Prominent midfoot involvement in children with enthesitis-related arthritis category of juvenile idiopathic arthritis

Advances in the Diagnosis and Treatment of Enthesitis-Related Arthritis

Enthesitis-related arthritis (ERA) represents 5-30% of all cases of juvenile idiopathic arthritis (JIA) and belongs to the spectrum of the disorders included in the group of juvenile spondyloarthritis. In the last decade, there have been considerable advances in the classification, diagnosis, monitoring, and treatment of ERA. New provisional criteria for ERA have been recently proposed by the Paediatric Rheumatology INternational Trials Organisation, as part of a wider revision of the International League of Associations for Rheumatology criteria for JIA. The increased use of magnetic resonance imaging has shown that a high proportion of patients with ERA present a subclinical axial disease. Diverse instruments can be used to assess the disease activity of ERA. The therapeutic recommendations for ERA are comparable to those applied to other non-systemic JIA categories, unless axial disease and/or enthesitis are present. In such cases, the early use of a TNF-alpha inhibitor is recommended. Novel treatment agents are promising, including IL-17/IL-23 or JAK/STAT pathways blockers.

Comparison of clinical characteristics between adult-onset and juvenile-onset non-radiographic axial spondyloarthritis in Chinese patients: results from the COCAS cohort

BACKGROUND

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease predominantly affecting the axial skeleton. We aimed to describe the clinical characteristics of patients with non-radiographic axSpA (nr-axSpA) in China and compare the differences between adult- and juvenile-onset cases.

METHODS

A cross-sectional study was conducted using data from 776 patients with nr-axSpA in the Clinical Characteristic and Outcome in Chinese Axial Spondyloarthritis (COCAS) study cohort. Patients were divided into two groups including the adult-onset group (n = 662) and the juvenile-onset group (n = 114) according to age at disease onset. Baseline demographics and clinical characteristics were compared between patients with adult-onset and juvenile-onset nr-axSpA.

RESULTS

Overall, the male-to-female ratio was 1.26:1, the prevalence of HLA-B27 positivity was 72.2%, and the median age at disease onset of nr-axSpA was 22 years. Nearly 75% of nr-axSpA patients had peripheral arthritis in the disease course, and the prevalence of extra-articular manifestations was 10.4%. The juvenile-onset group contained a higher proportion of men (66.7% vs. 53.9%, P = 0.011) and a longer baseline disease duration (4.0 [4.0] vs. 1.6 [3.5], P < 0.001) than the adult-onset group. A family history of spondyloarthritis was more frequent in the juvenile-onset group than in the adult-onset group (23.7% vs. 15.4%, P = 0.028), but no significant difference in the prevalence of HLA-B27 positivity was observed between the two groups (P = 0.537). Regarding initial symptoms, peripheral arthritis occurred more often in patients with juvenile-onset nr-axSpA, whereas patients with adult-onset nr-axSpA presented more frequently with axial involvement. The prevalence of inflammatory back pain (IBP) was higher in the adult-onset group than in the juvenile-onset group (85.0% vs. 75.4%, P = 0.010), whereas the juvenile-onset group showed a higher prevalence of peripheral arthritis and enthesitis than the adult-onset group (67.5% vs. 48.5%, P < 0.001; 35.1% vs. 23.3%, P = 0.007, respectively).

CONCLUSIONS

Compared with adult-onset nr-axSpA, juvenile-onset nr-axSpA was more common in men and those with a family history of spondyloarthritis. Juvenile-onset nr-axSpA presents with a "peripheral predominant" mode at disease onset and a higher frequency of peripheral arthritis and enthesitis during the disease course.

Ultrasound and MRI of the foot in children and adolescents newly diagnosed with juvenile idiopathic arthritis

Aim

To evaluate the spectrum of inflammatory features in foot joints which may be detected on routinely performed ultrasound (US) and magnetic resonance imaging (MRI) in children newly diagnosed with juvenile idiopathic arthritis (JIA).

