Clinical and ultrasonographic enthesopathy in inflammatory rheumatic diseases : Is MASEI or only calcaneal enthesitis sufficient?

The relationship between clinical parameters and ultrasonographic enthesitis assessment in patients with spondyloarthritis

Objectives

The study aimed to evaluate the role of ultrasonographic assessment of enthesitis in patients with spondyloarthritis (SpA) in terms of disease activity, functionality, and quality of life.

Patients and methods

Ninety SpA patients (57 males, 33 females; mean age: 37.5±9.7 years; range, 18 to 60 years) were included in cross-sectional study between November 2016 and January 2017. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Functional Index (BASFI), Short Form-12 (SF-12), and Ankylosing Spondylitis Quality of Life (ASQoL) were utilized for clinical evaluation. The clinical evaluation of enthesitis was performed with the Spondyloarthritis Research Consortium of Canada (SPARCC) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) via an algometer calibrated to 4 kg/cm2 of pressure. Ultrasound evaluation was performed according to Madrid Sonographic Enthesitis Index (MASEI). A total of 2,610 entheseal sites were examined clinically, and 1,080 were assessed ultrasonographically.

Results

A significant proportion of enthesitis (463/1,080) was detected on ultrasonographic evaluation but not with clinical enthesitis score (MASES and SPARCC). Although ultrasonographic entheseal evaluation detected enthesitis in at least one enthesis of all patients, 35 of the patients had no enthesitis with clinical examination. The sites most frequently involved in the entheses were the proximal patellar tendon and Achilles tendon. The MASEI score did not correlate with the MASES, SPARCC, BASDAI, SF-12, and ASQoL but moderately correlated with the C-reactive protein (CRP) level (r=0.348), ASDAS-CRP (r=0.294), and BASFI score (r=0.244).

Conclusion

The association of ultrasonography scores with CRP levels and ASDAS-CRP indicates that ultrasonography is effective in detecting inflammation. The MASEI score weakly correlates with functionality but not with quality of life. Ultrasonographic evaluation is invaluable and merits to be incorporated into SpA disease scoring system.

Peripheral Enthesitis in Spondyloarthritis: Lessons from Targeted Treatments

A significant proportion of patients with spondyloarthritis (SpA) have peripheral enthesitis. Data suggest that psoriatic arthritis (PsA) patients with enthesitis have a higher disease burden than those without enthesitis. Over the past decade, there has been a proliferation of treatment options for spondyloarthropathy. These medications target multiple signaling pathways, including tumor necrosis factor (TNF), interleukin (IL)-17A, IL-12/23, IL-23, thymus (T)-cell co-stimulation, intracellular Janus kinases, and phosphodiesterase enzymes. As a key domain in SpA, enthesitis outcomes are included in pivotal trials of these agents and are reported as secondary outcome measures. One significant limitation is that the clinical evaluation of enthesitis relies on eliciting tenderness on palpation and is insensitive when compared with imaging. Furthermore, direct comparisons between studies are not available due to the use of different outcome measures, lack of consistent and comprehensive reporting outcomes, and subgroup analyses with a lower number of patients with enthesitis. This systematic review describes the epidemiology, pathophysiology, and available targeted therapies against enthesitis, as well as a detailed report of their efficacy. One major trend identified during this review is incomplete reporting of outcome measures, as many studies reported proportions of enthesitis prevalence. Factors that affected responsiveness in clinical trials included the entheseal instrument used, the number of subjects available for comparison, as well as the therapeutic agent. In general, anti-TNF and anti-IL-17 agents, as well as Janus kinase inhibitors, show moderate responsiveness for enthesitis. The data for IL-23 targeting is contradictory.

Updating the use of the Madrid Sonographic Enthesis Index (MASEI): a systematic review of the literature

OBJECTIVE

To perform a systematic review of the literature to evaluate the use of the enthesis ultrasound Madrid Sonographic Entesis Index (MASEI) from its publication.

METHODS

A systematic search of MEDLINE, EMBASE, and Cochrane Central Register databases was performed. The search strategy was constructed to identify publications containing terms related to enthesis and ultrasound. The only applied filter was studies conducted in humans. One reviewer systematically screened the search. A second reviewer verified the selection. The data extraction was focused on study characteristics, including population and components of the OMERACT filter.

