Subclinical joint involvement in psoriasis: magnetic resonance imaging and X-ray findings

Sclerodermic hand: a retrospective study on the role of ultrasonography in the detection of subclinical joint involvement

INTRODUCTION

The inflammatory involvement of joints and tendons is common in Systemic Sclerosis (SSc). Ultrasonography (US) is a non-invasive tool commonly applied for the assessment of the main inflammatory arthropathies and could be also used in identifying pathological features in SSc patients, even without clinical evidence of joint complaint. So, the aim of this study was to assess the prevalence of US pathological features in a cohort of SSc patients and assessed the role of US in the detection of subclinical joint involvement.

METHODS

In this retrospective study, we collected data about the prevalence of US pathological features at the level of hands and wrists in a cohort of patients with a definite diagnosis of SSc, submitted to an ultrasound examination of hands and wrists according to the clinician's opinion, with or without joint involvement symptoms, in order to assess the US ability in detecting subclinical inflammatory signs in SSc patients.

RESULTS

In total, 47.5% of patients reported at least one US pathological feature. The most common was synovial hypertrophy (62.1%). Other assessed lesions were effusion (48%), tenosynovitis (37.9%), power Doppler (PD) signal (31.0%), and erosions (0.7%). Effusion and PD signal appeared significantly higher in symptomatic patients, with a p<0.01 and p=0.045, respectively.

CONCLUSIONS

In this cohort of SSc subjects, almost the half of the US-positive patients were clinically asymptomatic. Therefore, the application of US could be useful to detect the musculoskeletal involvement of SSc patients, a potential markers of disease severity. Further studies are required to assess the role of US in monitoring SSc patients. Key Points • The inflammatory involvement of joints and/or tendons is common in systemic sclerosis (SSc) but could be partially covered by other disease features. • Among the diagnostic methods able to increase the sensitivity of the musculoskeletal evaluation, Ultrasonography (US) is one of the most promising to reveal subclinical inflammation and predict the joint damage progression. • We retrospectively investigated the prevalence of US pathological features in a cohort of SSc patients, with or without symptoms of joint involvement, assessing the role of US in the detection of subclinical joint involvement. • We found that joint and tendon involvement, a potential marker of disease severity, is common in SSc.

Concepts of Entheseal Pain

Pain is the main symptom in entheseal diseases (enthesopathies) despite a paucity of nerve endings in the enthesis itself. Eicosanoids, cytokines, and neuropeptides released during inflammation and repeated nonphysiologic mechanical challenge not only stimulate or sensitize primary afferent neurons present in structures adjacent to the enthesis, but also trigger a "neurovascular invasion" that allows the spreading of nerves and blood vessels into the enthesis. Nociceptive pseudounipolar neurons support this process by releasing neurotransmitters from peripheral endings that induce neovascularization and peripheral pain sensitization. This process may explain the frequently observed dissociation between subjective symptoms such as pain and the structural findings on imaging in entheseal disease.

Diagnosis and Intervention in Early Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disorder that affects approximately 20–30% of patients with psoriasis. PsA causes deformities and joint damage, impairing quality of life and causing long-term functional disability. Several recent studies demonstrated that early diagnosis and intervention for PsA prevents permanent invalidity. However, the clinical features of PsA vary and are shared with other differential diseases, such as reactive arthritis, osteoarthritis, and ankylosing spondylitis. The common and overlapping features among these diseases complicate the accurate early diagnosis and intervention of PsA. Therefore, this review focuses on the current knowledge of the diagnosis of early PsA and discusses the meaning of early intervention for early PsA.

Nail and enthesis assessment in patients with psoriatic disease by high frequency ultrasonography: findings from a single-centre cross-sectional study

PURPOSE

To characterize nail and enthesis abnormalities using high frequency ultrasound (HFUS) in patients with psoriasis (PSO), psoriatic arthritis (PSA) with PSO, and PSA sine PSO.

MATERIAL AND METHODS

Patients with PSO, PSA with PSO, and PSA sine PSO were evaluated and compared in a cross-sectional single centre study. Nail and enthesis abnormalities were evaluated by HFUS using high frequency probes (27 MHz). After a descriptive assessment, Brown University Nail Enthesis Scale (BUNES) and Madrid Sonography Enthesitis Index (MASEI) were used to assess nail and enthesis, respectively.

