'Deep Koebner' phenomenon of the flexor tendon-associated accessory pulleys as a novel factor in tenosynovitis and dactylitis in psoriatic arthritis

Greater magnitude of entheseal microdamage and repair in psoriatic arthritis compared with ankylosing spondylitis on ultrasound

Objectives

AS and PsA share clinical and immunological features centred on enthesitis. However, a strong association between PsA and preceding injury has been recognized. The aim of this study was to test the hypothesis that the entheseal damage seen by US is commoner in PsA patients than in AS patients.

Methods

Seventy-nine AS and 85 PsA patients had US scans of 1640 entheses to calculate entheseal inflammation (hypoechogenicity, thickening and Doppler) and damage scores (calcifications, enthesophytes and erosions). Regression modelling was done to evaluate the effect of diagnoses on outcomes, controlling for age, gender, BMI, clinical enthesitis, HLA-B27, and anti-TNF use.

Results

Both inflammation and damage scores on US were correlated with BMI (r = 0.392; r = 0.320) and age (r = 0.308; r = 0.538) (P < 0.001), and men had higher inflammation scores than women [12.3 (7.5) vs 8.9 (7.3), P = 0.001]. In multivariate analysis, despite similar (anti-TNF-treated patients) or slightly less inflammation (anti-TNF-naïve patients) in the PsA group, they had 4.22 times more US damage than their counterparts with AS. The difference was even higher in the anti-TNF-naïve patients (5.6 times).

Conclusion

On US assessment, PsA patients have greater entheseal insertion damage scores compared with AS, suggesting potential differences in tissue repair, immunobiology or response to injury at insertions.

Transition phase towards psoriatic arthritis: clinical and ultrasonographic characterisation of psoriatic arthralgia

Objective

Non-specific musculoskeletal pain is common in subjects destined to develop psoriatic arthritis (PsA). We evaluated psoriatic patients with arthralgia (PsOAr) compared with psoriasis alone (PsO) and healthy controls (HCs) using ultrasonography (US) to investigate the anatomical basis for joint symptoms in PsOAr and the link between these imaging findings and subsequent PsA transition.

Methods

A cross-sectional prevalence analysis of clinical and US abnormalities (including inflammatory and structural lesions) in PsOAr (n=61), PsO (n=57) and HCs (n=57) was performed, with subsequent prospective follow-up for PsA development.

Results

Tenosynovitis was the only significant sonographic feature that differed between PsOAr and PsO (29.5% vs 5.3%, p<0.001), although synovitis and enthesitis were numerically more frequent in PsOAr. Five patients in PsOAr and one in PsO group developed PsA, with an incidence rate of 109.2/1000 person-years in PsOAr vs 13.4/1000 person-years in PsO (p=0.03). Visual Analogue Scale pain, Health Assessment Questionnaire, joint tenderness and US active enthesitis were baseline variables associated with PsA development.

Conclusion

Tenosynovitis was associated with arthralgia in subjects with psoriasis. Baseline US evidence of enthesitis was associated with clinical PsA development in the longitudinal analysis. These findings are relevant for enriching for subjects at risk of imminent PsA development.

Spondyloarthritis: new insights into clinical aspects, translational immunology and therapeutics

PURPOSE OF REVIEW

The spondyloarthopathies (SpA), which encompass related diseases that were originally viewed as autoimmune, are now known to have a strong innate immune or autoinflammatory initiation phase characterized by disease localization to tissue-specific sites based on the nuances and microanatomy and immunology of those sites. This review covers recent translational advances in the field of SpA.

RECENT FINDINGS

Imaging studies in SpA continue to add support for the pivotal role of enthesitis in disease initiation and expression. Although in its infancy, there is growing evidence for microbiotal intestinal dysbiosis in ankylosing spondylitis and psoriatic arthritis. The role of cytokines beyond tumour necrosis factor (TNF) continues to grow with support for the interleukin (IL)-23/17 axis being key to disease and emergent evidence for the importance of the IL-36 pathway. The treatment of inflammatory bowel disease (IBD) with vedolizumab an α4β7-integrin blocker has been associated with arthritis flares and small molecules with Janus kinase inhibition appear to be as effective as the anti-TNFs. The disparate response of different domains in SpA points towards immunological heterogeneity even within what was considered a homogeneous disease.

