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Szadek K, Cohen SP, de Andrès Ares J, Steegers M, Van Zundert J, Kallewaard JW. 5. Sacroiliac joint pain. Pain Pract 2024; 24:627-646. [PMID: 38155419 DOI: 10.1111/papr.13338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Sacroiliac (SI) joint pain is defined as pain localized in the anatomical region of the SI joint. The reported prevalence of SI joint pain among patients with mechanical low back pain varies between 15% and 30%. METHODS In this narrative review, the literature on the diagnosis and treatment of SI joint pain was updated and summarized. RESULTS Patient's history provides clues on the source of pain. The specificity and sensitivity of provocative maneuvers are relatively high when three or more tests are positive, though recent studies have questioned the predictive value of single or even batteries of provocative tests. Medical imaging is indicated only to rule out red flags for potentially serious conditions. The diagnostic value of SI joint infiltration with local anesthetic remains controversial due to the potential for false-positive and false-negative results. Treatment of SI joint pain ideally consists of a multidisciplinary approach that includes conservative measures as first-line therapies (eg, pharmacological treatment, cognitive-behavioral therapy, manual medicine, exercise therapy and rehabilitation treatment, and if necessary, psychological support). Intra- and extra-articular corticosteroid injections have been documented to produce pain relief for over 3 months in some people. Radiofrequency ablation (RFA) of the L5 dorsal ramus and S1-3 (or 4) lateral branches has been shown to be efficacious in numerous studies, with extensive lesioning strategies (eg, cooled RFA) demonstrating the strongest evidence. The reported rate of complications for SI joint treatments is low. CONCLUSIONS SI joint pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, corticosteroid injections and radiofrequency treatment can be considered.
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Affiliation(s)
- Karolina Szadek
- Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Steven P Cohen
- Department of Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | | | - Monique Steegers
- Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Department of Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Baraliakos X, Pournara E, Coates LC, Navarro-Compán V, Blanco R, O’Brien E, Schulz B, Landewe R. Magnetic resonance imaging characteristics in patients with psoriatic arthritis and axial manifestations from the MAXIMISE cohort. Rheumatology (Oxford) 2024; 63:85-92. [PMID: 37094184 PMCID: PMC10765145 DOI: 10.1093/rheumatology/kead162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/23/2023] [Accepted: 03/30/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE The current analysis of the MAXIMISE trial was conducted to investigate the presence of post-inflammatory and degenerative spinal changes and inflammatory changes in spinal processes identified in baseline MRIs and their potential for predicting differential treatment effects in a cohort of PsA patients with axial manifestations. METHODS Baseline spinal MRIs from the MAXIMISE trial were re-read to identify additional inflammatory (spinal process), post-inflammatory, and degenerative changes, and investigate the differential treatment effect of these imaging features using logistic regression modelling. RESULTS In addition to bone marrow oedema assessed at primary analysis, spinal process inflammation and post-inflammatory changes evaluated by FAt Spondyloarthritis Spine Score were documented in 11.1% and 20.2% patients, respectively. At least one type of degenerative change was noted in 64% patients, with Pfirrmann grade ≥3 (51.1%) being the most common. Combining primary and re-read MRI findings, 67.1% of patients presented with inflammatory or post-inflammatory changes while 21.2% had degenerative changes alone. Although not statistically significant, post-inflammatory changes were associated with a trend for better efficacy outcomes in terms of ASAS20, ASAS40 and BASDAI50 responses; a trend for worse outcomes was observed in the presence of degenerative changes. CONCLUSION The current analysis revealed the occurrence of additional inflammatory and post-inflammatory changes suggestive of axial PsA (axPsA) and a trend for better clinical outcomes for patients treated with secukinumab. These results elucidate the imaging characteristics and improve our current understanding of axPsA thereby supporting the interpretation of future trials. TRIAL REGISTRATION ClinicalTrials.gov, NCT02721966.
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Affiliation(s)
| | - Effie Pournara
- Novartis Pharma AG, Immunology, Hepatology and Dermatology, Basel, Switzerland
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Ricardo Blanco
- Divisions of Immunology, Endocrinology, and Rheumatology, Hospital University Marqués de Valdecilla, Santander, Spain
| | | | - Barbara Schulz
- Novartis Pharma AG, Immunology, Hepatology and Dermatology, Basel, Switzerland
| | - Robert Landewe
- Department of Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
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Lee YJ, Lee SH, Ahn SM, Hong S, Oh JS, Lee CK, Yoo B, Kim YG. When MRI would be useful in patients without evidence of sacroiliitis on radiographs? Rheumatol Int 2023:10.1007/s00296-023-05468-2. [PMID: 37733041 DOI: 10.1007/s00296-023-05468-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/10/2023] [Indexed: 09/22/2023]
Abstract
We aimed to identify when magnetic resonance imaging (MRI) would be useful to diagnose patients with suspected axial spondyloarthropathy (AxSpA) without evidence of sacroiliitis on radiographs. We retrospectively reviewed electronic medical records of patients who underwent pelvis MRI after radiographs at the rheumatology clinic in a single tertiary center in Korea. Patients underwent imaging from January 2020 to July 2022. We collected data including complete blood count, erythrocyte sedimentation rate, C-reactive protein (CRP), human leukocyte antigen (HLA)-B27, history of acute anterior uveitis (AAU), peripheral arthritis, dactylitis, inflammatory bowel disease (IBD), enthesopathy, and psoriasis. A total of 105 patients who showed no evidence of sacroiliitis on radiographs were included. The median age of patients was 41.0 years, and 44.8% were male. Of them, 34 showed sacroiliitis on MRI (group 1), and 71 showed no evidence of sacroiliitis even on MRI (group 2). Known AxSpA-related clinical features including AAU, peripheral arthritis, dactylitis, IBD, enthesopathy, and psoriasis were not different between the two groups. HLA-B27 positivity (79.4% vs. 40.0%, p < 0.001), median white blood cell count (7700 vs. 6300, p = 0.007), mean platelet count (307.7 ± 69.7 vs. 265.3 ± 68.9 × 103/µL, p = 0.005), and median CRP level (0.38 vs. 0.10, p = 0.001) showed significant differences between the two groups. In a multivariate analysis, HLA-B27 positivity and platelet count were significantly associated with sacroiliitis on MRI. In our cohort, sacroiliitis was observed on MRI in one-third of patients without radiographic evidence. MRI could be recommended to evaluate sacroiliitis in patients with positive HLA-B27 and a high platelet count.
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Affiliation(s)
- Yeo-Jin Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, 05505, Republic of Korea
| | - Sang Hoon Lee
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo-Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, 05505, Republic of Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, 05505, Republic of Korea
| | - Ji-Seon Oh
- Department of Information Medicine, Big Data Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, 05505, Republic of Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, 05505, Republic of Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Seoul, 05505, Republic of Korea.
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de Hooge M, Ishchenko A, De Craemer AS, Steinfeld S, Nzeusseu A, Elewaut D, Lories R, de Vlam K, Van den Bosch F. Extent of axial damage in psoriatic arthritis and spondyloarthritis: comparative data from the BEPAS and (Be-)GIANT multicentre cohorts. RMD Open 2023; 9:rmdopen-2023-002994. [PMID: 37137541 PMCID: PMC10163589 DOI: 10.1136/rmdopen-2023-002994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/02/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND To examine radiographic axial damage of the sacroiliac joints and spine in patients with psoriatic arthritis (PsA) and spondyloarthritis (SpA) in private and academic Belgian practices. METHODS Patients with PsA with clinical diagnosis of PsA and fulfilling the Classification Criteria for Psoriatic Arthritis from the prospective Belgian Epidemiological Psoriatic Arthritis Study and patients with SpA fulfilling the Assessment of SpondyloArthritis international Society classification criteria for SpA originate from the Ghent and BelGian Inflammatory Arthritis and spoNdylitis cohorTs were included in this study. Baseline pelvic and spinal radiographs were analysed by two calibrated readers. Blinded for the origin of the cohort or clinical data readers assessed the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) and modified New York criteria on spinal and pelvic radiographs, respectively. Data were compared between both patient groups. RESULTS Of the 525 patients included (312 PsA and 213 SpA), most patients showed normal spinal radiographs: 87.5% of the patients with PsA and 92.0% of the patients with SpA. Patients with SpA with spinal damage show higher mSASSS than the patients with PsA (p<0.05). In patients with PsA, cervical spine is more often affected; 24/33 patients (72.7%) compared with lumbar spine 11/33 (33.3%). While in patients with SpA, syndesmophyte location was more evenly distributed; cervical 9/14 (64.3%) and lumbar 10/14 (71.4%). CONCLUSION Minimal radiographic spinal damage was observed in Belgian patients with PsA or SpA. Patients with SpA tend to have higher mSASSS values and more syndesmophytes compared with PsA. Syndesmophytes were more often located in the cervical spine of patients with PsA, while the location was equally distributed in axSpA.
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Affiliation(s)
- Manouk de Hooge
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Molecular Immunology and Inflammation Unit, VIB-UGent Center for Inflammation Research, Zwijnaarde, Belgium
| | - Alla Ishchenko
- Department of Rheumatology, KU Leuven university Hospital, Leuven, Belgium
| | - Ann-Sophie De Craemer
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Molecular Immunology and Inflammation Unit, VIB-UGent Center for Inflammation Research, Zwijnaarde, Belgium
| | - Serge Steinfeld
- Department of Rheumatology, Clinique St Jean, Brussels, Belgium
| | - Adrien Nzeusseu
- Department of Rheumatology, St Luc University Hospitals, Brussels, Belgium
| | - Dirk Elewaut
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Molecular Immunology and Inflammation Unit, VIB-UGent Center for Inflammation Research, Zwijnaarde, Belgium
| | - Rik Lories
- Department of Rheumatology, KU Leuven university Hospital, Leuven, Belgium
- Department of Development and Regeneration, Catholic University College Leuven Skeletal Biology and Engineering Research Center, Leuven, Belgium
| | - Kurt de Vlam
- Department of Rheumatology, KU Leuven university Hospital, Leuven, Belgium
- Department of Development and Regeneration, Catholic University College Leuven Skeletal Biology and Engineering Research Center, Leuven, Belgium
| | - Filip Van den Bosch
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
- Molecular Immunology and Inflammation Unit, VIB-UGent Center for Inflammation Research, Zwijnaarde, Belgium
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Poddubnyy D. Managing Psoriatic Arthritis Patients Presenting with Axial Symptoms. Drugs 2023; 83:497-505. [PMID: 36976477 PMCID: PMC10126028 DOI: 10.1007/s40265-023-01857-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
Axial symptoms (i.e., back pain) are common in the general population. At the same time 25-70% of patients with psoriatic arthritis (PsA) exhibit signs of inflammatory axial involvement (axial PsA). The presence of unexplained chronic (duration ≥ 3 months) back pain in a patient with psoriasis or PsA should trigger evaluation of the presence of axial involvement. Evaluation of axial involvement normally involves imaging of the axial skeleton (sacroiliac joints and/or spine) in addition to clinical and laboratory evaluation. Symptomatic patients with confirmed axial PsA are treated with a combination of non-pharmacologic and pharmacologic methods including the use of non-steroidal anti-inflammatory drugs, tumour necrosis factor, interleukin 17, and Janus kinase inhibitors. Interleukin 23 blockade might also be effective in the axial domain of PsA; a dedicated clinical study is ongoing at present. Safety considerations, patient preference, as well as the presence of other disease manifestations (especially of extra-musculoskeletal manifestations-clinically relevant psoriasis, acute anterior uveitis, inflammatory bowel disease), define the choice of a specific drug or drug class.