RESULTS

Fifty-nine patients were enrolled (19 PSO, 22 PSA with PSO, 18 PSA sine PSO). In patients with PSO and in those with PSA and PSO, HFUS evaluation identified the following nail alterations characterised by thickened matrix, inhomogeneous echogenicity of the nail bed, and increased blood flow by power Doppler. In 38.9% patients with PSA sine PSO, a subclinical nail involvement was described. No difference was observed comparing BUNES values in three groups. In PSA patients with PSO and in those with PSA sine PSO, HFUS assessment of entheses mainly showed a hypoechoic aspect and thickness of the tendon, focal cortical erosion, and ossification. A subclinical enthesis involvement in 47.4% patients with PSO was observed. No difference was reported comparing MASEI values in three groups.

CONCLUSION

Qualitative and quantitative abnormalities of nail and enthesis were demonstrated by HFUS in patients with PSO, PSA with PSO, and PSA sine PSO, suggesting a practical additional tool to be used in clinical settings. Furthermore, HFUS highlighted a subclinical nail involvement in patients with PSA sine PSO and enthesis subclinical alterations in patients with PSO.

Role of diagnostic imaging in psoriatic arthritis: how, when, and why

Psoriasis is a common skin disease. Up to 30% of patients with psoriasis develop psoriatic arthritis (PsA) resulting, by far, the most prevalent coexisting condition. Heterogeneity of clinical and radiological presentation is a major challenge to diagnosis of PsA. Initial reports about PsA emphasized a benign course in most patients, but it is now recognized that psoriatic arthritis often leads to impaired function and a reduced quality of life. PsA is a progressive disease characterized by diverse clinical features, often resulting in diagnostic delay and treatment that are associated with poor clinical and structural outcomes. New effective treatments may halt PsA progression, and consequently, treatment goals have evolved from simple reduction of pain to achieving full remission or minimal disease activity. This emerging treat-to-target strategy paradigm emphasize a need for early diagnosis; sensitive imaging techniques may be of value in this process. While radiography and CT depict structural damage, US and MRI have emerged as helpful tools to evaluate magnitude and severity of active inflammatory lesions. This review aims to describe the role of imaging modalities in diagnosis, follow-up and prognosis of PsA.

Quality of life and its relation to periarticular bone changes in psoriatic patients with or without joint involvement

OBJECTIVES

To assess periarticular bone changes in psoriasis patients with or without joint involvement and its effect on patients' quality of life (QoL).

METHODS

This cross-sectional study enrolled 50 patients with psoriasis (25 only with skin psoriasis (PsO) and 25 with psoriatic arthritis (PsA)), as well as 25 healthy controls. All participants were analyzed by high-resolution computed tomography (HR-CT) scans of the dominant hand (second and third metacarpophalangeal joints) for detection of new bone formation (enthesophytes) and erosions. Demographic, laboratory, clinical, and disease-specific data, including physical function and QoL, were collected.

RESULTS

Physical function and QoL scores were significantly worse in the PsA patients than in the PsO patients. All 25 PsA patients (100%), 18 PsO patients (72%), and 5 healthy individuals (20%) had periarticular bone changes. Statistically significant higher erosion number and volume as well as higher enthesophyte number and height were found in PsA patients compared to both PsO patients and controls, and in PsO patients compared to controls. In PsO patients, the number of erosions and enthesophytes had a negative correlation with some Short Form (SF)-36 sub-scores. In the PsA patients, the number of erosions had a positive correlation with psoriasis disability index, while the number of enthesophytes had a negative correlation with the general health SF-36 sub-score.

CONCLUSION

In PsO patients, there may be subclinical periarticular inflammation (erosions and enthesophytes) that raise the suspicion of occult PsA or the possibility of PsO transition to PsA and these periarticular bone changes may worsen QoL in PsO patients. Key Points • Skin psoriasis patients may have subclinical PsA. • Periarticular bone changes in PsO patients may be the early sign for uploading PsA disease. • Quality of life is highly affected in PsA than in PsO patients.

