision with transfer learning is suitable for scoring synovitis. Integrating CNN-based approach into real-life patient management may improve the workflow between rheumatologists and pathologists.

Distinguishing Blau Syndrome from Systemic Sarcoidosis

PURPOSE OF REVIEW

The purpose of this review is to provide a framework to distinguish Blau syndrome/Early Onset Sarcoidosis and Sarcoidosis clinically. We also discuss relevant differences in genetics, pathogenesis, and management of these diseases.

RECENT FINDINGS

Blau syndrome and Sarcoidosis share the characteristic histologic finding of noncaseating granulomas as well as some similar clinical characteristics; nevertheless, they are distinct entities with important differences between them. Blau syndrome and Early Onset Sarcoidosis are due to one of numerous possible gain-of-function mutations in NOD2, commonly presenting before age 5 with a triad of skin rash, arthritis, and uveitis. However, as more cases are reported, expanded clinical manifestations have been described. In systemic Sarcoidosis, there are numerous susceptibility genes that have been identified, and disease is thought to result from an environmental exposure in a genetically susceptible host. It most often presents with constitutional symptoms and pulmonary involvement and typically affects adolescents and adults. This paper reviews the similarities and differences between Blau syndrome and Sarcoidosis. We also discuss the importance of distinguishing between them, particularly with regard to prognosis and outcomes.

Evaluation of Hip Pain and Management of Toxic Synovitis in the Ultrasound Era

ABSTRACT

The cause of acute onset hip pain in children can be difficult to determine. Once trauma is excluded, the workup revolves around determining whether there is a hip effusion and eliminating orthopedic emergencies. Point-of-care-ultrasound can be used as an adjunct in the workup. In this article, we review (1) differential diagnosis of hip pain, with a focus on toxic synovitis; (2) the evaluation of a hip for the presence of effusion, including the point-of-care ultrasound technique; and (3) the management of toxic synovitis.

PD-1 Expression on CD8+CD28- T cells within inflammatory synovium is associated with Relapse: A cohort of Rheumatoid Arthritis

Defect in T lymphocyte homeostasis could implicate initiation and development of rheumatoid arthritis (RA). Since PD-1 plays a key role in the regulation of T lymphocytes, its expression pattern in various CD8+ T cell subsets could be so effective in RA pathogenesis. Here, we investigated the expression of PD-1 and CXCR3 on CD8+CD28- T cells in association with the IFN-γ levels in patients with RA. A total of 42 RA patients, including 10 newly-diagnosed (ND) and 32 relapsed (RL) cases and also 20 healthy donors were enrolled. Phenotypic characterization of CD8+ T cells derived from peripheral blood (PB) and synovial fluid (SF) was performed by flow cytometry. The plasma and SF IFN-γ levels were also assessed by ELISA. The frequency of CD8+CD28- T cells showed no significant differences between patients and controls while its higher levels were observed in PB, versus SF of RL patients. Relapsed patients also showed higher CXCR3 and especially PD-1 expression on their CD8+CD28- T cells. The IFN-γ concentration was elevated in SF of ND patients while its plasma level was significantly lower in RL subgroup than controls. Although PD-1 could induce immune suppression in effector T cells, it is upregulated during inflammation and its overexpression on CD8+CD28- T cells within inflammatory synovium is associated with severity of disease in our cohort of RA patients.

Refining surgical models of osteoarthritis in mice and rats alters pain phenotype but not joint pathology