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Affiliation(s)
- Denis Poddubnyy
- Department of Gastroenterology, Infectiology and Rheumatology (including Nutrition Medicine), Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany.
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Wang Y, Xiao Y, Li F, Gu Y, Yang M, Zhang L, Tang J, Li W. The Clinical Characteristics of Psoriatic Arthritis: A Cross-Sectional Study Based on the Psoriatic Arthritis Cohort of West China Hospital. Rheumatol Ther 2023; 10:775-784. [PMID: 36792846 PMCID: PMC10140229 DOI: 10.1007/s40744-023-00537-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION This study aims to describe the demographic, clinical, laboratory, and ultrasonic characteristics of patients with psoriatic arthritis (PsA) in the Psoriatic Arthritis cohort of West China Hospital. METHODS In this cross-sectional study, we included patients diagnosed with PsA according to the Classification Criteria for Psoriatic Arthritis, collected their demographic information, medical histories, and treatments, evaluated all domains (skin and nail lesions, tenderness, swelling, enthesitis, dactylitis, and axial arthritis) related to PsA, and then performed descriptive statistical analyses of all data. RESULTS A total of 275 patients with PsA were included in this study. The ratio of male to female patients was 2.16:1. Skin lesions preceded arthritis in 86.5% of these patients with PsA with a mean interval of 10.1 years. The metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints of fingers, and sacroiliac joints are the most commonly involved sites of tenderness, swelling, and the spine, respectively. Among all comorbidities, fatty liver has the highest incidence with 33.1%. Finally, we noted that the mean disease duration of PsA was 4.2 years, suggesting a delay in the diagnosis of PsA. CONCLUSION Our study proposes that the prevalent population of PsA are male patients with psoriasis over 40 years of age who have a long disease course. For patients with PsA, MCP, PIP joints of fingers, and sacroiliac joints are the most frequently affected anatomical sites. With respect to comorbidities, the association between PsA and fatty liver and the underlying molecular mechanisms are worthy of further exploration.
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Affiliation(s)
- Yiyi Wang
- Department of Dermatology and Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yue Xiao
- Department of Dermatology and Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Furong Li
- Department of Dermatology and Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuanxia Gu
- Department of Dermatology and Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Min Yang
- Department of Rheumatology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lingyan Zhang
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Tang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wei Li
- Department of Dermatology and Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Gubar EE, Korotaeva TV. Axial involvement in psoriatic arthritis. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-546-560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Among the variety of clinical manifestations of psoriatic arthritis (PsA) – including peripheral arthritis, dactylitis, enthesitis, and axial disease – spondylitis is the least studied. There is no generally accepted definition of axial PsA (axPsA), nor is there any common terminology or diagnostic criteria for it. In the rheumatology community, there is also no consensus regarding radiological and MRI assessment of axial involvement in PsA patients, while disease activity indexes and the therapeutic tactics are borrowed from those used in treating axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS). However, despite a range of similarities in immunopathogenetic mechanisms of axPsA and axSpA, there are also certain differences that may affect the treatment response in these patients. The aim of this review is the analysis of data on axial disease in PsA. The article discusses the genetic features, clinical presentations, imaging techniques, differential diagnostics and treatment options of axPsA.
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Affiliation(s)
- E. E. Gubar
- V.A. Nasonova Research Institute of Rheumatology
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Artamonova OG, Karamova AE, Chikin VV, Kubanov AA. HLA-B27 and its role of the pathogenesis of psoriatic arthritis. VESTNIK DERMATOLOGII I VENEROLOGII 2022. [DOI: 10.25208/vdv1362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The literature review presents the characteristics of the human leukocyte antigen (HLA)-B27 as a factor contributing to the development of psoriatic arthritis. HLA-B27 is a class I surface antigen encoded by the major histocompatibility complex (MHC) B locus located on chromosome 6. The main function is to present antigenic peptides to the CD8+ T-cells. HLA-B27 is the most important genetic biomarker for psoriatic arthritis, as it provides phenotypic differentiation in the patient population. The prevalence of HLA-B27 in various population groups are presented. The structural features of the HLA-B27 molecule are described. The characteristics of methods for detecting HLA-B27 status and determining its subtypes are given. The main mechanisms of the HLA-B27 polymorphism influence on the development of psoriatic arthritis are considered, and hypotheses are analyzed that explain the pathogenic effect of HLA-B27: the arthritogenic peptide hypothesis, the misfolding hypothesis, the HLA-B27 heavy chain homodimer formation hypothesis. The features of the clinical manifestations and course of HLA-B27-positive psoriatic arthritis are presented, allowing the use of HLA-B27 to predict the development of psoriatic joint damage.
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Diaz P, Feld J, Eshed I, Eder L. Characterising axial psoriatic arthritis: correlation between whole spine MRI abnormalities and clinical, laboratory and radiographic findings. RMD Open 2022; 8:rmdopen-2021-002011. [PMID: 35074901 PMCID: PMC8788330 DOI: 10.1136/rmdopen-2021-002011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To describe the prevalence of inflammatory and structural lesions using whole spine MRI in patients with psoriatic disease, and to assess their correlation with clinical features and with axial spondyloarthritis (axSpA) classification criteria. METHODS This retrospective analysis included patients with whole spine and sacroiliac joints (SIJ) MRI, selected from 2 populations: (1) active psoriatic arthritis (PsA), irrespective of axial symptoms; (2) psoriasis with confirmed or suspected PsA and axSpA symptoms. MRI spondylitis and/or sacroiliitis (MRI-SpA) was defined according to Assessment of Spondyloarthritis International Society (ASAS) consensus and by radiologist impression. Agreement between MRI-SpA and different inflammatory back pain (IBP) definitions (Berlin/ASAS/rheumatologist criteria) and the axSpA classification criteria were calculated considering MRI as gold standard. Logistic regression determined MRI-SpA-associated factors. RESULTS 93 patients were analysed (69.9% PsA; 30.1% psoriasis). Back pain was present in 81.7%, defined as IBP in 36.6%-57%. MRI-SpA was found in 9.7% of patients by ASAS definition and in 12.9% by radiologist impression, of which 25% had isolated spondylitis.Low agreement was found between the three IBP definitions and MRI-SpA. Rheumatologist criteria was the most sensitive (50%-55.6%) while ASAS and Berlin criteria were the most specific (61.9%-63%). axSpA criteria had poor sensitivity for MRI-SpA (22.2%-25%). Late onset of back pain or asymptomatic patients accounted for most cases with MRI-SpA not meeting axSpA or IBP criteria. Male sex was associated with MRI-SpA (OR 6.91; 95% CI 1.42 to 33.59) in multivariable regression analysis. CONCLUSION Prevalence of MRI-defined axSpA was low and showed poor agreement with IBP and axSpA criteria.
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Affiliation(s)
- Pamela Diaz
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada.,Women's College Research Institute, Toronto, Ontario, Canada.,Departamento de Inmunología Clínica y Reumatología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joy Feld
- Rheumatology Unit, Carmel Hospital, Haifa, Israel
| | - Iris Eshed
- Radiology, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Israel
| | - Lihi Eder
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada .,Women's College Research Institute, Toronto, Ontario, Canada
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Zeidler HK. Psoriatic Spondylitis: A Disease Manifestation in Debate: Evidences to Know for the Clinical Rheumatologist. J Clin Rheumatol 2022; 28:38-43. [PMID: 34941618 DOI: 10.1097/rhu.0000000000001815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT With the advent of classification criteria for psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA), patients with axial manifestations associated with psoriasis, initially described in the l950s as a specific entity termed psoriatic spondylitis (PS), are now categorized within PsA, ankylosing spondylitis (AS), and axSpA. Thus, different terms are used to describe axial disease in patients with PsA including PS, axial psoriatic arthritis (axPsA), and psoriatic spondyloarthritis. Patients with PS may present with inflammatory and/or mechanical back pain, but also may display axial disease on imaging despite not complaining of back pain. Cervical spondylitis has been reported in 35% to 75% of patients with PsA. Axial disease is silent in 20% and 25% of patients with axial PsA and PsA, respectively. The majority of axPsA patients have peripheral arthritis alongside the axial involvement, whereas only 2% to 5% of PsA patients have solely axial arthritis with no peripheral arthritis.A debate is currently underway as to whether inflammatory axial disease and psoriasis represent axSpA with psoriasis or a subset of PsA named axPsA. Studies have recognized that axial disease in PsA patients seems to be different demographically, genetically, clinically, and radiographically when compared with AS with or without psoriasis. This narrative review summarizes current knowledge regarding axial involvement of PsA in terms of history, terminology, classification, epidemiology, clinical presentation, imaging, diagnosis, and treatment, with the aim of providing advice for management of PS in clinical evidence-based practice. Data-driven studies are needed to develop clear, nonoverlapping classification criteria for spinal involvement in PsA.
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Kubanov AA, Chikin VV, Karamova AE, Znamenskaya LF, Artamonova OG, Verbenko DA. Genetic markers for psoriatic arthritis among patients with psoriasis. Part II: HLA genes. VESTNIK DERMATOLOGII I VENEROLOGII 2021. [DOI: 10.25208/vdv1269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Psoriatic arthritis often leads to the development of severe outcomes ankylosis, deformities of the affected joints with severe impairment of their functions and disability. Early identification of patients with psoriasis with an increased risk of developing psoriatic arthritis for the purpose of its timely diagnosis and early initiation of therapy can prevent the development of severe disease outcomes. It is believed that the genes of the HLA system make the greatest individual genetic contribution to the formation of a predisposition to hereditary diseases with polygenic inheritance. The literature review considers the polymorphisms of the genes of the HLA system, associated with the development of psoriatic arthritis, in patients with psoriasis. The HLA alleles that contribute to the development of psoriatic arthritis and its individual forms have been identified. HLA alleles have been identified, which have a protective effect against the development of psoriatic arthritis.