Medical imaging examination in psoriasis and early psoriatic arthritis patients: an updated systematic review and meta-analysis

Psoriatic arthritis appears in one in four skin psoriasis patients. Early detection of the presence of joint involvement and early interception of its developments may minimize long-term functional disability, and the radiological methods may be a perfect choice. To summarize and compare different imaging methods for diagnosing early-stage psoriatic arthritis and determine the necessity of joint examination in all psoriasis patients, several electronic databases, including MEDLINE and EMBASE, were searched for English language studies. A specific selection criterion followed the retrieval of studies. Thirteen studies were finally enrolled in the meta-analysis, eight of which compared the bone changes presentat on medical imaging examination between psoriasis patients without psoriatic arthritis and healthy people; three studies focused on differences between psoriatic arthritis patients and free joint involvement psoriasis patients shown on medical imaging tests. Medical imaging examination, including ultrasound (US), high-resolution peripheral quantitative CT scans (HR-pQCT), and magnetic resonance imaging (MRI), can be good choices for detecting the start of asymptomatic joint inflammation in psoriasis patients, which is essential to early detection and interception of joint damage to lower joint deformities and improve the future quality of life for patients. Additionally, the examination for psoriasis patients with arthralgia is also highly recommended.

Recent Advances in Imaging for Diagnosis, Monitoring, and Prognosis of Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory condition characterized by a strong heterogeneity and multifaceted behavior. PsA manifests in two types—axial and peripheral—which may be present at the same time. Peripheral manifestations can be further divided into the articular (arthritis) and extra-articular (i.e., enthesitis and dactylitis) subgroups. In such a complex disease, imaging is often required to characterize the type of involvement and to evaluate the radiological damage and progression of PsA. In addition, imaging plays a pivotal role in clinical practice; that is, for axial involvement. Conventional radiology has been the main standard of reference for many years. However, in recent years, there has been growing interest in different imaging modalities, such as ultrasonography (US) and magnetic resonance imaging (MRI). All these techniques play a role in the diagnosis and follow-up of patients with PsA and cover all the types of the disease. US and MRI have good sensitivities and specificities for detecting synovitis, and this may be helpful for differential diagnosis with other musculoskeletal diseases and useful in the early or preclinical phases of the disease. However, US is not useful in the diagnosis of axial PsA. In addition, other modalities have been investigated in the field of PsA imaging. Computed tomography (CT), in particular, dual energy-CT and high-resolution peripheral CT (HRpQ-CT) might play an important role in the assessment of bone damage, erosions, and new bone formation. Regarding advanced functional imaging, FDG PET/CT is another interesting technique for exploring disease activity.

Preliminary validation of the Simplified Psoriatic Arthritis Radiographic Score (SPARS)

OBJECTIVE

To develop and validate in a preliminary way a novel radiographic scoring system for psoriatic arthritis (PsA), called Simplified Psoriatic Arthritis Radiographic Score (SPARS).

MATERIALS AND METHODS

Radiographs of hands and feet were obtained from consecutive PsA patients and assessed by two readers. For each joint (30 joints in the hands, ten joints in the feet), the combination of the erosions, joint narrowing space (JNS) and bony proliferation (BP) has been assessed, giving a value of 1 for erosions presence, 1 for JNS presence, and 1 for BP presence (SPARS score range, 0-120). Reliability was assessed by calculating the intraclass correlation coefficient (ICC) and smallest detectable difference (SDD) of the readings. To determine the convergent validity, SPARS was compared to the modified Sharp/van der Heijde Score (mSvdHS) and to the Ratingen scoring system (PARS).

RESULTS

One-hundred and five hands and feet radiographs have been assessed. The inter- and intra-rater reliability were excellent (inter-rater reliability 0.934, and intra-rater reliability for both readers 0.845 and 0.876). The SDD for the average SPARS scores of the two readers was 8.0. SPARS correlated strongly with mSvdHS (r = 0.926; p < 0.0001), and PARS (r = 0.904; p < 0.0001). The mean time to score each of the mSvdHS, PARS, and SPARS was 14.4, 10.1, and 4.5 min, respectively.