Material and methods

Two groups of children hospitalized in a reference center for rheumatology, newly diagnosed with JIA and suspected of foot involvement in the course of JIA were included in this retrospective study. In the first group of 47 patients aged 1-18 years, the imaging was restricted to US. The second group of 22 patients aged 5-18 years underwent only non-contrast MRI of the foot.

Results

The most frequent pathologies seen on US included effusion and synovial thickening in the first metatarsophalangeal joint (MTP1), followed by the tibiotalar joint. Synovial hyperemia on color Doppler US images was present most frequently in the Chopart and midtarsal joints (64%; 7/11 cases), followed by the tibiotalar joint (45%; 5/11), and MTP2-5 joint synovitis (40%; 4/10). Grade 3 hyperemia was present only in four cases; grades 1 and 2 were detected in the majority of cases. On MRI, bone marrow edema was the most frequent pathology, found mostly in the calcaneus (45%; 10/22 cases), while alterations of the forefoot were rare. No cases of bursitis, enthesitis, cysts, erosions or ankylosis were diagnosed in either of the analyzed groups.

Conclusions

Routine US of the foot is recommended for early detection of its involvement in JIA in daily clinical practice. Although MRI can identify features of various JIA stages, it is particularly useful for the detection of bone marrow alterations.

Predictors of long-term functional outcomes of juvenile idiopathic arthritis-enthesitis-related arthritis: a single centre experience

OBJECTIVES

Long-term functional outcomes in enthesitis-related arthritis (ERA) is limited from developing countries. We assessed the clinical and genetic factors that predicted the long-term functional outcome in ERA.

METHODS

Patients with ERA having ≥5 years of disease and >16 years of age were included in this cross-sectional study. Data on clinical features within 6 months of disease onset was collected from hospital records. Bath indices, HAQ Disability Index (HAQ-DI) and World Health Organization's Quality of Life (WHO-QOL) were assessed at last visit. Poor functional outcome (PFO) was defined as BASFI > 1.5 or HAQ-DI > 1. Persistent disease activity (PDA) was defined as BASDAI ≥ 4. Endoplasmic reticulum aminopeptidase 1 (ERAP1) and IL-23 receptor single nucleotide polymorphism genotyping was performed with the TaqMan method and HLA-B27 by PCR.

RESULTS

One hundred and eighty-one patients [170 male, median (interquartile range) age of disease onset 12.5 (10-15) years, disease duration 7 (5-11) years] were recruited. There was a delay in diagnosis of 3 (1-5) years. The median Ankylosing Spondylitis Disease Activity Score (ASDAS)-ESR, BASDAI, HAQ-DI and BASFI at inclusion were 2.6 (1.8-3.6), 2.6 (1-5.2), 0.5 (0-0.5) and 1.6 (0.3-3.2), respectively. BASFI and HAQ-DI correlated with ASDAS-ESR, ASDAS-CRP and WHO-QOL-BREF. Those with PFO (n = 98) had a longer delay in diagnosis (4 vs 2 years, P < 0.001), lower prevalence of arthritis at onset [odds ratio (OR) = 0.3; 95% CI: 0.1, 0.8], higher prevalence of ERAP1 (rs27044) allele C (OR = 7.2; 95% CI: 1.5, 33.7) and higher disease activity currently. Delay in diagnosis (OR = 1.2; 95% CI: 1.08, 1.4) was the sole predictor of PFO in multivariate analysis. One-third of patients had PDA. Tarsitis at disease onset was the sole predictor of PDA (OR = 2.3; 95% CI: 1.009, 5.4).

CONCLUSIONS

PFO was seen in one-half of JIA-ERA in the long-term and was associated with active disease with delay in diagnosis as its sole predictor.