The relationship between osteoarthritis (OA) structural change and pain is complex. Surgical models of OA in rodents are often rapid in onset, limiting mechanistic utility and translational validity. We aimed to investigate the effect of refining surgical small rodent models of OA on both joint pathology and pain behaviour. Adult male C57BL/6 mice (n = 76, 10-11 weeks of age at time of surgery) underwent either traditional (transection of the medial meniscotibial ligament [MMTL]) or modified (MMTL left intact, transection of the coronary ligaments) DMM surgery, or sham surgery. Adult male Sprague Dawley rats (n = 76, weight 175-199g) underwent either modified meniscal transection (MMNX) surgery (transection of the medial meniscus whilst the medial collateral ligament is left intact) or sham surgery. Pain behaviours (weight bearing asymmetry [in mice and rats] and paw withdrawal thresholds [in rats]) were measured pre-surgery and weekly up to 16 weeks post-surgery. Post-mortem knee joints were scored for cartilage damage, synovitis, and osteophyte size. There was a significant increase in weight bearing asymmetry from 13 weeks following traditional, but not modified, DMM surgery when compared to sham operated mice. Both traditional and modified DMM surgery led to similar joint pathology. There was significant pain behaviour from 6 weeks following MMNX model compared to sham operated control rats. Synovitis was significant 4 weeks after MMNX surgery, whereas significant chondropathy was first evident 8 weeks post-surgery, compared to sham controls. Pain behaviour is not always present despite significant changes in medial tibial plateau cartilage damage and synovitis, reflecting the heterogeneity seen in human OA. The development of a slowly progressing surgical model of OA pain in the rat suggests that synovitis precedes pain behaviour and that chondropathy is evident later, providing the foundations for future mechanistic studies into the disease.

Fibromyalgia in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome: prevalence and screening

OBJECTIVE

To explore the prevalence, clinical characteristics, and screening strategy for fibromyalgia (FM) in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.

METHODS

A total of 313 patients from a cohort of 354 SAPHO patients volunteered to participate in this study. Demographic, clinical and laboratory data were collected at baseline. Acute-phase reactants during the last 3 months were obtained. Patient-reported outcomes (PROs) and FM evaluation were recorded by questionnaires.

RESULTS

A total of 57 (18.2%) patients met the 2016 research criteria for FM. Compared to those without FM, these patients had significantly higher visual analog scale (VAS), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Bath Ankylosing Spondylitis Functional Index (BASFI) scores (all p < 0.001). However, no differences in the erythrocyte sedimentation rate (ESR) or hypersensitive C-reactive protein (hs-CRP) levels were identified between the two groups. Patients with FM were also markedly older [odds ratio (OR) 1.072, p = 0.032] and had higher Fibromyalgia Rapid Screening Tool (FiRST) scores (OR 1.607, p = 0.016). The FiRST score showed a sensitivity of 50.9% and a specificity of 89.8%, and with a cutoff of 3, the FiRST score presented a high sensitivity of 84.2%.

CONCLUSION

The prevalence of FM among SAPHO patients was similar to that among patients with other rheumatic diseases. Concomitant FM in SAPHO syndrome was associated with older age and worse PROs. Different cutoff values for FiRST screening should be used in patients with SAPHO syndrome. Key Points • The prevalence of FM among SAPHO patients was similar to that among patients with other rheumatic diseases. • Concomitant FM in SAPHO syndrome was associated with older age, widespread pain, and worse PROs. • Different cutoff values for FiRST screening should be used in patients with SAPHO syndrome.

[CME-Rheuma 21: Precision Medicine - Synovial Biopsy in Rheumatology]

CME-Rheuma 21: Precision Medicine - Synovial Biopsy in Rheumatology Abstract. Synovial biopsy is increasingly performed in the medicine of the musculoskeletal system. On the one hand it allows the in-depth diagnosis of unclear arthritides. On the other hand, there is an increasing body of publications showing that histology, immunohistochemistry and RNA analysis of synovial tissue may lead to subclassifications within rheumatoid arthritis. This in turn may have predictive value for the treatment response. We herein give a short overview of the joint biopsy technique, the basic evaluation of biopsy samples and the prospects of synovial biopsy.

Tissue-inhibitors of metalloproteinase-1 and vascular-endothelial growth-factor in severe haemophilia A children on low dose prophylactic recombinant factor VIII: Relation to subclinical arthropathy

BACKGROUND

Subclinical synovitis occur long before clinical haemophilic arthropathy (HA). New biomarkers are needed for early detection of HA.

AIM

To compare the levels of tissue inhibitors of metalloproteinase-1 (TIMP-1) and vascular endothelial growth factor (VEGF)in severe haemophilia A boys on prophylaxis and on-demand therapy to healthy boys and correlate them with the haemophilia joint health score (HJHS) & the Denver magnetic resonance imaging (MRI) scale; hence, determine their values in early detection of HA.

