Sonographic subclinical entheseal involvement in dialysis patients

Clinical and Ultrasonographic Characteristics of the Achilles Tendon in Hemodialysis Patients

Background and Objectives: The early recognition of tendon alterations in chronic hemodialysis (HD) patients, an awareness of the factors that influence the condition, and active intervention have considerable clinical relevance. The aim of this study was to investigate the musculoskeletal ultrasound (MSUS) features of the Achilles tendon in chronic HD patients and determine the factors associated with tendon abnormalities. Materials and Methods: This study was conducted on 46 HD patients and 24 sex- and age-matched controls. All participants were evaluated clinically for any signs of Achilles tendon abnormalities. Then, the Achilles tendon was scanned bilaterally using MSUS. Results: Among the 92 Achilles tendons in the HD patients, there was tenderness and swelling of only two (2.2%). Regarding MSUS features, there were statistically significant higher thicknesses in the proximal end (p < 0.001), midpoint (p < 0.001), and distal end (p < 0.001) of the Achilles tendons in the HD patients when compared with the healthy controls. Tendinosis was found in 12 (13%) of the HD patients' Achilles tendons, which was statistically significant in comparison to the healthy controls (p = 0.008). There were statistically significant higher scores of structural abnormalities (p = 0.005), bone erosions (p = 0.017), and calcifications (p = 0.015) in the HD patients when compared to the healthy controls. According to the results of a univariate regression analysis, age and male gender were predictive for US abnormalities in HD patients (p = 0.002 and 0.025, respectively). Conclusions: The Achilles tendon in subjects on chronic HD showed frequent US abnormalities. These abnormalities in HD patients appear to be more related to age and gender and may be asymptomatic.

Sonographic evaluation of subclinical entheseal involvement in patients with hypoparathyroidism: a case control study

PURPOSE

Hypoparathyroidism is a disease characterized by low serum calcium, increased serum phosphorus and low PTH levels. Although patients are treated with active vitamin D and calcium, a proper serum calcium phosphorus balance cannot always be achieved. Ectopic calcifications that develop in organs during treatment are the most common complications. To date, there is not any published study on enthesopathy in patients with hypoparathyroidism. The aim of this study was to evaluate subclinical enthesopathy in patients with hypoparathyroidism with ultrasound and to compare the results with those of the control group.

METHODS

The study included patients aged 18-65 years with postoperative hypoparathyroidism and hypothyroidism (group hypoP + hypoT), patients with postoperative hypothyroidism (group hypoT), and healthy age and sex-matched volunteers (group C). Ultrasonographic findings of enthesopathy in both extremities were documented according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS).

RESULTS

GUESS scores in group hypoP + hypoT, were significantly higher when compared to the other groups. There was a statistically significant correlation between the total GUESS scores and total enthesophyte scores and the duration of hypoparathyroidism (p < 0.05, r = 0.43) (p < 0.05, r = 0.39) respectively. In the correlation analysis of all groups, a significant negative correlation was found between serum Ca and PTH levels and the total GUESS scores (p < 0.01, r = - 0.37; p < 0.01, r = - 0.54, respectively).

CONCLUSION

This study showed that GUESS scores were significantly higher in patients with hypoparathyroidism compared to those with hypothyroidism and control subjects. GUESS scores were positively correlated with disease duration. Patients with hypoparathyroidism need to be evaluated for subclinical enthesopathy during follow-up.

Ultrasonographic assessment of entheseal sites of upper and lower extremities in hemodialysis patients using Madrid Sonography Enthesitis Index

Background

There is no much information about the entheseal involvement among hemodialysis (HD) patients. The aim of this study was to assess the frequency and distribution of ultrasonographic (US) entheseal alterations in HD patients and to evaluate the association between US abnormalities and both clinical and laboratory data.

Methods

This study was conducted on 41 HD patients and 23 sex- and age- matched controls. All participants were evaluated clinically for any signs of enthesopathy. Six entheses sites were scanned bilaterally using grey scale (GS) and power Doppler (PD) US and were scored using Madrid Sonography Enthesitis Index (MASEI) scoring system.

Results

In HD patients, at least one clinical sign suggestive of enthesopathy was found in 69 (14%) of 492 entheses. HD patients had statistically significant higher scores of structural tendon abnormalities (p < 0.001), enthesis thickening (p < 0.001), bone erosions (p < 0.001) and calcification (p = 0.037) than the healthy controls. Total MASEI score was higher in HD patients than healthy controls (median;18 vs 8, p < 0.001), also, MASEI-inflammatory (median;11 vs 3, p < 0.001) and damage scores (median;6 vs 0, p < 0.001). There was a statistically significant positive association between total MASEI score and both age (p = 0.032) and duration of HD (p = 0.037). Duration of HD was predictive for both MASEI-damage component (p = 0.004) and total MASEI score (p = 0.014).

Conclusion

There is a high prevalence of subclinical enthesopathy in HD patients. The entheseal US alterations is much higher in HD patients than in healthy subjects. The duration of HD is the significant predictor of enthesopathy in HD patients.