Recent updates in enthesitis-related arthritis

Enthesitis-related arthritis (ERA) is a category of juvenile idiopathic arthritis which belongs to the spectrum of diseases that are included in juvenile spondyloarthropathy. In recent years, there have been significant advances in understanding pathogenesis, tools to assess disease activity, early recognition of the axial disease, and targeted therapy using IL-17 inhibitors and small molecule inhibitors. The current narrative review highlights these new advances. Among many hypotheses linking HLA B27 to ERA, one of them is the effect of HLA B27 on gut dysbiosis. However, recent data suggest that gut dysbiosis is probably not determined by HLA B27. Though children present with arthritis and enthesitis, axial disease is present in 50-60% on MRI. Using data-driven approach, discriminative MRI finding for active and chronic diseases has been defined for children. This will help in the early recognition of disease. An abridged version of juvenile spondyloarthropathy disease activity (JSpADA) score without the need for acute phase reactants and Schober test performed as well as the original score may increase its acceptance in routine practice. Secukinumab (anti-IL-17 antibody) has shown a more than 75% response rate in children with ERA and may be a good alternative to anti-TNF therapy. Initial data with tofacitinib also look promising. All these will translate into better outcomes for children with ERA.

MRI and Sonography of the Knee in Acute Reactive Arthritis: An Observational Cohort Study

INTRODUCTION

Reactive arthritis (ReA) is a unique subgroup of spondyloarthritis with acute presentation and tendency to develop chronicity. Magnetic resonance imaging (MRI) has enabled identification of sensitive markers of response to therapy.

METHODS

A longitudinal pilot study of acute ReA with knee joint involvement satisfying the Braun's criteria was undertaken. Magnetic resonance imaging of the knee was assessed at baseline, and agreement with ultrasonography was assessed. Clinical details were recorded using a detailed and structured case record form. Patients were followed up, and MRI predictors of transition to chronic arthritis were looked for.

RESULTS

In 25 patients with ReA, synovial thickening was the most common feature. Enthesitis was observed on MRI in 20%. Urethritis-related and HLA-B27-positive ReA had higher synovial thickening scores (p = 0.007). Agreement was poor between MRI and ultrasonography (synovial hypertrophy: k = 0.04). On follow-up, 34% (n = 7/21 for >12 months) continued to have active disease. None of the clinical or radiological features were predictive of chronicity.

CONCLUSIONS

Posturethritis and B27-positive ReA was more severe than postenteritis ReA and RA on MRI. One third develop chronic disease on follow-up. Magnetic resonance imaging is superior to sonography, although baseline imaging is not predictive of chronicity. The results of this pilot exploratory study argue for larger studies on MRI in ReA.

Ankle Magnetic Resonance Imaging in Juvenile Idiopathic Arthritis Versus Non-Juvenile Idiopathic Arthritis Patients with Arthralgia

This retrospective case–control study aimed to evaluate whether Magnetic Resonance Imaging (MRI) enables differentiation of ankle arthritis in Juvenile Idiopathic Afrthritis JIA from ankle arthralgia of unknown aetiology in patients clinically suspected of JIA. Forty-four children, at ages 5–16, who underwent MRI of the ankle from January 2016 to March 2021 for clinically suspected active ankle arthritis in the course of JIA were included. MRI findings in both groups—patients with the final diagnosis of JIA and without final diagnosis of JIA—were compared and scored. The sum of the scores of 22 ankle lesions in an individual patient (active, destructive and developmental), so-called the MRI summarized score, was calculated and tested in terms of the most optimal diagnosis of JIA. Interobserver agreement was calculated. Inflammatory features were seen on MRI in 38 out of all the included patients (86%). The most common lesions in both groups were effusion in the tibio-talar joint (68% in JIA and 64% in the arthralgia group) and effusion in subtalar joint (64% in JIA vs. 59% in the arthralgia group). In general, more lesions were identified in the JIA group than in non-JIA. However, only tenosynovitis was significantly more common in the JIA vs. non-JIA group (p = 0.031). The MRI summarized score did not allow for discrimination between ankle arthritis in JIA from non-JIA patients; the best levels of sensitivity (32%), specificity (91%), positive predictive value PPV (78%) and negative predictive value NPV (57%) were achieved only at the cut-off point of 10.