METHODS

Haemophilia joint health score, serum TIMP-1, VEGF and Denver MRI score were assessed in 50 boys with severe haemophilia A (31 on prophylactic factor VIII therapy (62%) with a dose of 15 IU/kg/twice weekly) and 50 age-matched healthy boys.

RESULTS

Boys with severe haemophilia A had significantly higher TIMP-1 240 ng/mL, SD200-350 (P < .001) and VEGF 600 pg/mL, SD400-1100 (P < .001). Their mean HJHS was 4.5 ± 3.0 (0-11) and their mean Denver MRI score was 5.55 ± 1.6 (2.00-8.00). A significant positive correlation was found between TIMP-1 and VEGF (P < .001), BMI Z-score (P = .029), HJHS (P = .041)and total MRI score (<.001). Significant correlations were found between VEGF and age (P < .001), HJHS (P = .003) and total MRI score (P < .001). Boys with severe haemophilia A on prophylaxis therapy had significantly lower HJHS (P = .021), VEGF (P < .001), TIMP-1 (P = .002) and total MRI score (P = .021) than those on on-demand therapy. Receiver operating characteristic curve, defined a cut-off value of 160 ng/mL for TIMP-1 with a sensitivity of 90% and specificity of 60% and that of 350 pg/mL for VEGF with a sensitivity of 78% and specificity of 88% for discrimination between severe haemophilia A and healthy boys.

CONCLUSION

Vascular endothelial growth factor and TIMP-1 can be used for early detection of HA. Further prospective studies should include larger study populations. In addition, studies should address the role of various anti-VEGFs as potential therapy for HA and their impact on prevention and treatment of HA.

Demographic, clinical, and scintigraphic comparison of patients affected by palmoplantar pustulosis and severe acne: a retrospective study

OBJECTIVE

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome encompasses heterogeneous dermatological manifestations, mainly palmoplantar pustulosis (PPP) and severe acne (SA). This study aims to explore the necessity of stratified management according to skin lesions.

METHODS

In a cohort of SAPHO patients, we compared the demographic, clinical, and scintigraphic characteristics of the SAPHO patients whose skin lesion was PPP or SA.

RESULTS

A total of 249 patients were included (227 affected by PPP and 22 affected by SA). Patients with SA were younger at onset (20, interquartile ranges (IQR) 15-30 vs. 37, IQR 30-46 years old; p < 0.001) and enrollment (35, IQR 25-38 vs. 41, IQR 33-50 years old; p = 0.001), and they had a prolonged disease duration (88.5 months, IQR 18.7-216.0 vs. 16.0, IQR 7.0-48.0 months; p < 0.001) and time needed for diagnosis (7.5, IQR 2.0-19.0 vs. 1.0, IQR 1.0-4.0 years; p < 0.001). Adjusted by age, sex, and disease duration, SA was significantly associated with more disease-modifying anti-rheumatic drug (DMARD) use (adjusted odds ratio (OR) 3.72; 95% confidence interval (CI) 1.23, 12.62; p = 0.019) and more sternoclavicular joint involvement (adjusted OR 5.91; 95% CI 1.17, 61.3; p = 0.030) in two separate Firth's logistic regression models.

CONCLUSION

SAPHO patients affected by PPP or SA as the only skin lesion may have different epidemiologic features, osteoarticular manifestations, and treatment history.Key Points• SAPHO patients with PPP or SA were heterogenous in both demographic, clinical, and imaging features.• SAPHO patients with SA were mainly male and had a significantly younger age and longer duration of symptoms before diagnosis.• SA in SAPHO patients was significantly associated with more sternoclavicular involvement and more DMARD use history.

Management of suprapatellar synovial plica, a common cause of anterior knee pain: a clinical review

BACKGROUND AND AIM OF THE WORK

Suprapatellar synovial plica is caused by a congenital thickening of the synovial membrane and is generally asymptomatic. In the literature, suprapatellar plicae are described as one of the causes of anterior knee pain however, their real role in determining symptoms is controversial. The aim of the current paper is to describe the anatomy, classifications, pathophysiology, symptoms and management of suprapatellar plica syndrome, as well as the differential diagnosis from other causes of anterior knee pain.