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Lorenzin M, Ortolan A, Vio S, Cozzi G, Scapin V, De Conti G, Doria A, Ramonda R. Psoriasis and Imaging Progression in early Axial Spondyloarthritis: Results from a 48-month follow-up (Italian arm of SPACE study). Rheumatology (Oxford) 2021; 61:2375-2387. [PMID: 34605894 DOI: 10.1093/rheumatology/keab728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/13/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To assess the influence of psoriasis on spinal/pelvic radiographic progression and magnetic resonance imaging (MRI) features in early-stage axial spondyloarthritis (axSpA). METHODS Analysis of baseline data from the Italian SPACE cohort, including patients with chronic-back-pain (CBP; duration ≥ 3 months and ≤2 years; onset <45 years) was performed. Patients underwent a diagnostic work-up, including MRI and X-rays of the sacroiliac joints (SIJ), to establish diagnosis of axSpA (ASAS criteria). Clinical features, disease activity and functional indices, imaging were collected at baseline and yearly during 48-months. Spinal and SIJ X-rays and MRIs were scored by 2 readers following SPARCC, mSASSS and mNY-criteria. Characteristics of axSpA patients with/without psoriasis were compared over-time with descriptive statistics; multivariate-logistic-regression model was constructed to assess predictors of spinal/pelvic radiographic progression. RESULTS 88 patients had axSpA (84.1% non-radiographic; 15.9% radiographic); 36.4% had psoriasis. Patients with psoriasis were older; less frequently had HLA-B27+ and radiographic sacroiliitis with unilateral/asymmetric pattern and more signs of spondylitis. Functional and disease activity indices decreased with slightly higher BASDAI and BASFI in axSpA with psoriasis. All patients showed slight spinal/pelvic radiographic progression. Patients without psoriasis showed increased sacroiliitis progression and low-grade spinal progression. More inflammatory corner lesions on cervical/thoracic MRI-spine were observed in patients with psoriasis. Significant downtrend of SPARCC SIJ/spine scores in all patients was found. Psoriasis was a predictor of increased spinal progression (OR = 0.18; 95%CI : 0.04-0.78). CONCLUSIONS Psoriasis was associated with distinct axSpA features, increased spinal radiographic progression and low-grade radiographic sacroiliitis.
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Affiliation(s)
- Mariagrazia Lorenzin
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Augusta Ortolan
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Stefania Vio
- Radiology Unit, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Giacomo Cozzi
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Vanna Scapin
- Radiology Unit, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Giorgio De Conti
- Radiology Unit, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine-DIMED, Padova University Hospital, Giustiniani 2, Padova, 35128, Italy
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13
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Crespo-Rodríguez AM, Sanz Sanz J, Freites D, Rosales Z, Abasolo L, Arrazola J. Role of diagnostic imaging in psoriatic arthritis: how, when, and why. Insights Imaging 2021; 12:121. [PMID: 34432145 PMCID: PMC8387520 DOI: 10.1186/s13244-021-01035-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/16/2021] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Ana María Crespo-Rodríguez
- Radiology Department, Hospital Clinico San Carlos, Madrid, Spain. .,Faculty of Medicine, Complutense University of Madrid (UCM), Madrid, Spain. .,Biomedical Imaging Research Group, Health Research Institute of the Hospital Clinico San Carlos, IdISSC, Madrid, Spain. .,c/ Profesor Martín Lagos S/N, 28040, Madrid, Spain.
| | - Jesús Sanz Sanz
- Reumathology Department, Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain
| | - Dalifer Freites
- Reumathology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Zulema Rosales
- Reumathology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Lydia Abasolo
- Research Group On Inflammation, Infection, Immunity and Allergy, Health Research Institute of the Hospital Clinico San Carlos (IDISSC), Madrid, Spain
| | - Juan Arrazola
- Radiology Department, Hospital Clinico San Carlos, Madrid, Spain.,Faculty of Medicine, Complutense University of Madrid (UCM), Madrid, Spain.,Biomedical Imaging Research Group, Health Research Institute of the Hospital Clinico San Carlos, IdISSC, Madrid, Spain
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14
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Makino T, Ihn H, Nakagawa M, Urano M, Okuyama R, Katoh N, Tateishi C, Masuda K, Ogawa E, Nishida E, Nishimoto S, Muramoto K, Tsuruta D, Morita A. Effect of adalimumab on axial manifestations in Japanese patients with psoriatic arthritis: a 24 week prospective, observational study. Rheumatology (Oxford) 2021; 60:3669-3678. [PMID: 33394051 DOI: 10.1093/rheumatology/keaa829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES PsA is characterized by enthesitis, synovitis and osseous involvement in the peripheral and axial joints. Few studies have examined axial involvement in PsA using imaging techniques. Here we examined axial involvement in PsA patients using MRI. In addition, we determined the efficacy of 24 week adalimumab treatment in improving the MRI findings of spondylitis and sacroiliitis. METHODS This was a prospective, open-label, single-arm study in patients with PsA. Adalimumab was administered to patients for a total of 24 weeks. MRI examinations were conducted at baseline and at week 24 of adalimumab treatment. RESULTS Thirty-seven patients with PsA were included in this study. Spondylitis was observed in at least one site of the positive scan in 91% (n = 31) of patients with PsA. The number of arthritic sites in the cervical, thoracic and lumbar regions of the spine was 48, 67 and 53, respectively. All patients had MRI-determined sacroiliitis of grade ≥1 severity while 28 patients (82%) had grade ≥2 sacroiliitis in at least one sacroiliac region. Sacroiliac arthritis was statistically more severe on the right side than on the left side (P < 0.05). In 34 patients with PsA, the thoracic spine was the most common site of spondylitis. In addition, 24 week adalimumab treatment led to an improvement in the mean number of spondylitis sites and the mean grade of sacroiliitis. CONCLUSION Treatment with adalimumab for 24 weeks resulted in improvement in spondylitis and sacroiliitis.
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Affiliation(s)
- Takamitsu Makino
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Motoo Nakagawa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Misugi Urano
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ryuhei Okuyama
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine Graduate School of Medical Sciences, Kyoto, Japan
| | - Chiharu Tateishi
- Department of Dermatopathology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Masuda
- Department of Dermatology, Kyoto Prefectural University of Medicine Graduate School of Medical Sciences, Kyoto, Japan
| | - Eisaku Ogawa
- Department of Dermatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Emi Nishida
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | | | - Daisuke Tsuruta
- Department of Dermatopathology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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15
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Giovannini I, Zabotti A, Cicciò C, Salgarello M, Cereser L, De Vita S, Tinazzi I. Axial Psoriatic Disease: Clinical and Imaging Assessment of an Underdiagnosed Condition. J Clin Med 2021; 10:jcm10132845. [PMID: 34199051 PMCID: PMC8268702 DOI: 10.3390/jcm10132845] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/29/2021] [Accepted: 06/15/2021] [Indexed: 02/06/2023] Open
Abstract
The frequent involvement of the spine and sacroiliac joint has justified the classification of psoriatic arthritis (PsA) in the Spondyloarthritis group. Even if different classification criteria have been developed for PsA and Spondyloarthritis over the years, a well-defined distinction is still difficult. Although the majority of PsA patients present peripheral involvement, the axial involvement needs to be taken into account when considering disease management. Depending on the definition used, the prevalence of axial disease may vary from 25 to 70% in patients affected by PsA. To date, no consensus definition has been reached in the literature and the definition of axial involvement in PsA has varied from isolated sacroiliitis to criteria used in ankylosing spondylitis. This article reviews the unmet needs in the clinical and radiological assessment of axial PsA, reporting the various interpretations of axial involvement, which have changed over the years. Focusing on both imaging and clinical standpoints, we reported the prevalence of clinical and radiologic features, describing the characteristics of axial disease detectable by X-rays, magnetic resonance imaging, and PET-CT, and also describing the axial symptoms and outcome measures in patients affected by axial disease.
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Affiliation(s)
- Ivan Giovannini
- Department of Medical and Biological Sciences, Institute of Rheumatology, University Hospital ‘Santa Maria della Misericordia’, 33100 Udine, Italy; (I.G.); (S.D.V.)
| | - Alen Zabotti
- Department of Medical and Biological Sciences, Institute of Rheumatology, University Hospital ‘Santa Maria della Misericordia’, 33100 Udine, Italy; (I.G.); (S.D.V.)
- Correspondence:
| | - Carmelo Cicciò
- Departments of Diagnostic Imaging and Interventional Radiology, IRCCS Sacro Cuore Don Calabria Hospital, 27024 Negrar di Valpolicella, Italy;
| | - Matteo Salgarello
- Nuclear Medicine, IRCCS Sacro Cuore Don Calabria Hospital, 27024 Negrar di Valpolicella, Italy;
| | - Lorenzo Cereser
- Department of Medicine, Institute of Radiology, University of Udine, 33100 Udine, Italy;
| | - Salvatore De Vita
- Department of Medical and Biological Sciences, Institute of Rheumatology, University Hospital ‘Santa Maria della Misericordia’, 33100 Udine, Italy; (I.G.); (S.D.V.)
| | - Ilaria Tinazzi
- Unit of Rheumatology, IRCSS Ospedale Sacro Cuore Don Calabria, 27024 Negrar di Valpolicella, Italy;
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16
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Poddubnyy D, Jadon DR, Van den Bosch F, Mease PJ, Gladman DD. Axial involvement in psoriatic arthritis: An update for rheumatologists. Semin Arthritis Rheum 2021; 51:880-887. [PMID: 34198146 DOI: 10.1016/j.semarthrit.2021.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023]
Abstract
Psoriatic arthritis (PsA) is a heterogenous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. Axial involvement occurs in 25% to 70% of patients with PsA, varying greatly depending on its definition, with the key manifestations being sacroiliitis and/or spondylitis. However, there are no agreed-upon classification or diagnostic criteria for axial involvement in PsA and no consensus on treatment paradigms, which complicates management of PsA. There have only been a few studies assessing biologics in patients with PsA with axial involvement, and most treatment plans are based on evidence from patients with axial spondyloarthritis. Rheumatologists therefore face many challenges in the management of axial PsA, including diagnosis, differential diagnosis, and choice of appropriate treatment. In this review, we summarize the clinical presentation, imaging characteristics, differential diagnoses, treatment options, and prognosis of axial PsA, with the aim of increasing rheumatologists' knowledge of this phenotype of PsA and thereby aiding its optimal management.