CONCLUSIONS

The SPARS properties are close to those of the mSvdHS and PARS and is quicker to calculate.

Imaging in rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and osteoarthritis: An international viewpoint on the current knowledge and future research priorities

Imaging is increasingly used in the routine management of rheumatic diseases as well as in the clinical trials of these disorders. This viewpoint, authored by a group of international imaging experts following two meetings dedicated to imaging in rheumatology, reports a consensus about the current knowledge and addresses where further research should be focused based on the views of the international imaging experts and discussion of the evidence with attending imaging practitioners. The goal was to maximize the potential of imaging to improve the clinical management of four rheumatic diseases. These rheumatic diseases include rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and osteoarthritis.

Remission in psoriatic arthritis-where are we now?

Advances in treatments and treatment strategies for PsA have led to many patients responding well to management of their disease, and targeting remission as a treatment goal is now a possibility. Treat to target is a strategy aimed at maximizing benefit, irrespective of the type of medication used, by monitoring disease activity and using it to guide therapy. The measurement of response to treatment has been the subject of wide discussions among experts for some time, and many instruments exist. Comparisons of the different measures and their different strengths and weaknesses is ongoing. The impact of modern imaging techniques on monitoring disease progression is also evolving, and advanced techniques using both MRI and US have the potential to improve management of PsA through identification of risk factors for poor prognosis as well as accurate assessment of inflammation and damage, including subclinical disease. Increased understanding of the pathways that drive the pathogenesis of PsA will be key to identifying specific biomarkers for the disease and developing effective treatment strategies. Targets for response, considerations for use of a treat to target strategy in PsA, different imaging techniques and serological aspects of remission are all discussed in this review, and areas for further research are identified.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

Investigation of Enthesopathy with Ultrasonography and Comparison with Skin Findings in Asymptomatic Psoriatic Patients

BACKGROUND

Joint involvement associated with psoriasis is referred to as psoriatic arthritis. A late diagnosis of psoriatic arthritis may cause a variety of morbidities; therefore, an early diagnosis and treatment of psoriatic arthritis are required. Asymptomatic psoriatic arthritis has been found in 8-70% of patients with psoriasis using imaging techniques.

OBJECTIVE

To investigate joint and enthesis regions by ultrasonography in patients with psoriasis without inflammatory joint symptoms to detect subclinical psoriatic arthritis.

METHODS

We included 50 psoriasis patients and 30 healthy control subjects without joint complaint in this study. Twelve joint regions of all subjects in each group were examined by ultrasonography.

RESULTS

The presence of any pathological ultrasonography finding (30%) was higher but did not significantly differ in psoriasis patients compared with the control group (13.33%; p > 0.05).

CONCLUSION

Although statistically not significant, the pathological ultrasonography findings were approximately twofold more common in patients with psoriasis compared with the control group. Therefore, the development of psoriatic arthritis in patients with psoriasis should be more closely followed.

The Epidemiology of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic systemic inflammatory disorder characterized by joint and entheseal inflammation with a prevalence of 0.05% to 0.25% of the population and 6% to 41% of patients with psoriasis. PsA is a highly heterogeneous inflammatory arthritis. In this review, current knowledge is discussed regarding the epidemiology of PsA, including disease manifestations, classification criteria for adult and juvenile PsA, methods for recognizing early PsA, including use of screening tools and knowledge of risk factors for PsA, and medical comorbidities associated with PsA.

What is the prevalence of MRI-detected inflammation and erosions in small joints in the general population? A collation and analysis of published data

Introduction

MRI sensitively depicts erosions, bone marrow edema (BME) and synovitis in rheumatoid arthritis (RA). Recently developed European League Against Rheumatism (EULAR) recommendations stated that MRI is valuable to improve the certainty of a considered diagnosis and to detect structural damage at an early time point. However, these recommendations were mainly based on the data of patients with RA; prevalences of MRI features in the general population were not extensively explored. We reviewed the literature on MRI studies including symptom-free persons to assess the occurrence of MRI features.

Methods

Medical literature databases up to September 2013 were systematically reviewed for symptom-free persons with MRI data on metacarpophalangeal, wrist and metatarsophalangeal joints. Data were extracted and summarised. When allowed because of comparable scanning and scoring protocols, a mean frequency of features was calculated.