Presence of enthesopathy in patients with primary Sjogren's syndrome: ultrasonographic study of a local cohort

BACKGROUND

Musculoskeletal findings in Sjögren's syndrome are arthralgia, arthritis, myalgia, myositis, fibromyalgia, and chronic fatigue. Enthesis zones are important in the formation of pain in the musculoskeletal system. Musculoskeletal ultrasound (US) may show subclinical enthesitis in the synovial joints and in the axial skeleton before joint swelling in inflammatory diseases characterized by arthritis.

OBJECTIVE

In this study, we aimed to determine the presence of enthesopathy using the Madrid sonographic enthesitis index (MASEI) in patients with primary Sjögren's syndrome (PSS).

PATIENTS AND METHODS

Consecutive patients with PSS and age-matched healthy controls were included in this study. All the patients met the 2002 American College of Rheumatology/European League against Rheumatism classification criteria for PSS. The demographic characteristics of the patients were recorded. Six enthesis sites were evaluated using gray-scale and Doppler US with a linear transducer, and they were scored using the MASEI. They were assessed by the EULAR Sjögren's syndrome disease activity index (ESSDAI).

RESULTS

We evaluated 40 patients with PSS (average age 48.67 ± 11.23 years) and 30 healthy controls (average age 45.40 ± 8.24 years). Patients with PSS had significantly higher MASEI scores than the healthy controls. Plantar fascia, Achilles tendon, and distal patellar tendons were significantly thicker in the PSS group than in the healthy controls. The MASEI total score had a positive correlation with age. There was no correlation between MASEI total score and BMI and ESSDAI.

CONCLUSION

In this study, it was shown that the MASEI scores assessed by US were significantly higher in patients with PSS than in healthy controls. Plantar fascia, Achilles tendon, and distal patellar tendon were significantly thicker in the PSS group than in the healthy controls. This result suggests that PSS may be one of the causes of musculoskeletal pain that can be seen in patients with PSS. Our study was the first study to use an enthesis index ultrasonographically in patients with PSS. In addition, it is the first study to investigate the relationship between the presence of enthesopathy and disease activity by means of US.

Ultrasound Evaluation of the Entheses in Daily Clinical Practice during Tumor Necrosis Factor-α Blocking Therapy in Patients with Ankylosing Spondylitis

OBJECTIVE

To assess structural and inflammatory ultrasound (US) lesions of entheses in ankylosing spondylitis (AS) patients with active disease and to evaluate inflammatory lesions after 6 months of tumor necrosis factor (TNF-α) blocking therapy, in daily clinical practice.

METHODS

Consecutive patients with AS were clinically evaluated and underwent US examination of 9 bilateral entheses before and after 6 months of TNF-α blocking therapy. US examination included the following as inflammatory lesions: bone erosions/cortical irregularities, enthesophytes, calcifications as structural lesions; adjacent bursitis, effusion, increased tendon hypoechogenicity or thickness; and positive power Doppler (PD) signal.

RESULTS

At baseline, 105 (95%) of 111 included patients showed US abnormalities. Structural lesions were seen in 74 patients (67%) and inflammatory lesions in 88 (79%). Enthesophytes and positive PD signal were the most prevalent structural and inflammatory lesions, respectively. Most lesions were found at the lower extremities. Additionally, inflammatory lesions occurred at the lateral epicondyle of the elbow. Patients with structural lesions at baseline were significantly older, had longer disease duration, higher modified Stoke AS Spine score, and higher C-reactive protein. Individually, there was a great diversity in changes of inflammatory entheseal lesions during treatment, but on the group level no significant decrease was found.

CONCLUSION

This prospective observational cohort study in daily clinical practice shows a high prevalence of structural and inflammatory US lesions in AS patients with longstanding and active disease. Positive PD signal was the most common inflammatory feature. No significant change in inflammatory US lesions was found after 6 months of TNF-α blocking therapy.

Entheseal involvement in systemic disorders

The objective of this study is to review the data on entheseal involvement in systemic disorders. A Pubmed search utilizing the indexing terms "enthesis" and "enthesitis" was conducted and the data pertinent to the aim of the review was extracted and organized in accordance with the preplanned structure of the manuscript. A number of cadaver-based studies, as well as studies using ultrasonography and magnetic resonance imaging, have detailed new distinct aspects of enthesis physiology and pathology in a variety of rheumatic and non-rheumatic systemic disorders. Major progress has been done in characterization of separate components of the enthesis organ, imaging of entheses, elaboration of the role and features of entheseal disease in spondyloarthropathies, juvenile idiopathic arthritis, osteoarthritis, familial Mediterranean fever, hyperuricemia, and other systemic conditions. The knowledge acquired and summarized herein shows that entheses can be affected in various ways in variety of medical disorders with different pathogenesis. Better understanding of the risk factors, mechanisms and natural history of enthesopathies is warranted. The current progress in the understanding of entheseal involvement in systemic disorders represents just the first step in resolving the entheses-related enigmas.