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Affiliation(s)
- Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Deepak R Jadon
- Department of Rheumatology, University of Cambridge, Cambridge, United Kingdom
| | - Filip Van den Bosch
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium, and VIB Center for Inflammation Research, Ghent, Belgium
| | - Philip J Mease
- Swedish Medical Center/Providence St Joseph Health, Seattle, WA, USA, and University of Washington, Seattle, WA, USA
| | - Dafna D Gladman
- Schroeder Arthritis Institute, Krembil Research Institutef, University of Toronto, Toronto Western Hospital, Toronto, ON, Canada
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17
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Mathew AJ, Østergaard M, Eder L. Imaging in psoriatic arthritis: Status and recent advances. Best Pract Res Clin Rheumatol 2021; 35:101690. [PMID: 34016527 DOI: 10.1016/j.berh.2021.101690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The heterogeneous nature of psoriatic arthritis (PsA), encompassing several domains, with varied presentations brings about considerable challenges in disease evaluation. Prompt diagnosis and targeted therapy have resulted in disease remission being accepted as an attainable goal in PsA. Imaging has played a pivotal role in early diagnosis, better understanding of pathogenesis, monitoring of disease, and as an outcome measurement tool in clinical trials in PsA. Conventional radiography has been the cornerstone of assessing structural damage. With the advent of ultrasound and magnetic resonance imaging, better delineation of the various structures involved in the disease process is possible, thus enabling sensitive assessment of inflammatory and structural pathologies together. In this review, imaging modalities used in routine assessment and clinical trials in PsA will be discussed in detail, focusing on advances over the past 5 years.
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Affiliation(s)
- Ashish J Mathew
- Copenhagen Center for Arthritis and Research (COPECARE), Center for Rheumatology and Spine Diseases, University Hospital, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Immunology & Rheumatology, Christian Medical College, Vellore, India.
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis and Research (COPECARE), Center for Rheumatology and Spine Diseases, University Hospital, Glostrup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Lihi Eder
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
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18
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Furer V, Levartovsky D, Wollman J, Wigler I, Paran D, Kaufman I, Elalouf O, Borok S, Anouk M, Sarbagil-Maman H, Berman M, Polachek A, Matz H, Flusser G, Druckmann I, Eshed I, Elkayam O. Prevalence of Nonradiographic Sacroiliitis in Patients With Psoriatic Arthritis: A Real-life Observational Study. J Rheumatol 2021; 48:1014-1021. [PMID: 33452174 DOI: 10.3899/jrheum.200961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To establish the prevalence of nonradiographic sacroiliitis within a real-life sample of patients with psoriatic arthritis (PsA), using pelvic radiographs and magnetic resonance imaging (MRI) of sacroiliac joints (SIJs). METHODS This cross-sectional study included 107 consecutive adults with PsA (Classification Criteria for Psoriatic Arthritis criteria). Participants completed clinical and laboratory evaluation, pelvic radiographs scored for radiographic sacroiliitis according to the modified New York (mNY) criteria, and noncontrast MRI of SIJs, scored by the Berlin score and categorized into active sacroiliitis using the 2016 Assessment of Spondyloarthritis international Society (ASAS) criteria and the presence of structural sacroiliitis. RESULTS Radiographic sacroiliitis/mNY criteria were detected in 28.7% (n = 29), confirmed by MRI-detected structural lesions in 72.4% (n = 21). Active sacroiliitis was detected by MRI in 26% (n = 28) of patients, with 11% (n = 11) qualifying for nonradiographic sacroiliitis. Patients with radiographic and nonradiographic sacroiliitis had similar clinical characteristics, except for a longer duration of psoriasis (PsO) and PsA in the radiographic subgroup (PsO: 23.8 ± 12.5 vs 14.1 ± 11.7 yrs, P = 0.03; PsA: 12.3 ± 9.8 vs 4.7 ± 4.5 yrs, P = 0.02, respectively). Inflammatory back pain (IBP) was reported in 46.4% (n = 13) with active sacroiliitis and 27% (n = 3) with nonradiographic sacroiliitis. The sensitivity of IBP for detection of nonradiographic sacroiliitis was low (27%) and moderate for radiographic sacroiliitis (52%), whereas specificity ranged from 72% to 79% for radiographic and nonradiographic sacroiliitis, respectively. CONCLUSION The prevalence of active sacroiliitis among a real-life population of patients with PsA was 26%. However, the prevalence of nonradiographic sacroiliitis was low (11%) compared to the radiographic sacroiliitis (28.7%) seen in patients with longer disease duration. IBP was not a sensitive indicator for the presence of early-stage sacroiliitis that was commonly asymptomatic.
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Affiliation(s)
- Victoria Furer
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv;
| | - David Levartovsky
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Jonathan Wollman
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Irena Wigler
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Daphna Paran
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Ilana Kaufman
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Ofir Elalouf
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Sara Borok
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Marina Anouk
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Hagit Sarbagil-Maman
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Mark Berman
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Ari Polachek
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Hagit Matz
- H. Matz, MD, Department of Dermatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Gideon Flusser
- G. Flusser, MD, I. Druckmann, MD, Department of Radiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Ido Druckmann
- G. Flusser, MD, I. Druckmann, MD, Department of Radiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | - Iris Eshed
- I. Eshed, MD, Department of Radiology, Sheba Medical Center, Ramat Gan, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Elkayam
- V. Furer, MD, D. Levartovsky, MD, J. Wollman, MD, I. Wigler, MD, D. Paran, MD, I. Kaufman, MD, O. Elalouf, MD, S. Borok, MD, M. Anouk, MD, H. Sarbagil-Maman, MD, M. Berman, MD, A. Polachek, MD, O. Elkayam, MD, Department of Rheumatology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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Abstract
Back pain has long been considered an uncommon complaint in the pediatric population. When present, teaching had been that pediatric back pain almost always has a diagnosable cause, many of which are progressive and potentially debilitating. Recent evidence has suggested that pediatric back pain is not only more common than once thought but also, within certain populations, benign and idiopathic. This, in turn, places an increasing amount of pressure on pediatricians to accurately assess and manage their patients presenting with complaints of back pain. The aim of this article is to serve as a review of the current literature on pediatric back pain. The article reviews the epidemiology, basic anatomy, and important elements of a history and examination, which should be considered when a child presents complaining of back pain. Last, a common differential diagnosis with evaluation and management is also given to help guide pediatricians through their medical decision making.
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Affiliation(s)
- Micah Lamb
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joel S Brenner
- Children's Specialty Group PLLC, Norfolk, VA.,Children's Hospital of The King's Daughters, Norfolk, VA.,Eastern Virginia Medical School, Norfolk, VA
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20
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Renson T, Carron P, De Craemer AS, Deroo L, de Hooge M, Krabbe S, Jans L, Chen M, Østergaard M, Van den Bosch FE, Elewaut D. Axial involvement in patients with early peripheral spondyloarthritis: a prospective MRI study of sacroiliac joints and spine. Ann Rheum Dis 2020; 80:103-108. [PMID: 33115761 DOI: 10.1136/annrheumdis-2020-218480] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To assess axial involvement on MRI in early peripheral spondyloarthritis (pSpA) and to evaluate whether axial inflammation predicts relapse on treatment withdrawal. METHODS Fifty-six patients with early, active, newly diagnosed pSpA underwent MRI of the sacroiliac joints (SIJs) and spine prior to golimumab initiation. At sustained clinical remission of pSpA, treatment was withdrawn and a second MRI was performed. Bone marrow oedema (BME) was scored by three readers according to the Spondyloarthritis Research Consortium of Canada (SPARCC) method. Scores were compared with an axial spondyloarthritis cohort (Belgian Arthritis and Spondylitis cohort). Structural lesions were assessed using a similar method. Furthermore, fulfilment of the Assessment of Spondyloarthritis International Society (ASAS) definition of a positive MRI for sacroiliitis was assessed. Spinal images were evaluated for BME and structural lesions using the Canada-Denmark MRI spine scoring system by two readers. RESULTS Thirty-six per cent showed SIJ BME at baseline, all fulfilling the ASAS definition of sacroiliitis. No association with back pain was found. Twenty-one per cent displayed SIJ structural lesions. Spinal BME was limited: the median inflammation scores were low and no patients had ≥5 inflammatory corner lesions. On clinical remission, a significant decrease in SIJ SPARCC scores was detected. On clinical remission, no significant differences in SIJ SPARCC scores were noted between patients relapsing and those maintaining remission after treatment discontinuation. CONCLUSION In patients with early pSpA, a surprisingly high prevalence of sacroiliitis on MRI was observed; SPARCC scores decreased significantly on tumour necrosis factor inhibition. Residual inflammation on MRI was not predictive of relapse of peripheral manifestations. No relevant inflammatory spinal involvement was detected. Collectively, our findings suggest a higher inflammatory burden in patients with early pSpA than anticipated.
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Affiliation(s)
- Thomas Renson
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium .,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Philippe Carron
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium.,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Ann-Sophie De Craemer
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium.,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Liselotte Deroo
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium.,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Manouk de Hooge
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium.,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Simon Krabbe
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lennart Jans
- Radiology, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Min Chen
- Radiology, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark.,Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Filip E Van den Bosch
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium.,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Dirk Elewaut
- Internal Medicine and Pediatrics, Ghent University Faculty of Medicine and Health Sciences, Ghent, Belgium.,VIB-UGent Center for Inflammation Research, Ghent, Belgium
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Saif DS, El Tabl MA, Afifi N, Abdallah MS, El Hefnawy SM, Hassanein SA. Interleukin-17A biomarker as a predictor for detection of early axial spondyloarthritis changes in patients with psoriasis. Int J Rheum Dis 2020; 23:1664-1669. [PMID: 33016599 DOI: 10.1111/1756-185x.13997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/13/2020] [Accepted: 09/16/2020] [Indexed: 01/29/2023]
Abstract
AIM Although the pathogenic mechanisms of psoriatic arthritis (PsA) are not completely clarified, evidence suggests that interleukin 17A (IL-17A)-mediated immune responses play a pivotal role in the disease. This is best underscored by the important clinical effectiveness of IL-17A inhibitors in psoriasis treatment. We aim to investigate the predictive value of IL-17A in detecting the early axial spondyloarthropic (SpA) changes in psoriatic patients. METHODS The study enrolled 100 patients with psoriasis, classified into group 1, included 62 patients with only psoriatic skin lesions (Ps), and group 2 included 38 patients with PsA, and 100 age and gender matched healthy volunteers. All participants were subjected to general and local clinical examination, laboratory assessment including IL-17A in the serum by means of enzyme-linked immunosorbent assay, and axial joint radiological assessment. RESULTS Our study included 60 males (60%) and 40 females (40%).The positive radiological findings of early axial SpA changes were found among 30.6% of the Ps group and among 84.2% of the PsA group. There were significant differences between patients with positive magnetic resonance imaging (MRI) findings of early axial SpA and patients with negative MRI findings in both groups regarding IL-17A levels. There was a significant association between IL-17A level and early axial SpA changes in psoriatic patients with a clear cutoff point (222.5). CONCLUSION Our study can imply that IL-17A is a valuable, useful and low-cost biomarker in detecting early axial SpA changes in asymptomatic and nonradiographic axial SpA (nr-axial SpA) psoriatic patients that helps early management and prevent progressive axial involvement and disabilities.