Results

Of the 338 articles screened, 31 studies evaluated MRI findings in symptom-free persons (n=516 in total). Both the imaging techniques (<1/≥1 T, with/without contrast enhancement) and the scoring methods (non-validated or RA MRI score (RAMRIS)) varied widely, prohibiting direct comparisons of the results of many studies. 15 studies scored data according to RAMRIS; combining data of similar joint regions showed that erosions (RAMRIS ≥1) were present in 33–52% of symptom-free persons. Similarly, synovitis was present in 27% and BME in 0–16% of symptom-free persons. The prevalence of MRI-detected erosions increased with age.

Conclusions

MRI features, erosions in particular, occur frequently in symptom-free persons. Before MRI can be implemented in the diagnostic process, larger studies should be conducted determining the degree and combination of MRI features that are disease specific.

Analysis of periarticular bone changes in patients with cutaneous psoriasis without associated psoriatic arthritis

Objectives

To search for structural bone changes in the joints of psoriasis patients without psoriatic arthritis (PsA).

Methods

55 psoriasis patients without any current or past symptoms of arthritis or enthesitis and 47 healthy controls were examined by high-resolution peripheral quantitative CT scans of the metacarpophalangeal joints. Number, size and exact localisation of erosions and enthesiophytes were recorded by analysing axial scans of the metacarpal heads and phalangeal bases and were confirmed in additional coronal and/or sagittal sections. In addition, we collected demographic and clinical data including subtype, duration and severity of psoriasis.

Results

Psoriasis patients showed a larger and significantly increased number of enthesiophytes (total number 306; mean±SD/patient 5.62±3.30) compared with healthy controls (total number 138; mean±SD/patient 3.04±1.81, p<0.001). Enthesiophytes were typically found at the dorsal and palmar sides of the metacarpal heads where functional entheses related to extensor and flexor tendons are localised. Bone erosions were rare and not significantly different between psoriasis patients and healthy controls. If present, erosions were almost exclusively found at the radial side of the second metacarpal head in both psoriasis patients and healthy controls.

Conclusions

Psoriasis patients without PsA show substantial signs of enthesiophyte formation compared with healthy controls. These changes represent new bone formation at mechanically exposed sites of the joint and substantiate the concept of the existence of a ‘Deep Koebner Phenomenon’ at enthesial sites in psoriasis patients.

Imaging in psoriatic arthritis

Psoriatic arthritis (PsA), a chronic inflammatory arthritis associated with psoriasis, is often associated with significant inflammation and joint damage leading to a decrease in quality of life measures. Plain radiographs have traditionally been used to detect and estimate the extent of joint damage. Newer imaging modalities such as ultrasound and MRI however, have provided the ability to detect joint damage earlier and measure the extent of joint damage more accurately, than with radiographs. These imaging modalities also provide a sensitive means of assessing for the presence of and quantifying the amount of inflammation. Furthermore, these imaging modalities can help with the identification of enthesitis, tendonitis, and dactylitis, features that can help make a diagnosis of PsA. Additionally, MRI and scintigraphy can help in the early detection and assessment of sacroiliitis and axial disease. In addition to benefits with diagnosis and prognosis, recent advances in imaging techniques have led to their increased use in the assessment of efficacy of novel therapies for psoriatic arthritis. Imaging modalities therefore allow for early detection, assessment of joint inflammation and joint damage as well as in the estimation of disease activity of PsA and thereby enable the clinician to treat PsA early, adequately, and safely.