METHOD

Via a search within the MEDLINE/PubMed database, a current review was conducted, and the results summarized.

RESULTS

Due to idiopathic, traumatic or inflammatory conditions, plicae can become pathological, causing anterior knee pain with possible knee clicking, swelling, giving way and locking after prolonged flexion of the knee. The diagnosis should be formulated based on an accurate medical history and clinical examination, followed by an appropriate imaging study. However, arthroscopy remains the "golden standard" for detecting all synovial plica.

CONCLUSIONS

In patients with anterior knee pain, where doubt is present in the imaging investigation for intraarticular or periarticular lesions, pathological suprapatellar synovial plica must be suspected. The treatment should initially be conservative, but in cases where symptoms persist, patients should undergo arthroscopy to confirm diagnosis and to determine a suitable treatment. In the presence of pathological plica associated with cartilage damage of the femoral condyle or patella at the time of diagnostic arthroscopy, plicae excision leads to favourable results in a high number of cases.

Calculated Decisions: Kocher criteria for septic arthritis

The Kocher criteria for septic arthritis are used to distinguish between septic arthritis and transient synovitis in a child with an in amed hip.

Pattern and diagnostic evaluation of systemic autoinflammatory diseases other than familial Mediterranean fever among Arab children: a multicenter study from the Pediatric Rheumatology Arab Group (PRAG)

To define the spectrum and phenotypic characteristics of systemic autoinflammatory diseases (SAIDs) other than familial Mediterranean fever (FMF) in Arab children and to delineate diagnostic evaluation. Data retrospectively collected on patients with clinical and/or genetically proven SAIDs other than FMF at 10 tertiary Arab pediatric rheumatology clinics from 1990 to 2018. The collected data comprised the clinical findings and diagnostic evaluation including genetic testing, the provided treatment and the accrual damage related to SAIDs. A total of 144 patients (93 female) with a median age at onset of 2.5 (range 0.1-12) years were enrolled. The initial diagnosis was inaccurate in 49.3%. Consanguinity rate among parents was 74.6%. The median time-to-diagnosis for all SAIDs was 2.5 (range 0.1-10) years. There were 104 patients (72.2%) with a confirmed diagnosis and 40 patients with suspected SAIDs. Seventy-two had monogenic and 66 patients with multifactorial SAIDs while six patients had undifferentiated SAIDs. The most frequent monogenic SAIDs were LACC1 mediated monogenic disorders (n = 23) followed by CAPS (12), TRAPS (12), HIDS (12), and Majeed's syndrome (6). The most frequent multifactorial SAIDs was CRMO (34), followed by PFAPA (18), and early onset sarcoidosis (EOS) (14). Genetic analysis was performed in 69 patients; 50 patients had genetically confirmed disease. Corticosteroid used for 93 patients while biologic agents for 96 patients. Overall, growth failure was the most frequent accrual damage (36%), followed by cognitive impairment (13%). There were three deaths because of infection. This study shows a heterogenous spectrum of SAIDs with a high number of genetically confirmed monogenic diseases; notably, LACC1 associated diseases. Hopefully, this work will be the first step for a prospective registry for SAIDs in Arab countries.

Synchronous Occurrence of Bazex Syndrome and Remitting Seronegative Symmetrical Synovitis with Pitting Edema Syndrome in a Patient with Lung Cancer

A 69-year-old man developed bilateral polyarthritis, edematous extremities, and skin desquamation on the fingers and ears. He did not meet the criteria for any connective tissue disease, including rheumatoid arthritis. An examination revealed advanced lung cancer. His systemic manifestations were attributed to paraneoplastic Bazex syndrome and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome. Treatment with pembrolizumab (an anti-programmed death-1 antibody) for lung cancer relieved his symptoms and shrank the lung tumor. Bazex and RS3PE syndromes are rare paraneoplastic diseases. We herein report this unique case of synchronous development of these two paraneoplastic syndromes in the presence of advanced lung cancer.

Overweight and obesity affect clinical assessment of synovitis in rheumatoid arthritis: comparison of ultrasonography and clinical exam

OBJECTIVES

Body mass index (BMI) might affect rheumatoid arthritis (RA) outcomes. Clinical assessment of swollen joint count (SJC) might also be affected by obesity in terms of obesity-related excess adipose tissue. In this study, we compared ultrasonography (US) and clinical examination in assessing the effect of BMI on RA disease activity assessment.