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Affiliation(s)
- Dalia S Saif
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Mohamed A El Tabl
- Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Naglaa Afifi
- Department of Internal Medicine and Rheumatology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mahmoud S Abdallah
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Sadat City (USC), Menoufia, Egypt
| | - Sally M El Hefnawy
- Department of Biochemistry, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Shimaa A Hassanein
- Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
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22
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Axial psoriatic arthritis: An update for dermatologists. J Am Acad Dermatol 2020; 84:92-101. [PMID: 32747079 DOI: 10.1016/j.jaad.2020.05.089] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/30/2020] [Accepted: 05/11/2020] [Indexed: 12/17/2022]
Abstract
Psoriasis is a chronic, immune-mediated, systemic, inflammatory disorder characterized by skin plaques and, often, nail disease and arthritis that contribute to reduced quality of life. Psoriatic arthritis-a heterogeneous, inflammatory, musculoskeletal disease that can cause permanent damage to both peripheral and axial joints-is the most common comorbidity of psoriasis. Axial disease occurs in 25% to 70% of patients with PsA, with some patients exclusively experiencing axial joint involvement. Early therapeutic intervention is important for preventing permanent joint and spine damage and loss of functionality in these patients. Because skin symptoms associated with psoriasis often precede psoriatic arthritis, dermatologists are uniquely positioned to play an important role in identifying and treating patients with psoriatic arthritis. Proactive screening of patients with all severities of psoriasis for the signs and symptoms of psoriatic arthritis is key to early diagnosis and intervention. In this review, we discuss the clinical presentation, risk factors, and treatment options for psoriatic arthritis with axial involvement, with the aim of helping dermatologists understand the disease and identify patients who might benefit from further assessment, treatment, and/or referral to a rheumatology practice.
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Prevalence of sacroiliitis and acute and structural changes on MRI in patients with psoriatic arthritis. Sci Rep 2020; 10:11580. [PMID: 32665619 PMCID: PMC7360582 DOI: 10.1038/s41598-020-68456-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/25/2020] [Indexed: 01/15/2023] Open
Abstract
Sacroiliac joint involvement is one of the earliest manifestations of psoriatic arthritis (PsA). Magnetic resonance imaging (MRI) is a useful tool in the early diagnosis of axial disease due to its sensitivity for detecting acute and chronic changes associated with sacroiliitis. In this study, we evaluated the prevalence of sacroiliitis, acute and structural image changes on MRI in PsA patients and identified predictive clinical, laboratory and disease activity factors. Cross-sectional study on PsA patients submitted to MRI of the sacroiliac joints. The scans were evaluated by two blinded radiologists and the level of agreement was calculated (kappa). Clinical, disease activity and quality-of-life indices (DAS28, BASDAI, PASI, MASES, HAQ, CRP, ESR) were estimated. The sample consisted of 45 PsA patients with a mean age of 50.1 ± 11.5 years. The prevalence of sacroiliitis was 37.8% (n = 17), 47% of which was unilateral. The kappa coefficient was 0.64. Only 5 (29.4%) of the 17 patients with sacroiliitis on MRI had back pain. The most prevalent acute and chronic changes on MRI were, respectively, subchondral bone edema (26.7%) and enthesitis (20%), periarticular erosions (26.7%) and fat metaplasia (13.3%). CRP levels were higher among sacroiliitis patients (p = 0.028), and time of psoriasis was positively associated with chronic lesions (p = 0.006). Sacroiliitis on MRI was highly prevalent in our sample of PsA patients. Raised CRP levels were significantly associated with sacroiliitis, and longer time of psoriasis was predictive of chronic sacroiliitis lesions. Most sacroiliitis patients displayed no clinical symptoms.
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Abstract
Axial involvement in psoriatic arthritis is a well-recognized manifestation with a prevalence between 12.5% and 78%. This huge heterogeneity is due to the different criteria used by authors to define psoriatic arthritis with axial involvement combining clinical features with radiographic evidence of disease. Specific genetic and clinical attributes of axial psoriatic arthritis might differentiate it from axial spondyloarthritis with concurrent skin psoriasis. Few studies address the specific management. The purpose of this review is to acknowledge the current understanding of axial involvement in psoriatic arthritis and highlight the need for a definition to facilitate research and clinical recognition.
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25
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Feld J, Chandran V, Haroon N, Inman R, Gladman D. Axial disease in psoriatic arthritis and ankylosing spondylitis: a critical comparison. Nat Rev Rheumatol 2019; 14:363-371. [PMID: 29752461 DOI: 10.1038/s41584-018-0006-8] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Ankylosing spondylitis (AS) was first identified in the late 17th century. 250 years later, inflammatory spine disease was recognized to be one of the patterns of psoriatic arthritis (PsA). Isolated spondylitis is rare among patients with PsA, occurring in less than 5% of patients; however, many patients with PsA have axial disease that is concurrent with peripheral arthritis. At the other end of the spondyloarthritis spectrum, psoriasis is observed in 10% of patients with AS. Although axial involvement in PsA can be indistinguishable from axial disease in AS, it can also differ in several respects, raising the question of whether axial PsA and AS (with or without psoriasis) are different clinical presentations of the same disease, or whether they are separate diseases that have overlapping features. In this Review, the clinical presentation, metrology, radiographic characteristics, genetic factors, treatment options and axial prognosis of the two diseases are addressed. The aim of this Review is to capture all available comparisons made to date, to highlight the similarities and differences between AS and axial PsA and to propose a research agenda.
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Affiliation(s)
- Joy Feld
- Centre for Prognosis Studies in Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Vinod Chandran
- Centre for Prognosis Studies in Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Nigil Haroon
- Centre for Prognosis Studies in Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Robert Inman
- Centre for Prognosis Studies in Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Immunology, Medical Sciences Building, University of Toronto, Toronto, Ontario, Canada
| | - Dafna Gladman
- Centre for Prognosis Studies in Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada. .,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
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26
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Bratu VA, Häusermann P, Walker UA, Daikeler T, Zubler V, Jaeger VK, Weber U, Studler U. Do Patients With Skin Psoriasis Show Subclinical Axial Inflammation on Magnetic Resonance Imaging of the Sacroiliac Joints and Entire Spine? Arthritis Care Res (Hoboken) 2019; 71:1109-1118. [DOI: 10.1002/acr.23767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/18/2018] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | | | | | - Ulrich Weber
- King Christian 10th Hospital for Rheumatic Diseases, Gråsten, and University of Southern Denmark Odense Denmark
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Watad A, Bridgewood C, Russell T, Marzo-Ortega H, Cuthbert R, McGonagle D. The Early Phases of Ankylosing Spondylitis: Emerging Insights From Clinical and Basic Science. Front Immunol 2018; 9:2668. [PMID: 30505307 PMCID: PMC6250731 DOI: 10.3389/fimmu.2018.02668] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022] Open
Abstract
In our paper, we discuss how the early phases of ankylosing spondylitis (AS) are linked to peri-firbocartilagenous osteitis in the sacroiliac joint and entheseal bone related anchoring sites. This skeletal proclivity is linked to an abnormal immunological response to skeletal biomechanical stress and associated microdamage. A key event in the early stages of AS appears to be the association with subclinical Crohn's-like colitis with this gut inflammation being pivotal to the osteitis reaction. Whether this osteitis is consequent to non-specific intestinal innate immune activation or adaptive immune responses against specific microbiotal or self-antigens is unknown. Recurrent iritis is an HLA-B27 associated feature that may predate AS and pursues a course independent of joint involvement, and points toward the pivotal role of organ specific immunology over generalized systemic immune responses in disease expression. Human genetics and animal model studies strongly incriminate the IL23/17 axis and TNF-α in disease pathogenesis. Preliminary work shows a strong convergence of innate immune cells including type 3 innate lymphoid-cells (ILC3) and γδ T-cells in skin, gut, entheseal, and eye inflammation. Despite the HLA-B27 association, the role of adaptive immunity, especially CD8+ T-cells mediated responses remains unproven and alternative theories have been proposed. The emerging non-dependence of axial inflammation on IL-23 but dependence on IL-17A is an unexpected new twist that awaits full explanation. In this mini-review, we discuss the key events in the early stages of human AS from clinical and basic science aspects, which could be crucial for attempted disease prevention studies in at risk subjects.
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Affiliation(s)
- Abdulla Watad
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
- Department of Medicine “B”, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Charlie Bridgewood
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Tobias Russell
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Helena Marzo-Ortega
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Richard Cuthbert
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Dennis McGonagle
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
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Yap KS, Ye JY, Li S, Gladman DD, Chandran V. Back pain in psoriatic arthritis: defining prevalence, characteristics and performance of inflammatory back pain criteria in psoriatic arthritis. Ann Rheum Dis 2018; 77:1573-1577. [PMID: 30077991 DOI: 10.1136/annrheumdis-2018-213334] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We aimed to determine the agreement between rheumatologist-judged inflammatory back pain (IBP) and criteria defining IBP in patients with psoriatic arthritis (PsA) and predictive value of IBP in identifying axial involvement in PsA. METHODS Using prospectively collected data, we investigated the agreement between rheumatologist judgement of IBP and IBP criteria (Calin, Rudwaleit and Assessment of Spondyloarthritis International Society) using the kappa coefficient. We also determined the sensitivity, specificity and likelihood ratios of the presence of back pain, rheumatologist-judged IBP and the three IBP criteria for detecting axial PsA (AxPsA). Finally, we compared the clinical and genetic markers in patients with PsA with axial radiological changes with and without back pain. RESULTS 171 patients (52% male, mean age 46.6 years) were identified. Ninety-six (56.13%) patients reported chronic back pain. Sixty-five (38.01%) had IBP. 54 (32%) patients had evidence of radiological change in the spine. The agreement between rheumatologist judgement of IBP and IBP criteria was highest for the Calin criteria (0.70). Positive likelihood ratio for the presence of radiological axial involvement was highest for Rudwaleit criteria (2.17). No differences between patients with AxPsA with or without back pain were found, except for higher Bath Ankylosing Spondylitis Disease Activity Index and lower prevalence of human leucocyte antigen-B*38 in those with back pain. CONCLUSION Rheumatologist-judged IBP or the criteria for IBP developed for ankylosing spondylitis may not perform well when ascertaining axial involvement in PsA.