MRI and ultrasonography for diagnosis and monitoring of psoriatic arthritis

Imaging techniques such as magnetic resonance imaging (MRI) and ultrasound (US) have been increasingly used in psoriatic arthritis (PsA) providing additional clues to the pathogenesis of this peripheral, axial and dermatologic disease. This has improved our understanding of the disease and can be used to aid diagnosis and then to follow outcomes of treatment. Both imaging modalities have highlighted the differing involvement of PsA when compared with rheumatoid arthritis (RA) with a significant burden of entheseal disease, flexor tenosynovitis (occurring alone or as part of dactylitis) and other extra-capsular inflammatory changes. MRI scanning has also highlighted the link between the nail and the distal interphalangeal (DIP) joint confirming previous clinical observations. Imaging studies in psoriasis patients have discovered a high level of subclinical inflammatory change but the clinical importance of such findings has not yet been defined. The potential use of MRI and US to monitor treatment outcomes has encouraged research in this field. In MRI, the PsA MRI Score (PsAMRIS) has been developed with promising initial validation. In US, work is ongoing with the OMERACT group to define key pathologies and to develop scoring systems. A few scoring systems are available for enthesitis scoring using US which are further being developed and refined. Further improvements in technologies in both of these fields offer exciting possibilities for future research. New MRI techniques offer the chance to image previously 'dark' structures such as tendons which is key in spondyloarthritides (SpA). Sonoelastography may also improve our understanding of tendon involvement in SpA. Whole-body multi-joint MRI allows a 'snapshot' of inflammation in PsA including joints, entheses and spinal involvement. Three-dimensional US should improve reliability and comparability of US scoring reducing inter-operator variability. The latest machines offer real-time fusion imaging employing US machines with an in-built virtual navigator system linked to previous MRI acquisitions. All of these new techniques should aid our understanding of PsA and our ability to objectively measure response to therapy.

Recent advances in imaging in psoriatic arthritis

The recent introduction of effective therapies in psoriatic arthritis (PsA) has increased the demand for efficient tools for diagnosis, monitoring and prognostication of PsA, and has caused an increased research effort within imaging in this disease. The clinical appearance of PsA is very diverse, involving the spine, sacroiliac joints, peripheral joints and/or entheses, and accordingly imaging findings vary. In the present paper, we present a review of the recent advances in imaging in PsA, focusing primarily on ultrasonography and magnetic resonance imaging of peripheral disease manifestations.

Knee enthesitis and synovitis on magnetic resonance imaging in patients with psoriasis without arthritic symptoms

OBJECTIVE

This case-control study was designed to evaluate magnetic resonance imaging (MRI) findings of knee joints in patients with psoriasis without clinical peripheral or axial joint involvement, and to correlate MRI findings with disease and demographic variables.

METHODS

In total 48 patients with psoriasis and no clinical evidence of synovitis or enthesitis in any peripheral or axial joints were enrolled. A random sample of 20 healthy subjects without knee or other joint complaints and matched for age and sex served as controls. All patients and controls underwent enhanced MRI studies of both knee joints, and MRI findings were compared.

RESULTS

Among 48 patients (96 knees), a total of 90 entheseal lesions were detected, with no enthesitis in 2 cases (6.3%). Signs of continuing inflammation bilaterally were frequently found: soft tissue edema (STE; n = 52), bone marrow edema (BME; n = 20), perientheseal BME (n = 3), cartilaginous erosions (n = 42), and bone erosions (n = 27). In controls, 2 (10%) subjects had BME and another 5 (25%) showed cartilaginous erosions. None showed evidence of enthesitis. Significant correlations were observed between the number of entheseal lesions of both knees vs STE (present vs absent; r = 0.314, p = 0.030) and STE (number of lesions; r = 0.351, p = 0.014). Enthesitis (unilateral vs bilateral) was significantly and positively correlated with STE (r = 0.304, p = 0.036), cartilaginous erosions (r = 0.304, p = 0.036), and villous projections (r = 0.347, p = 0.016).

CONCLUSION

Subclinical synovitis and enthesitis are frequently found in the knee joint of patients with psoriasis. These may be an early sign of psoriatic arthritis.

[Diagnosis and therapy of early psoriatic arthritis]

Early diagnosis of psoriatic arthritis is of importance because an erosive disease is already detectable after a 2-year duration of symptoms. Often psoriatic arthritis cannot easily be detected because of the diversity of disease manifestations in early stages. As up to 30% of psoriasis patients develop psoriatic arthritis an interdisciplinary dermatologic/rheumatologic approach to diagnose findings and treatment decisions would be desirable. Screening tools, such as validated questionnaires allow an early detection and selection of patients with a high probability of psoriatic arthritis even in dermatological care or on a house physician basis. The implementation of the CASPAR criteria as a classification tool for psoriatic arthritis has also improved the diagnosis finding in patients with a recent onset of active musculoskeletal disease. Data from early psoriatic arthritis cohorts illustrate that drug-free remission is rare. An adequate treatment is of importance. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) has developed treatment recommendations based on the available evidence for different treatment modalities.