Update on Juvenile Spondyloarthritis

Spondyloarthritis (SpA) is a blanket term encompassing entities such as enthesitis-related arthritis, nonradiographic axial SpA, and ankylosing spondylitis. These diseases share many clinical features, including a predilection for inflammation of the entheses and the sacroiliac joints. The nomenclature is based on the evolution of the classification of the disease and the age of the patient. SpA has a prevalence of approximately 1% of the population of the United States, with 10% to 20% of patients experiencing the onset during childhood. Children with onset of arthritis before age 16 years are classified as having juvenile idiopathic arthritis. Children with enthesitis and/or sacroiliitis are further classified as belonging to the enthesitis-related arthritis subtype of juvenile idiopathic arthritis. The initial manifestations can be subtle and will usually include a peripheral pattern of arthritis and enthesitis. It may take several years for axial disease to develop in children. Except for an association with the human leukocyte antigen (HLA-B27) serotype, there are no laboratory markers for the disease, and the radiographic findings are often negative. A careful clinical evaluation for evidence of inflammation in the entheses and the joints and a search for comorbidities are required. Magnetic resonance imaging facilitates the early detection of sacroiliitis, an important feature that may be clinically silent. Because recent studies indicate that earlier introduction of therapy can help achieve better outcomes, rapid identification and treatment of children with SpA is essential.

Recent Updates in Juvenile Spondyloarthritis

Spondyloarthritis represents a group of disorders characterized by enthesitis and axial skeletal involvement. Juvenile spondyloarthritis begins before age 16. Joint involvement is usually asymmetric. Bone marrow edema on noncontrast MRI of the sacroiliac joints can facilitate diagnosis. The most significant risk factor for axial disease is HLA-B27. Most patients have active disease into adulthood. Enthesitis and sacroiliitis correlate with greater pain intensity and poor quality-of-life measures. Tumor necrosis factor inhibitors are the mainstay of biologic therapy. Although other biologics such as IL-17 blockers have shown benefit in adult spondyloarthritis, none are approved by the US Food and Drug Administration.

Outcomes in Juvenile-Onset Spondyloarthritis

Some studies have suggested children with juvenile onset spondyloarthritis (JoSpA) have a relatively poor outcome compared to other juvenile idiopathic arthritis (JIA) categories, in regards to functional status and failure to attain remission. Thus, in the interest of earlier recognition and risk stratification, awareness of the unique characteristics of this group is critical. Herein, we review the clinical burden of disease, prognostic indicators and outcomes in JoSpA. Of note, although children exhibit less axial disease at onset compared to adults with spondyloarthritis (SpA), 34–62% have magnetic resonance imaging (MRI) evidence for active inflammation in the absence of reported back pain. Furthermore, some studies have reported that more than half of children with “enthesitis related arthritis” (ERA) develop axial disease within 5 years of diagnosis. Axial disease, and more specifically sacroiliitis, portends continued active disease. The advent of TNF inhibitors has promised to be a “game changer,” given their relatively high efficacy for enthesitis and axial disease. However, the real world experience in various cohorts since the introduction of more widespread TNF inhibitor usage, in which greater than a third still have persistently active disease, suggests there is still work to be done in developing new therapies and improving the outlook for JoSpA.

The Development of Extra-Articular Manifestations in Children With Enthesitis-Related Arthritis: Natural Course or Different Disease Entity?

Introduction: Enthesitis-related Arthritis (ERA) is a specific category of juvenile idiopathic arthritis (JIA) characterized by axial and/or peripheral arthritis, and enthesitis, although other different extra-articular manifestations may encompass its clinical spectrum.

Materials and Methods: In order to examine if ERA-JIA with extra-articular involvement may represent a different entity from ERA without extra-articular involvement, we performed a retrospective, observational, monocentric study, in a cohort of ERA patients followed between 2001 and September 2020 at the Pediatric Rheumatology Unit of Meyer Children Hospital of Florence. We analyzed the demographic, clinical, laboratory and imaging data at the disease onset, as well as after 3, 6, and 12 months follow up.