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Affiliation(s)
- Kristy S Yap
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Y Ye
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Suzanne Li
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Dafna D Gladman
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Vinod Chandran
- University of Toronto Psoriatic Arthritis Clinic, Centre for Prognostic Studies in the Rheumatic Diseases, Krembil Research Institute, Toronto Western Hospital, Toronto, Ontario, Canada.,Division of Rheumatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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30
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J P Bray T, Vendhan K, Ambrose N, Atkinson D, Punwani S, Fisher C, Sen D, Ioannou Y, Hall-Craggs MA. Diffusion-weighted imaging is a sensitive biomarker of response to biologic therapy in enthesitis-related arthritis. Rheumatology (Oxford) 2017; 56:399-407. [PMID: 27994095 DOI: 10.1093/rheumatology/kew429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Indexed: 11/14/2022] Open
Abstract
Objective The aim was to evaluate diffusion-weighted imaging (DWI) as a tool for measuring treatment response in adolescents with enthesitis-related arthropathy (ERA). Methods Twenty-two adolescents with ERA underwent routine MRI and DWI before and after TNF inhibitor therapy. Each patient's images were visually scored by two radiologists using the Spondyloarthritis Research Consortium of Canada system, and sacroiliac joint apparent diffusion coefficient (ADC) and normalized ADC (nADC) were measured for each patient. Therapeutic clinical response was defined as an improvement of ⩾ 30% physician global assessment and radiological response defined as ⩾ 2.5-point reduction in Spondyloarthritis Research Consortium of Canada score. We compared ADC and nADC changes in responders and non-responders using the Mann-Whitney-Wilcoxon test. Results For both radiological and clinical definitions of response, reductions in ADC and nADC after treatment were greater in responders than in non-responders (for radiological response: ADC: P < 0.01; nADC: P = 0.055; for clinical response: ADC: P = 0.33; nADC: P = 0.089). ADC and nADC could predict radiological response with a high level of sensitivity and specificity and were moderately sensitive and specific predictors of clinical response (the area under the receiver operating characteristic curves were as follows: ADC: 0.97, nADC: 0.82 for radiological response; and ADC: 0.67, nADC: 0.78 for clinical response). Conclusion DWI measurements reflect the response to TNF inhibitor treatment in ERA patients with sacroiliitis as defined using radiological criteria and may also reflect clinical response. DWI is more objective than visual scoring and has the potential to be automated. ADC/nADC could be used as biomarkers of sacroiliitis in the clinic and in clinical trials.
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Affiliation(s)
- Timothy J P Bray
- University College London Centre for Medical Imaging (Academic Radiology), NW1 2PG.,Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London
| | - Kanimozhi Vendhan
- University College London Centre for Medical Imaging (Academic Radiology), NW1 2PG
| | - Nicola Ambrose
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London
| | - David Atkinson
- University College London Centre for Medical Imaging (Academic Radiology), NW1 2PG
| | - Shonit Punwani
- University College London Centre for Medical Imaging (Academic Radiology), NW1 2PG
| | - Corinne Fisher
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London
| | - Debajit Sen
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London
| | - Yiannis Ioannou
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London
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31
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Uson J, Loza E, Möller I, Acebes C, Andreu JL, Batlle E, Bueno Á, Collado P, Fernández-Gallardo JM, González C, Jiménez Palop M, Lisbona MP, Macarrón P, Maymó J, Narváez JA, Navarro-Compán V, Sanz J, Rosario MP, Vicente E, Naredo E. Recommendations for the Use of Ultrasound and Magnetic Resonance in Patients With Spondyloarthritis, Including Psoriatic Arthritis, and Patients With Juvenile Idiopathic Arthritis. ACTA ACUST UNITED AC 2017; 14:27-35. [PMID: 28277255 DOI: 10.1016/j.reuma.2016.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging in patients with spondyloarthritis, including psoriatic arthritis, and juvenile idiopathic arthritis. METHODS Recommendations were generated following a nominal group technique. A panel of experts (15 rheumatologists and 3 radiologists) was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of participants voted≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence Based Medicine levels of evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. RESULTS A total of 12 recommendations were proposed for each disease. They include, along with explanations of the validity of US and magnetic resonance imaging regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. CONCLUSIONS These recommendations will help clinicians use US and magnetic resonance imaging in patients with spondyloarthritis and juvenile idiopathic arthritis.
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Affiliation(s)
- Jacqueline Uson
- Servicio de Reumatología, Hospital Universitario de Móstoles, Móstoles, Madrid, España
| | | | - Ingrid Möller
- Servicio de Reumatología, Instituto Poal de Reumatología, Barcelona, España
| | - Carlos Acebes
- Servicio de Reumatología, Hospital General de Villalba, Collado Villalba, Madrid, España
| | - Jose Luis Andreu
- Servicio de Reumatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Enrique Batlle
- Servicio de Reumatología, Hospital Universitario Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Ángel Bueno
- Servicio de Radiología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Paz Collado
- Servicio de Reumatología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | | | - Carlos González
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - Mercedes Jiménez Palop
- Servicio de Reumatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | | - Pilar Macarrón
- Servicio de Reumatología, Hospital Universitario Clínico San Carlos, Madrid, España
| | - Joan Maymó
- Servicio de Reumatología, Hospital del Mar, Barcelona, España
| | - Jose Antonio Narváez
- Servicio de Radiodiagnóstico, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | | | - Jesús Sanz
- Servicio de Reumatología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | | - Esther Vicente
- Servicio de Reumatología, Hospital Universitario de La Princesa, Madrid, España
| | - Esperanza Naredo
- Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Zisman D, Gladman DD, Stoll ML, Strand V, Lavi I, Hsu JJ, Mellins ED. The Juvenile Psoriatic Arthritis Cohort in the CARRA Registry: Clinical Characteristics, Classification, and Outcomes. J Rheumatol 2017; 44:342-351. [DOI: 10.3899/jrheum.160717] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2016] [Indexed: 02/08/2023]
Abstract
Objective.Children with clinically diagnosed juvenile psoriatic arthritis (JPsA) who were enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry (CARRA-JPsA) were classified according to pediatric International League of Associations for Rheumatology (ILAR) and adult criteria [Classification criteria for Psoriatic Arthritis (CASPAR)]. Data on demographic and clinical features at baseline and 1-year followup were analyzed and compared.Methods.Cross-sectional analysis was performed of CARRA-JPsA patients enrolled between May 2010 and December 2013 and stratified according to age at disease onset (≤ or > 4 yrs). Features of patients fulfilling ILAR and CASPAR criteria were compared at baseline and followup using chi square, Fisher’s exact, Mann-Whitney-McNemar, Wilcoxon signed rank, and t tests, as appropriate.Results.Among 361 children enrolled as CARRA-JPsA, 72.02% had symptom onset at > 4 years of age, with a male predominance and high prevalence of enthesitis. At followup, statistically significant improvements were reported in arthritis, dactylitis, enthesitis, psoriasis, sacroiliitis, and nail pitting, but not in health questionnaire (HQ) scores. Of the patients, 80.5% fulfilled ILAR criteria for JPsA. Fifty-two patients, whose disease fulfilled CASPAR criteria but had not been included in the JPsA cohort, manifested more enthesitis, sacroiliitis, inflammatory bowel disease and uveitis and less psoriasis.Conclusion.The data support division of patients with JPsA into 2 clinical subgroups, according to age at disease onset. Improvement in objective findings did not correlate with changes in HQ scores. Pediatric rheumatologists currently do not diagnose JPsA in all children whose disease manifestations meet CASPAR criteria. Unification of adult and pediatric PsA classification criteria warrants consideration.
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33
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Bray TJP, Vendhan K, Roberts J, Atkinson D, Punwani S, Sen D, Ioannou Y, Hall-Craggs MA. Association of the apparent diffusion coefficient with maturity in adolescent sacroiliac joints. J Magn Reson Imaging 2016; 44:556-64. [PMID: 26898474 PMCID: PMC4988410 DOI: 10.1002/jmri.25209] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/09/2016] [Indexed: 11/05/2022] Open
Abstract
PURPOSE To determine the extent to which apparent diffusion coefficient (ADC) values vary with skeletal maturity in adolescent joints. MATERIALS AND METHODS A retrospective study was performed with Institutional Review Board (IRB) approval. We used a picture archiving and communication system (PACS) search to identify and recruit all adolescents who had undergone 1.5T magnetic resonance imaging (MRI) of the sacroiliac joints (SIJs) between January 2010 and June 2015, and had no evidence of sacroiliitis and normal inflammatory markers. In all, 55 individuals were assessed. For each patient, coronal and sagittal images of the sacrum were visually analyzed to determine sacral maturity. Patients were divided into three groups depending on the degree of fusion of the sacral segmental apophyses: "Fused," "Partial," and "Unfused." For each group, SIJ ADC was measured using a linear region-of-interest technique. RESULTS Mean ADC values were 690 × 10(-6) mm(2) /s in the fused group, 720 × 10(-6) mm(2) /s in the partial group, and 842 × 10(-6) mm(2) /s in the unfused group. ADC values were significantly higher in the unfused group than in the fused group (P = 0.046). ADC values were also higher in unfused subjects than partially fused subjects (P = 0.074). CONCLUSION Joint ADC values are higher in skeletally immature (unfused) patients than in skeletally more mature (fused) patients. ADC values measured in the unfused group overlap with those previously reported in sacroiliitis. These results suggest that ADC measurements in adolescent joints must be interpreted in light of joint maturity. Joint immaturity may lead to misdiagnosis of sacroiliitis, since immature juxta-articular bone may appear similar to inflammation. J. Magn. Reson. Imaging 2016. J. Magn. Reson. Imaging 2016;44:556-564.