Magnetic Resonance Imaging in Psoriatic Arthritis — Update on Current Status and Future Perspectives: A Report from the GRAPPA 2010 Annual Meeting

The potential of magnetic resonance imaging (MRI) for use in clinical practice and research has gained increasing interest over the last decade. International collaborative initiatives from GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis) and/or OMERACT (Outcome Measures in Rheumatology) may contribute to facilitating research, identifying appropriate areas for use, and reaching consensus on the optimal examination technique. Accordingly, GRAPPA, a primary driver of international research in psoriasis and psoriatic arthritis (PsA), has focused on the current use and future development of MRI and other modern imaging modalities in PsA. This review, presented at the GRAPPA 2010 annual meeting, describes the current status of MRI in PsA, with a focus on its use in diagnosis, monitoring, and prediction of the disease course and treatment response. Important areas for future research are also outlined.

Imaging in arthritis: quantifying effects of therapeutic intervention using MRI and molecular imaging

Modern imaging techniques are becoming increasingly important in assessing the course of arthritis and in permitting measurement of response to treatment as part of the follow-up of patients. They include ultrasonography (US), MRI, PET/CT, and biofluorescence. In patients with rheumatoid arthritis, clinical evaluation is significantly less sensitive than either US or MRI in detecting synovitis. As a result, imaging is a useful alternative to achieving proper assessment of disease activity. The different areas in which the new imaging techniques could help practicing rheumatologists and internal physicians include the following: early and differential diagnosis of arthritis, evaluation of disease activity, prognosis, assessment of treatment efficacy, assessment of remission, and evaluation of subclinical disease. MRI is probably the best imaging method to study disease activity in RA, because it can study all the joints with similar efficacy, has been sufficiently standardised, and yields data on inflammation that can be quantified. Different methods, developed to score synovitis activity, are increasingly used in clinical trials. The main application of PET/CT in rheumatology is the diagnosis and follow-up of large vessel vasculitis. More recently, also RA disease activity has been evaluated, allowing a panoramic view of the patient. Molecular imaging studies molecular and cellular processes in intact living organisms in a non-invasive fashion. In fluorescence, dyes, that emit light upon excitation by a light source and are read by a camera, can be used to show inflamed areas where neoangiogenesis, vasodilatation, and increased vessel permeability are present. These dyes can be coupled with different compounds including antibodies and drugs.

Cyst-like lesions in finger joints detected by conventional radiography: comparison with 320-row multidetector computed tomography

OBJECTIVE

Many rheumatologists and radiologists routinely assess conventional radiographs of the hands, and it is often unclear how to proceed if radiography reveals only cyst-like lesions (CLLs), with otherwise normal findings. The present study was undertaken to evaluate the use of 320-row multidetector computed tomography (MDCT) of the hands in the further assessment of CLLs of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints identified on conventional radiography.

METHODS

MCP and PIP joints (n = 1,120 joints) of 56 consecutive patients (44 women [mean age 55 years, range 31-72 years] and 12 men [mean age 57 years, range 37-77 years]) were prospectively scored for the presence of cysts, CLLs, and erosions of the PIP and MCP joints, first on conventional radiographs, then on MDCT. Scoring was performed by 2 independent readers under blinded conditions. Intraclass correlation coefficients were calculated.

RESULTS

By conventional hand radiography, 13 patients (total of 260 joints assessed) were identified as having CLLs in 1 or more joints (total of 36 joints [11 PIP and 25 MCP]). By MDCT, the findings in 19 of 36 joints (53%) were diagnosed as erosions, while 7 of 36 (19%) were confirmed as true cysts, and 10 joints (28%) were normal (false positive). Among the patients with CLLs, 10 of 224 joints with no abnormality seen radiographically had erosions as seen on MDCT. Interreader agreement for erosions was 0.854 (95% confidence interval [95% CI] 0.831-0.874) by conventional hand radiography and 0.952 (95% CI 0.943-0.959) by MDCT.