SUMMARY

The clinical aspects and translational immunology and therapeutics of SpA continue to evolve and indicate the complexity of diagnosis and treatment of these conditions.

Opportunities and challenges in the treatment of psoriatic arthritis

In this chapter, we review the opportunities and challenges posed by the treatment options currently available in the treatment of psoriatic arthritis. Both established and new or emerging treatment options are discussed using a domain-based approach. Finally, approaches to how treatment can be optimized together with some clinical pearls are presented and discussed. With the increasing treatment options available, we need a better way of deciding which treatment should be considered for which patient. On the basis of current knowledge, some guidance is provided on how these choices might best be made.

Imaging in Psoriatic Arthritis-Insights About Pathogenesis of the Disease

PURPOSE OF REVIEW

Heterogeneity is a hallmark of PsA as musculoskeletal inflammation can affect different tissues including the synovial joint, tendons, entheses, bursa, and bone.

RECENT FINDINGS

Relying on clinical examination for investigating underlying mechanisms in PsA is limited by the inherent inaccuracies of examination of the joints, enthesis, and spine. In addition, unlike synovial-centered diseases, histology is hard to obtain for the entheses and spine, limiting the knowledge for different manifestations of PsA. These limitations prompted the use of imaging modalities to improve our understanding of the underlying mechanisms in PsA. Imaging modalities can identify and quantify the extent of inflammation and damage in the synovial joints, entheses, and tendons which all contribute to the heterogeneity of PsA. This review summarizes the contribution of imaging to the understanding of the underlying mechanisms of different clinical manifestations of PsA.

The thickening of flexor tendons pulleys: a useful ultrasonographical sign in the diagnosis of psoriatic arthritis

PURPOSE

To investigate the frequency of thickening of pulleys for flexor tendons in patients with early arthritis in their hands, and to evaluate it as a predictive sign of PsA.

METHODS

A prospective observational study involving 228 consecutive patients presenting with recent onset of arthritis in their hands was conducted at rheumatology outpatient clinics in the Veneto region of Italy between October 2014 and September 2017. Diabetic patients were excluded because of the high frequency of trigger finger. The final diagnosis of the rheumatologist delivered after 12 months of follow-up, was considered as the gold standard for the analysis of diagnostic accuracy.

RESULTS

Twenty-two patients were excluded from the study because of diabetes. A total of 86 patients with thickening of A1 pulleys in flexor tendons and 120 without were evaluated. Pulley thickness was significantly associated with a family history of psoriasis (18/86 vs 3/120, p ˂ 0.001) and diabetes (9/86 vs 4/120, p = 0.036), and with a personal history of cutaneous psoriasis (25/86 vs 10/120, p ˂ 0.001), psoriatic onychopathy (7/86 vs 2/120, p = 0.028), lower back pain (22/86 vs 11/120, p = 0.001), Dupuytren's disease (7/86 vs 2/120 p = 0.028) and De Quervain tenosynovitis (4/86 vs 0/120, p = 0.028). In isolation, this sign had a good sensitivity rate (80%). The specificity rate for the disease was barely significative (71%), with an LR+ of 2.71 for PsA.

CONCLUSIONS

The thickening of the pulleys in the flexor tendons is an easy-to-detect sign with good sensitivity for the diagnosis of PsA. Its specificity and positive predictive value are not very high; however, if it is included in a complete classification process, sonographers should report it during hand evaluations of patients with arthritis.

Update on the epidemiology, risk factors, and disease outcomes of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that affects different structures of the musculoskeletal system in addition to the skin and the nail. The complexity of the disease had been a barrier to understand the pathogenesis and define valid outcome tools; however, our understanding about the disease has considerably increased with time mainly because of the advances in imaging, new discoveries in genetics and underlying inflammatory pathways, and better understanding of the epidemiology of the disease and environmental risk factors. The purpose of this review is to summarize developments and changes in epidemiology, risk factors for developing PsA, and outcome measures with a focus on data obtained in the last 10 years.