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Affiliation(s)
- Timothy J P Bray
- UCL Centre for Medical Imaging (Academic Radiology), London, UK
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK
| | | | - James Roberts
- UCL Centre for Medical Imaging (Academic Radiology), London, UK
| | - David Atkinson
- UCL Centre for Medical Imaging (Academic Radiology), London, UK
| | - Shonit Punwani
- UCL Centre for Medical Imaging (Academic Radiology), London, UK
| | - Debajit Sen
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK
| | - Yiannis Ioannou
- Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, UK
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Akkoc N, Khan MA. ASAS classification criteria for axial spondyloarthritis: time to modify. Clin Rheumatol 2016; 35:1415-23. [PMID: 27094940 DOI: 10.1007/s10067-016-3261-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 01/17/2023]
Abstract
The relationship between ankylosing spondylitis and the recently proposed entity called axial spondyloarthritis with its radiographic and non-radiographic forms that have been defined by the Assessment of Spondyloarthritis International Society (ASAS) criteria for axial spondyloarthritis (axSpA), is currently being debated. The Food and Drug Agency (FDA) had criticized the ASAS criteria and the studies which used these criteria to enroll patients in a clinical trial of certolizumab and adalimumab for the treatment of non-radiographic axial spondyloarthritis. The primary aim of classification criteria is to create homogenous patient populations for basic and clinical research. But the multi-arm construct of the ASAS criteria is a potential source of heterogeneity reducing their utility. Criteria sets should be regarded as dynamic concepts open to modifications or updates as our knowledge advances. We provide evidence to conclude that it is time to modify the ASAS Criteria for axSpA, and we propose some of the steps that can be taken to start moving forward in improving the validity of these criteria.
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Affiliation(s)
- Nurullah Akkoc
- Department of Rheumatology, Faculty of Medicine, Dokuz Eylul University, Balcova, 35340, Izmir, Turkey
| | - Muhammad A Khan
- Case Western Reserve University, Cleveland, OH, USA.
- MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
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Looking into the new ASAS classification criteria for axial spondyloarthritis through the other side of the glass. Curr Rheumatol Rep 2016; 17:515. [PMID: 25921789 DOI: 10.1007/s11926-015-0515-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The new concept of axial spondylitis (axSpA) and the Assessment of Spondyloarthritis International Society (ASAS) classification criteria for axSpA have induced new clinical research that has broadened our understanding of spondyloarthritis (SpA) and has had indeed a positive impact on earlier diagnosis and treatment of patients with axSpA who have not yet developed radiographic sacroiliitis. The primary goal of any valid classification criteria for any disease is to provide a homogeneous study population with a common etiopathogenesis, similar prognosis, and similar response to identical treatment. Without such a homogeneous study population, robust clinical and basic science research in any subtype of SpA is not possible. All criteria are dynamic concepts that need updating as our knowledge advances and our review of the ASAS classification criteria of axSpA indicates that complex multi-selection design and unclear (not mutually exclusive) definitions of the imaging and clinical arms of the criteria results in patient heterogeneity across study populations. Therefore, there is a need to improve the validity of the ASAS criteria for axSpA. It is our opinion that in the meantime, the clinically well-established entity of AS, as defined by the modified New York (mNY) criteria, should be preserved for the most accurate comparison of the new research studies with those conducted over the last three decades, and that the use of the ASAS criteria should be restricted to patients with nr-axSpA, who are not recognized by the mNY criteria.
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Poggenborg RP, Østergaard M, Terslev L. Imaging in Psoriatic Arthritis. Rheum Dis Clin North Am 2015; 41:593-613. [DOI: 10.1016/j.rdc.2015.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Sudoł-Szopińska I, Kwiatkowska B, Włodkowska-Korytkowska M, Matuszewska G, Grochowska E. Diagnostics of Sacroiliitis According to ASAS Criteria: A Comparative Evaluation of Conventional Radiographs and MRI in Patients with a Clinical Suspicion of Spondyloarthropathy. Preliminary Results. Pol J Radiol 2015; 80:266-76. [PMID: 26082819 PMCID: PMC4444172 DOI: 10.12659/pjr.892529] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 10/28/2014] [Indexed: 11/16/2022] Open
Abstract
Background The objective of this study was a comparative evaluation of radiography and MRI in the diagnostics of sacroiliitis in patients with a clinical diagnosis of spondyloartropathy, according to the current ASAS criteria. Material/Methods Sacroiliac joints radiograms and MRI were conducted in 101 consecutive patients, aged 19–71 yrs (mean age: 40.6 yrs). The patients were referred by a senior rheumatologist, with symptoms of the chronic back pain. The sacroiliac joints were assessed on AP radiograms of the pelvis according to the modified New York criteria for ankylosing spondylitis. MRI was performed to look for active and chronic inflammatory lesions. Results Of 14 patients with radiographic sacroiliitis according to modified New York criteria, only 50% had sacroiliitis on MRI. The sensitivity and specificity of conventional radiography were 22% and 94% and of MRI were 71% and 90%. Cohen’s kappa coefficient was κ=0.0187, agreement of radiograms and MRI was 58%. Among 86 patients displaying no sacroiliitis on radiograms, MRI showed sacroiliitis in 34 patients (39.5%). Positive predictive value was 0.429, negative predictive value was 0.605. Conclusions MRI allowed to diagnose sacroiliitis in 39,5 % of patients in preradiographic stage. MRI ruled out the presence of active inflammatory lesions in 60.4% of patients with sacroiliitis on radiograms according to modified New York criteria.
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Affiliation(s)
- Iwona Sudoł-Szopińska
- Department of Radiology, Institute of Rheumatology, Warsaw, Poland ; Department of Diagnostic Imaging, Second Faculty, Warsaw Medical University, Warsaw, Poland
| | | | - Monika Włodkowska-Korytkowska
- Department of Radiology, Institute of Rheumatology, Warsaw, Poland ; Department of Diagnostic Imaging, Second Faculty, Warsaw Medical University, Warsaw, Poland
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Mandl P, Navarro-Compán V, Terslev L, Aegerter P, van der Heijde D, D'Agostino MA, Baraliakos X, Pedersen SJ, Jurik AG, Naredo E, Schueller-Weidekamm C, Weber U, Wick MC, Bakker PAC, Filippucci E, Conaghan PG, Rudwaleit M, Schett G, Sieper J, Tarp S, Marzo-Ortega H, Østergaard M. EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis 2015; 74:1327-39. [DOI: 10.1136/annrheumdis-2014-206971] [Citation(s) in RCA: 300] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/07/2015] [Indexed: 12/26/2022]
Abstract
A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9–9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.
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Hamdy M, Omar G, Elshereef RR, Ellaban AS, Amin M. Early detection of spondyloarthropathy in patients with psoriasis by using the ultrasonography and magnetic resonance image. Eur J Rheumatol 2015; 2:10-15. [PMID: 27708913 DOI: 10.5152/eurjrheumatol.2015.0075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/01/2014] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To assess the validity of ultrasound (US) in the early detection of arthritis and enthesitis, with assessment of the validity of magnetic resonance imaging (MRI) in the early detection of sacroiliitis and spondylitis in patients with psoriasis and to compare the findings of clinical examination and conventional radiography. MATERIAL AND METHODS The study included 50 patients with psoriasis and 20 healthy controls. All patients and controls underwent US and power Doppler analyses for the joints of both hands and feet and the entheseal sites. MRI of the lumbosacral spine and sacroiliac joints was performed. RESULTS Abnormal US findings of arthritis were present in 18% patients, whereas only 6% patients had X-ray abnormalities, the enthesopathy represent 74%, at a higher percentage than clinical and radiological assessment (46, 26% respectively). MRI and radiological study demonstrated evidence of inflammation in the spine in 44% and 16% patients, respectively, and evidence of sacroiliitis in 10% and 6% patients, respectively. CONCLUSION Use of newer imaging modalities allows early diagnosis and early initiation of therapy.
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Affiliation(s)
- Maha Hamdy
- Department of Rheumatology, Faculty of Medicine, Al-Minia University, Al-Minia, Egypt
| | - Gihan Omar
- Department of Rheumatology, Faculty of Medicine, Al-Minia University, Al-Minia, Egypt
| | - Rawhya R Elshereef
- Department of Rheumatology, Faculty of Medicine, Al-Minia University, Al-Minia, Egypt
| | - Abdou S Ellaban
- Department of Rheumatology, Faculty of Medicine, Al-Minia University, Al-Minia, Egypt
| | - Mohamed Amin
- Department of Radiology, Faculty of Medicine, Al-Minia University, Al-Minia, Egypt
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Dalal DS, Lin YC, Brennan DM, Borkar N, Korman N, Husni ME. Quantifying harmful effects of psoriatic diseases on quality of life: Cardio-metabolic outcomes in psoriatic arthritis study (COMPASS). Semin Arthritis Rheum 2015; 44:641-5. [PMID: 26058346 DOI: 10.1016/j.semarthrit.2015.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 01/02/2015] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Up to 30% of patients with psoriasis suffer from concurrent psoriatic arthritis, and both the diseases have worse quality-of-life outcomes compared to the general population. There is limited literature comparing quality-of-life outcomes between these diseases. We seek to compare quality-of-life outcomes between both these groups. METHODS The current study is a cross-sectional analysis of a cohort of 252 patients with psoriatic diseases, who were recruited from 2 tertiary-care centers. A self-administered questionnaire was used to collect demographic and validated quality-of-life data using short form-12 (SF 12), health assessment questionnaire (HAQ), and dermatology life quality index (DLQI). Univariate and multivariate analyses were conducted to compare the quality-of-life outcomes. RESULTS We included 107 (42.5%) psoriatic arthritis and 145 (57.5%) psoriasis patients in the cohort. The groups had comparable gender distribution and co-morbid diseases prevalence, but arthritis patients were older and received biologics/DMARDs more frequently than psoriasis patients. The physical indices (identified by HAQ and SF 12 PCS) were worse for psoriatic arthritis, whereas the mental/psychometric indices (identified by DLQI and SF 12 MCS) were comparable between both the groups. CONCLUSIONS Despite aggressive therapy, physical quality of life was worse in psoriatic arthritis patients compared to psoriasis patients. The mental quality-of-life indices were comparable in both the groups and were still below the population norm. These results suggest need for screening for psoriatic arthritis in patients with psoriasis to reduce the burden of physical quality of life and screening for early signs of psychiatric illnesses in both these disease populations.