Three-dimensional versus two-dimensional ultrasonographic assessment of peripheral enthesitis in spondylarthritis

To compare the intra- and interobserver reliability of three-dimensional (3D) volumetric versus conventional two-dimensional (2D) power Doppler ultrasonography (US) in the assessment of peripheral enthesitis in spondylarthritis (SpA). Sixteen patients with SpA according to ASAS criteria were included. Two rheumatologists (one experimented in musculoskeletal US (sonographer 1) and one beginner (sonographer 2)) performed independently a 2D US scoring of the enthesis using the Madrid Sonographic Enthesis Index score followed by a 3D acquisition of the same entheseal sites. The reading of the 3D acquisition was performed a minimum of 1 week apart. Intraobserver reliability was evaluated by a second reading of the same images. The duration of 2D US scanning, 3D US acquisition and reading was recorded. Intraclass correlation coefficients (ICCs) were used for the reliability analysis. Intraobserver reproducibility was good to excellent for 2D US and good for 3D US (ICC (95 %CI) 2D US 0.776 (0.471-0.916) and 0.96 (0.892-0.986) and ICC (95 %CI) 3D US 0.796 (0.498-0.921) and 0.703 (0.325-0.886) for sonographer 1 and 2, respectively). Interobserver reliability was slightly better for 3D US than for 2D US (ICC (95 %CI) 0.776 (0.471-0.916) for 3D US versus 0.641 (0.221-0.859) for 2D US). The mean time (±SD) for 2D US scanning was 23 min (±4) whereas the mean time for 3D US volume acquisition and reading was 16.5 min (±2.6) (p < 0.001). 3D US showed good intra- and interobserver reliability in the assessment of enthesitis in SpA and shortened the needed time for scanning. It can be performed by a nonexperienced examiner without loss of reliability.

Ultrasonographic assessment of enthesitis in HLA-B27 positive patients with rheumatoid arthritis, a matched case-only study

Introduction

HLA-B27 has a modifier effect on the phenotype of multiple diseases, both associated and non-associated with it. Among these effects, an increased frequency of clinical enthesitis in patients with Rheumatoid Arthritis (RA) has been reported but never explored again. We aimed to replicate this study with a sensitive and quantitative assessment of enthesitis by using standardized ultrasonography (US).

Methods

The Madrid Sonography Enthesitis Index (MASEI) was applied to the US assessment of 41 HLA-B27 positive and 41 matched HLA-B27 negative patients with longstanding RA. Clinical characteristics including explorations aimed to evaluate spondyloarthrtitis and laboratory tests were also done.

Results

A significant degree of abnormalities in the entheses of the patients with RA were found, but the MASEI values, and each of its components including the Doppler signal, were similar in HLA-B27 positive and negative patients. An increase of the MASEI scores with age was identified. Differences in two clinical features were found: a lower prevalence of rheumatoid factor and a more common story of low back pain in the HLA-B27 positive patients than in the negative. The latter was accompanied by radiographic sacroiliitis in two HLA-B27 positive patients. No other differences were detected.

Conclusion

We have found that HLA-B27 positive patients with RA do not have more enthesitis as assessed with US than the patients lacking this HLA allele. However, HLA-B27 could be shaping the RA phenotype towards RF seronegativity and axial involvement.

Increased enthesopathy in patients with familial Mediterranean fever: evaluation with a new sonographic enthesitis index

OBJECTIVES

The aim of this study was to determine the frequency of enthesopathy in familial Mediterranean fever by using a newly developed sonographic method, the Madrid Sonographic Enthesitis Index (MASEI).

METHODS

The study included 50 consecutive patients with familial Mediterranean fever and 57 healthy sex- and age-matched control participants. Six entheseal sites (olecranon tuberosity, superior and inferior poles of the patella, tibial tuberosity, and superior and inferior poles of the calcaneus) on both lower limbs were evaluated. All sonographic findings were identified according to MASEI. Validity was analyzed by receiver operating characteristic curves. P < .05 was considered significant.

RESULTS

Mean total enthesitis scores ± SD were 7.54 ± 4.99 for patients and 3.63 ± 3.03 for controls (P < .001). No statistically significant correlation was found between the MASEI score and familial Mediterranean fever duration or colchicine treatment duration. There was no difference between the MASEI score and the presence or absence of arthritic involvement among the patients. The area under the receiver operating characteristic curve was 0.74 (95% confidence interval, 0.649-0.839). When analyzed by sex, men with familial Mediterranean fever had significantly higher MASEI scores than women (P < .05).

CONCLUSIONS

This study showed significant enthesopathy in patients with familial Mediterranean fever. The findings support the hypothesis that familial Mediterranean fever and spondyloarthropathy may have common inflammatory mechanisms and suggest that the MASEI scoring system can be incorporated into clinical protocols for studying patients with familial Mediterranean fever in daily practice.