CONCLUSION

Our results indicate that radiographic appearance of cyst-like lesions may actually represent erosions and should lead to initiation of further imaging tests.

High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: a prospective case-control study

OBJECTIVE

To investigate the presence of synovitis, tenosynovitis and enthesitis with power Doppler (PD) ultrasonography (US) in patients with psoriasis without musculoskeletal diseases as compared with controls with other skin diseases without musculoskeletal disorders.

METHODS

A total of 162 patients with plaque psoriasis and 60 age-matched controls with other skin diseases, all without musculoskeletal diseases, were prospectively recruited at 14 centres. They underwent dermatological and rheumatological assessment and a blinded PDUS evaluation. Clinical assessment included demographics, comorbidities, severity of psoriasis, work and sport activities and musculoskeletal clinical examination. PDUS evaluation consisted of the detection of grey scale (GS) synovitis and synovial PD signal in 36 joints, GS tenosynovitis and tenosynovial PD signal at 22 sites, and GS enthesopathy and entheseal PD signal in 18 entheses.

RESULTS

US synovitis and enthesopathy were significantly more frequent in psoriatic patients than in controls (P = 0.024 and 0.005, respectively). The percentage of joints with US synovitis was 3.2% in the psoriasis group and 1.3% in the control group (P < 0.0005). US enthesopathy was present in 11.6% of entheses in the psoriasis group and 5.3% of entheses in the control group (P < 0.0005). Entheseal PD signal was found in 10 (7.4%) psoriatic patients, whereas no controls showed this finding (P = 0.05). Among demographic and clinical data, having psoriasis was the only significant predictive variable of the presence of US synovitis [odds ratio (OR) 2.1; P = 0.007] and enthesopathy (OR 2.6; P = 0.027).

CONCLUSION

Psoriatic patients showed a significant prevalence of asymptomatic US synovitis and enthesopathy, which may indicate a subclinical musculoskeletal involvement.

Systemic and vascular inflammation in patients with moderate to severe psoriasis as measured by [18F]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT): a pilot study

OBJECTIVE

To evaluate the feasibility of using [18F]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) to detect and quantify systemic inflammation in patients with psoriasis.

DESIGN

Case series with a nested case-control study.

SETTING

Referral dermatology and preventive cardiology practices.

PARTICIPANTS

Six patients with psoriasis affecting more than 10% of their body surface area and 4 controls age and sex matched to 4 of the patients with psoriasis for a nested case-control study.

MAIN OUTCOME MEASURES

The FDG uptake in the liver, musculoskeletal structures, and aorta measured by mean standardized uptake value, a measure of FDG tracer uptake by macrophages and other inflammatory cells.

RESULTS

FDG-PET/CT identified numerous foci of inflammation in 6 patients with psoriasis within the skin, liver, joints, tendons, and aorta. Inflammation in the joints was observed in a patient with psoriatic arthritis as well as in 1 patient with no history of joint disease or joint symptoms. In a nested case-control study, FDG-PET/CT imaging demonstrated increased vascular inflammation in multiple segments of the aorta compared with controls. These findings persisted after adjustment for traditional cardiovascular risk factors in multivariate analysis (mean β = 0.33; P < .001). Patients with psoriasis further demonstrated increased hepatic inflammation after adjusting for cardiovascular risk factors (β = 0.18; P < .001), but the association was no longer significant when adjusted for alcohol intake (β = -0.25; P = .07).

CONCLUSION

FDG-PET/CT is a sensitive tool for identifying inflammation and can be used to identify clinically observed inflammation in the skin and subclinical inflammation in the blood vessels, joints, and liver of patients with psoriasis.

MRI findings in psoriatic arthritis of the hands

OBJECTIVE

The purpose of this essay is to provide a practical review of the spectrum of morphologic and functional MRI findings in psoriatic arthritis of the hand joints.

CONCLUSION

The MRI findings of psoriatic arthritis include enthesitis, bone marrow edema, and periostitis accompanying articular or flexor tendon sheath synovitis in the early stage accompanied by destructive and proliferative bony changes, subluxation, and ankylosis in the late stage.