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Affiliation(s)
- Deepan S Dalal
- Rheumatology, Boston University Medical Center, Boston, MA
| | - Yih Chang Lin
- Division of Rheumatology, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Danielle M Brennan
- Department of Rheumatology, Orthopedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Neil Borkar
- Baylor University Medical Center, Dallas, TX
| | - Neil Korman
- Department of Dermatology, University Hospitals - Case Medical Center, Cleveland, OH
| | - M Elaine Husni
- Department of Rheumatology, Orthopedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, OH.
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Castillo-Gallego C, Aydin SZ, Emery P, McGonagle DG, Marzo-Ortega H. Magnetic resonance imaging assessment of axial psoriatic arthritis: extent of disease relates to HLA-B27. ACTA ACUST UNITED AC 2013; 65:2274-8. [PMID: 23780792 DOI: 10.1002/art.38050] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 06/04/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine the prevalence, on magnetic resonance imaging (MRI), of bone marrow edema lesions in symptomatic axial psoriatic arthritis (PsA), and to compare this prevalence with that in nonradiographic axial spondyloarthritis (SpA) and ankylosing spondylitis (AS) and its relationship to HLA-B27 status. METHODS We performed a cross-sectional audit of MRI scans of lumbar spine (L-spine) and sacroiliac (SI) joints. Using the semiquantitative Leeds Scoring System in which bone marrow edema is graded from 0 to 3 according to severity of the lesions, MRI scans were scored independently by 2 expert readers who were blinded to the clinical characteristics of the patients. Concordant data from the 2 readers were used to report on definite lesions. RESULTS MRIs from 76 patients with comparable age ranges were categorized into 3 groups: those from PsA patients, those from patients with nonradiographic axial SpA, and those from AS patients. HLA-B27 positivity was similar in PsA patients (10 of 33) and patients with nonradiographic axial SpA (10 of 24) and higher in AS patients (18 of 19). Total MRI scores (L-spine plus SI joints) were higher in AS patients than in PsA patients (P = 0.025) or in patients with nonradiographic axial SpA (P = 0.007). A relationship was seen between the severity and extent of disease and HLA-B27 positivity in PsA patients, which was comparable to that in AS patients. HLA-B27-negative PsA patients had lower MRI scores than HLA-B27-positive PsA patients (P = 0.03) and AS patients (P = 0.006), whereas scores were similar in HLA-B27-positive PsA patients and AS patients. Similarly, MRI scores of HLA-B27-negative patients with nonradiographic axial SpA were lower than those of AS patients (P = 0.01). CONCLUSION HLA-B27 positivity defines a group of patients with more severe axial bone marrow edema that is likely related to the classic AS phenotype. Clinically, HLA-B27-negative PsA is more likely to be reported as a "negative" MRI examination result.
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Affiliation(s)
- Concepción Castillo-Gallego
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Paparo F, Revelli M, Semprini A, Camellino D, Garlaschi A, Cimmino MA, Rollandi GA, Leone A. Seronegative spondyloarthropathies: what radiologists should know. LA RADIOLOGIA MEDICA 2013; 119:156-63. [DOI: 10.1007/s11547-013-0316-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 07/17/2012] [Indexed: 11/24/2022]
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Abstract
Psoriatic arthritis (PsA) has been recognized as a distinct entity different from rheumatoid arthritis. Classification and phenotyping of PsA have progressed substantially since the first classification criteria of the disease were published in 1973 by Moll and Wright. The initial disease patterns described by Moll and Wright have been found to overlap and change over time. There has been controversy about whether these should be maintained or whether the phenotype of PsA should include peripheral and axial disease only. PsA is a multifaceted disease that can present as different clinical phenotypes: peripheral arthritis, axial disease, skin and nail disease, dactylitis, and enthesitis. Development of the high-sensitivity and high-specificity CASPAR criteria was the first step to conducting high-quality trials and observational studies in the field.
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TEH J. Imaging of spondylodiscitis, inflammatory spondyloarthropathy and pars defects. IMAGING 2013. [DOI: 10.1259/imaging/22676126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Spondyloarthropathy (or spondyloarthritis) can begin in childhood (defined as individuals less than 16 years of age). These diseases are distinct in childhood, when compared with adult-onset disease. Because of overlapping features, especially sacroiliac joint involvement, diagnostic difficulty may arise from Behcet's disease, as well as familial Mediterranean fever. Despite advances in diagnostic techniques such as magnetic resonance imaging, the diagnosis of juvenile spondyloarthropathy may still be delayed many years from the onset of symptoms. Treatment of juvenile spondyloarthropathy has advanced rapidly in the last several years, with increasing evidence that agents targeting tumor necrosis factor are effective. These agents also have serious complications, including induction of other autoimmune diseases.
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Affiliation(s)
- R Hal Scofield
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation (RHS, ALS), Oklahoma City, OK, USA.
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Weiss PF. Diagnosis and treatment of enthesitis-related arthritis. ADOLESCENT HEALTH MEDICINE AND THERAPEUTICS 2012; 2012:67-74. [PMID: 23236258 PMCID: PMC3518441 DOI: 10.2147/ahmt.s25872] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is a chronic, inflammatory disease of unknown etiology. The enthesitis-related arthritis (ERA) JIA category describes a clinically heterogeneous group of children including some who have predominately enthesitis, enthesitis and arthritis, juvenile ankylosing spondylitis, or inflammatory bowel disease-associated arthropathy. ERA accounts for 10%–20% of JIA. Common clinical manifestations of ERA include arthritis, enthesitis, and acute anterior uveitis. Axial disease is also common in children with established ERA. Treatment regimens for ERA, many of them based on adults with rheumatoid arthritis and ankylosing spondylitis, include the use of nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs, and biologic agents either individually or in combination.
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Affiliation(s)
- Pamela F Weiss
- Division of Rheumatology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Departments of Pediatrics and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Axial psoriatic arthritis: an intriguing clinical entity or a subset of an intriguing disease? Clin Rheumatol 2012; 31:1027-32. [DOI: 10.1007/s10067-012-1990-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 02/13/2012] [Accepted: 04/18/2012] [Indexed: 12/17/2022]
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Arnbak B, Leboeuf-Yde C, Jensen TS. A systematic critical review on MRI in spondyloarthritis. Arthritis Res Ther 2012; 14:R55. [PMID: 22405031 PMCID: PMC3446421 DOI: 10.1186/ar3768] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 02/21/2012] [Accepted: 03/09/2012] [Indexed: 12/17/2022] Open
Abstract
Introduction Magnetic resonance imaging (MRI) has been proven capable of showing inflammatory and structural changes in patients with spondyloarthritis (SpA) and has become widely used in the diagnosis of SpA. Despite this, no systematic reviews evaluate the diagnostic utility of MRI for SpA. Therefore, the objective of this systematic review was to determine the evidence for the utility of MRI in the clinical diagnosis of SpA. The aims were to identify which MRI findings are associated with the diagnosis of SpA and to quantify this association. Methods MEDLINE and EMBASE were electronically searched. Inclusion criteria were cross-sectional or longitudinal case-control or cohort MRI studies. The studies required a group with either SpA or inflammatory back pain (IBP) and a non-case group without SpA or IBP. Each group required a minimum of 20 participants. The included articles had to report results containing raw numbers suitable for the construction of two-by-two tables or report results by sensitivity and specificity for cross-sectional studies or odds ratios, relative risk ratios, or likelihood ratios for longitudinal studies. Method quality was assessed by using criteria based on the QUADAS tool. Results In total, 2,395 articles were identified in MEDLINE and EMBASE before November 2011. All articles were reviewed by title and abstract. Seventy-seven articles were reviewed by full text, and 10 met the inclusion criteria. Two were considered of high quality: one evaluated the sacroiliac joints, and the other, the spine. Because of the small number of high-quality studies, a meta-analysis was not performed. The two high-quality studies found a positive association between MRI findings (bone marrow edema, erosions, fat infiltrations, global assessment of sacroiliitis, and ankylosis) and the diagnosis of IBP and SpA. Conclusion In this review, several MRI findings were found to be associated with SpA. However, because of the small number of high-quality studies, the evidence for the utility of MRI in the diagnosis of SpA must be considered limited. Therefore, caution should be taken to ensure that inflammatory and structural MRI findings are not interpreted as being more specific for SpA than is supported by research.
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Affiliation(s)
- Bodil Arnbak
- Research Department, Spine Centre of Southern Denmark, Hospital Lillebaelt, Clinical Locomotion Network, Oestre Hougvej 55, Middelfart 5500, Denmark.
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ØSTERGAARD MIKKEL, POGGENBORG RENÉPANDURO. Magnetic Resonance Imaging in Psoriatic Arthritis — Update on Current Status and Future Perspectives: A Report from the GRAPPA 2010 Annual Meeting. J Rheumatol 2012; 39:408-12. [DOI: 10.3899/jrheum.111235] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Weiss PF, Klink AJ, Behrens EM, Sherry DD, Finkel TH, Feudtner C, Keren R. Enthesitis in an inception cohort of enthesitis-related arthritis. Arthritis Care Res (Hoboken) 2011; 63:1307-12. [PMID: 21618453 DOI: 10.1002/acr.20508] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To describe an enthesitis-related arthritis (ERA) inception cohort and determine which entheses and joints are most commonly affected. METHODS We reviewed a retrospective inception cohort study of children with ERA who were diagnosed and treated at The Children's Hospital of Philadelphia between November 2007 and December 2009. RESULTS During the study period, there were 32 newly diagnosed ERA patients. Fifty-nine percent were male, and the median age at the date of initial evaluation was 12.5 years (interquartile range [IQR] 10.2-14.3 years). The median number of tender entheses at presentation was 2 (IQR 0-5), and 21 subjects (66%) had at least 1 tender enthesis. The most prevalent tender entheses were the patellar ligament insertion at the inferior pole of the patella, the plantar fascial insertion at the calcaneus, the Achilles tendon insertion at the calcaneus, and the plantar fascial insertion at the metatarsal heads. Enthesitis was most often symmetric. The median number of active joints was 2 (IQR 0-4). The most commonly affected joints were the sacroiliacs, knees, and ankles. Sacroiliitis, which was defined clinically, was most often symmetric, while peripheral arthritis was most frequently asymmetric. The odds of having active enthesitis at 6 months increased significantly with each additional tender enthesis at the initial evaluation. CONCLUSION Among pediatric patients with ERA, lower extremity enthesitis is prevalent at the time of diagnosis and is likely to persist 6 months later. Future studies should address standardization of the enthesitis examination, the pattern of enthesitis over time, enthesitis response to therapy, and the impact of enthesitis on quality of life.
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Affiliation(s)
- Pamela F Weiss
- The Children's Hospital of Philadelphia, Pennsylvania, USA.
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