RESULTS

Sixty-eight of the 1581 identified studies had used MASEI, including 41 (60%) abstracts and 27 (40%) articles. Of the 27 articles, MASEI was mainly used for spondyloarthritis and related diseases in 12 (44%) articles, followed by both psoriatic arthritis and rheumatoid arthritis in five (19%) articles; however, it was also used in diseases such as Behçet disease, FM, familiar Mediterranean fever, SS, crystal arthropathies and systemic sclerosis. The feasibility of MASEI was reported in three (11%) articles, and the reliability in 12 (44%) with good to excellent values. No article evaluated the responsiveness to treatment. The construct validity of MASEI was assessed using biomarkers in seven (26%) articles, clinical examination in 13 (48%) and imaging procedures (only X-rays) in two (7%). The discriminative validity was assessed in 16 (59%) articles, not only in SpAs.

CONCLUSION

MASEI is a feasible, reliable and valid ultrasound score for the study of enthesis in spondyloarthritis, psoriatic arthritis and other diseases.

Ultrasonographic evaluation of Achilles tendon: Is there any difference between ankylosing spondylitis, non-radiographic axial spondyloarthropathy and controls?

PURPOSE

The aim is to evaluate Achilles tendon enthesopathy with ultrasound (US) in ankylosing spondylitis (AS) and non-radiographic axial SpA (nr-axSpA) patients and controls, and compare these groups in terms of associations between disease activity parameters and ultrasonographic Achilles enthesitis signs.

METHODS

A total of 24 AS and 20 nr-axSpA patients fulfilling the Assessment in Spondyloarthritis International Working Group criteria for axSpA and 30 controls were enrolled. Demographic characteristics, erythrocyte sedimentation rate, C-reactive protein (CRP), human leukocyte antigen (HLA)-B27, Bath AS Disease Activity Index, Bath AS Functional Index, Bath AS Metrology Index, Maastricht AS Enthesitis Score (MASES), AS Disease Activity Score-CRP, modified Stoke AS Spine Score (m-SASSS) scores and ultrasonographic findings were noted.

RESULTS

HLA-B27 positivity, extra-articular and peripheral involvement, disease activity, functional status, mean m-SASSS, ultrasonographic gray scale (GS) and total scores were similar between AS and nr-axSpA groups. In GS, tendon echotexture scores were significantly different across all groups (0.812 ± 0.384 in AS, 0.575 ± 0.466 in nr-axSpA, 0.017 ± 0.091 in controls; P < .001). Entheseal calcification scores were similar in AS and nr-axSpA patients, and higher than controls (P = .001). Bone profile scores were similar in patients with AS and nr-axSpA, and higher than controls (P = .010). When the correlations between US findings and disease activity and functional status were considered, power Doppler US (PDUS) and MASES total scores were positively correlated in the AS group (P = .045; r = .41).

CONCLUSION

AS and nr-axSpA patients were found to be similar in various clinical, functional, and US findings indicating that these 2 entities are different phenotypic reflections of the same disease spectrum. The positive correlation between PDUS and MASES scores in AS patients substantiate the performance of MASES in evaluation of entheseal activity.

Retrocalcaneal Bursitis Precedes or Accompanies Achilles Tendon Enthesitis in the Early Phase of Rheumatoid Arthritis

The consecutive reports and stored images of ultrasound examinations for 100 symptomatic ankles of 74 patients with rheumatoid arthritis (RA) were reviewed for the presence or absence of retrocalcaneal bursitis (RCB) and Achilles tendon enthesitis (ATE). The ankles were classified into 4 categories based on the presence or absence of RCB or ATE. The number of RCB(−)/ATE(−), RCB(+)/ATE(−), RCB(+)/ATE(+), and RCB(−)/ATE(+) ankles was 62, 16, 12, and 10, respectively. When classifying patients into early RA and established RA, the percentage of RCB(−)/ATE(+) ankles with early RA was significantly lower than that with established RA (P = .00595). The disease duration was significantly longer in the RCB(−)/ATE(+) ankles than in the RCB(+)/ATE(−) ankles (median [interquartile range]: 15.29 [8.69] months vs 3.6 [3.06] months, P = .0247). It was speculated that RCB precedes or accompanies ATE in the early phase of RA, which suggests that entheseal inflammation in RA arises from synovial tissues.