Results: We have enrolled 53 patients, 33 males. At the time of diagnosis, average age was 10.9 years, 53 patients had active arthritis and 25 active enthesitis. The middle foot involvement was present in 20 patients. Twenty-five children achieved clinical remission on medication. Extra-articular manifestations were observed in 14 patients, of whom 3 had inflammatory bowel disease, 5 uveitis, one uveitis associated with Crohn disease, 4 SAPHO syndrome, one celiac disease. The cohort was stratified according to the presence/absence of extra-articular manifestations. It was observed that middle foot involvement was more frequent in patients with no extra-articular manifestations (18/39 vs. 2/14; χ² = 4.45, p = 0.05). Additionally, patients presenting extra-articular manifestation needed more frequently (12/14 vs. 21/39, χ²= 4.45, p = 0.05), and preciously (months: 3.7 ± 5.4 vs. 16.7 ± 26.5, p = 0.02), treatment with biologic agents. Finally, these patients achieved belatedly (months: 31.6 ± 32.3 vs. 22.9 ± 18.3, p = 0.01) and less frequently (3/14 vs. 22/39; χ²= 5.50, p = 0.03) the clinical remission on medication. Eventually, extra-articular involvement inversely correlated with the middle-foot arthritis (ρ_s −0.29, p = 0.03), the chance to achieve remission on medication (ρ_s −0.31 e p = 0.02), as well as the chance to keep overall remission, with and without medication (ρ_s −0.28, p = 0.04).

Conclusion: In our cohort, children diagnosed with ERA-JIA at the onset of disease and then developed extra-articular manifestations show the absence of middle foot involvement and worse prognosis with an early need for the use of biologic agents, and overall low chance to achieve remission.

Midfoot Arthritis in Children: Is There Any Relation With Malignancy?

Background:

Musculoskeletal symptoms are a presenting manifestation in a number of lymphoproliferative disorders including leukemia, especially in children. Among these primary symptoms, midfoot arthritis seems to be an important alarm for malignancy in children. The aim of this study is evaluation association of midfoot arthritis with malignancy in children.

Method:

In this cross-sectional study, all medical records of patients with arthritis were identified and reviewed. All clinical and laboratory data were recorded in the information form and data were analyzed by SPSS 25 software.

Results:

A total of 557 cases of arthritis were evaluated, of which 18 (3.2%) cases have primary symptoms of midfoot arthritis. Four of 18 patients (22.2%) had B-cell precursor acute lymphoblastic leukemia, that midfoot arthritis was their first manifestation. Also, their laboratory findings confirmed that platelet, lactic acid dehydrogenesis, and uric acid values were significantly higher in these children. Based on statistical evaluation, there was no significant difference between age and sex in these patients.

Conclusion:

According to the findings of the present study, it can be concluded that “midfoot arthritis” may be the first manifestation of leukemia in children even with a near-normal hematologic values.

Musculoskeletal ultrasound in children: Current state and future directions

Juvenile idiopathic arthritis (JIA) is a heterogeneous group of chronic inflammatory arthritides that if inadequately treated, may be associated with chronic disability and deformity. Early diagnosis and treatment initiation is essential in the management of patients with JIA. Conventional means of evaluation of disease presence, disease activity and response to therapy including physical exam, labs and x-rays are at times limited and may be insufficient in making an accurate assessment. Musculoskeletal ultrasound (MSUS) is a well-established modality that is patient and family-friendly, non-invasive, does not require sedation and can be performed at the bedside in real-time. MSUS offers information that cannot be attained by standard outcome measures, and may help to advance both diagnosis and treatment of patients with JIA ultimately improving patient outcomes. This review explores the background of MSUS and the current evidence to support its potential role as a diagnostic, disease activity monitoring and interventional tool.

Juvenile Spondyloarthritis: A Distinct Form of Juvenile Arthritis

Juvenile spondyloarthritis (SpA) is a distinct form of juvenile arthritis characterized by male predominance and adolescent onset. Clinical manifestations include lower extremity and sacroiliac joint arthritis, enthesitis, and subclinical gastrointestinal inflammation. Juvenile SpA is an immune-mediated inflammatory disease long recognized as associated with HLA-B27, which may be related to the microbial environment as suggested by its coexistence with reactive arthritis and psoriasis. Treatment of peripheral arthritis includes nonsteroidal anti-inflammatory drugs, joint injections, and disease-modifying agents, whereas treatment of axial disease may necessitate a tumor necrosis factor inhibitor biologic agent. Fewer than half of children achieve remission off medication 5 years after diagnosis.