METHODS

This was a single-centre study including RA (ACR/EULAR criteria) patients. US assessment was performed by one trained rheumatologist blinded to clinical data. US synovitis was defined as grey-scale score ≥2 and/or power Doppler score ≥1. The primary outcome measure was difference in SJC (ΔSJC) between clinical and US assessment (US-clinical examination). The secondary outcome was to evaluate the difference between clinical and US assessment of the Disease Activity Score in 28 joints (ΔDAS28) in the 3 BMI subgroups according to the WHO classification.

RESULTS

We included 76 RA patients (mean age 53.8 ± 11.8 years; 67% female). Overall, 28 (36.8%), 33 (43.4%) and 15 (19.7%) were normal weight, overweight and obese, respectively. Baseline characteristics did not differ between the 3 BMI subgroups. US-determined SJC was significantly higher than clinical-determined SJC for overweight and obese RA patients: p=0.001 and p=0.049, respectively. The DAS28 was higher with US than clinical examination within the overweight group only (p=0.002). One-way analysis of variance (ANOVA) revealed a significant difference between ΔDAS28 among the 3 BMI subgroups (p=0.046).

CONCLUSIONS

In high BMI RA patients both SJC and DAS28 seem to be undervalued by clinical assessment when compared to US.

Identifying Predictive Factors of Pediatric Septic Arthritis of the Knee in a Lyme Endemic Area

BACKGROUND

Septic arthritis of the knee in the pediatric patient is a diagnosis that requires prompt identification and treatment. The purpose of this study was to identify clinical and laboratory parameters that allow differential diagnosis of septic arthritis from non-septic arthritis in children.

METHODS

Fifty-four pediatric patients with atraumatic isolated knee pain were retrospectively identified at three institutions and diagnosed with septic arthritis (SA, N = 28), Lyme arthritis (LA, N = 11), or transient synovitis (TS, N = 15). Clinical and laboratory data were analyzed to identify which factors were most predictive of SA of the knee.

RESULTS

Fever at time of presentation, a negative anti-streptolysin-O (ASO), erythrocyte sedimentation rate (ESR) > 40 mm/hr, and C-reactive protein (CRP) > 20 mg/L were the most predictive factors for distinguishing between septic arthritis (SA) and non-septic arthritis (transient synovitis or Lyme arthritis). Elevated ESR and CRP were both significantly higher in patients with SA when compared to TS or LA.

CONCLUSION

When evaluating children with atraumatic isolated knee pain, a combination of the above factors should be utilized when ruling out septic arthritis.

The Tumor-Like Phenotype of Rheumatoid Synovium: Molecular Profiling and Prospects for Precision Medicine

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by destructive hyperplasia of the synovium. Fibroblast-like synoviocytes (FLS) are a major component of synovial pannus and actively participate in the pathologic progression of RA. How rheumatoid FLS acquire and sustain such a uniquely aggressive phenotype remains poorly understood. We describe the current state of knowledge of the molecular alterations in rheumatoid FLS at the genomic, epigenomic, transcriptomic, proteomic, and metabolomic levels, which offers a means to reconstruct the pathways leading to rheumatoid pannus. Such data provide new pathologic insight and suggest means to more sensitively assess disease activity and response to therapy, as well as support new avenues for therapeutic development.

Carpal synovitis with capitate bone tuberculosis in a child

We present a 10-year-old boy with 2-month duration non-traumatic wrist pain and inflammatory signs. Due to elevated inflammatory markers on blood tests, with an increase in radiocarpal and intercarpal joints synovial fluid and no bony lesions, the patient was submitted to wrist arthrocentesis for the suspicion of septic arthritis. The patient did not improve on conventional treatment, however. An MRI showed synovitis around the carpus and a lytic lesion of the capitate bone due to osteomyelitis. A biopsy was able to identify the causative agent as Mycobacterium tuberculosis, and the patient was treated with antibiotics. He improved significantly, with no pain and signs of normal capitate bone remodelling on the last radiograph.