Ultrasound in psoriatic arthritis. Can it facilitate a best routine practice in the diagnosis and management of psoriatic arthritis?

Improved diagnostic performance of CASPAR criteria with integration of ultrasound

Background

The difficulty in determining synovitis, tenosynovitis, or enthesitis by physical examination (PE) has limited the diagnostic capability of CASPAR for psoriatic arthritis (PsA). Therefore, we aimed to evaluate the diagnostic utility of CASPAR with the integration of ultrasound (US).

Methods

Patients with a hint of PsA were enrolled. Besides routine PE for tender or swollen joints, enthesitis, and dactylitis, US was performed to evaluate peripheral joints, entheses, and tendons. The additional value of the US to the CASPAR criteria was analyzed.

Results

A total of 326 consecutive patients with 164 PsA and 162 non-PsA were enrolled. A total of 162 non-PsA patients consisted of 58 cases of psoriasis (PsO), 27 osteoarthritis with PsO/family history of PsO, five fibromyalgia with PsO, 69 sero-negative rheumatoid arthritis, and three undifferentiated arthritis. Significantly higher frequencies of tenosynovitis and enthesitis on US and new bone formation on X-rays were found in PsA vs. non-PsA patients (59.1% vs. 13.0%; 63.4% vs. 14.2%; 62.2% vs. 8.0%, p <0.01 for all). Logistic regression analysis showed that dactylitis (OR = 12.0, p <0.01), family history of PsO/PsA (OR = 3.1, p <0.05), nail involvement (OR = 3.5, p = 0.01), new bone formation on X-ray (OR = 14.8, p <0.01), tenosynovitis on US (OR = 21.3, p <0.01), and enthesitis on US (OR = 21.7, p <0.01) were independent risk factors for PsA. By combining US tenosynovitis and/or enthesitis, the diagnostic utility of CASPAR criteria was improved, with superior specificity (91.4% vs. 84.0%) and similar sensitivity (95.7% vs. 94.5%). Replacing X-ray by US or adding US, the CASPAR criteria showed comparable sensitivity and specificity for PsA diagnosis. The diagnostic accuracy was 89.3% for CASPAR criteria based on PE, 93.6% for CASPAR added with US, and 93.3% for CASPAR with US replacing X-ray.

Conclusion

The diagnostic utility of the CASPAR was improved by integrating tenosynovitis and/or enthesitis when using US. US provides additional value for PsA recognition.

Treating the skin with biologics in patients with psoriasis decreases the incidence of psoriatic arthritis

OBJECTIVES

To compare the incidence of psoriatic arthritis (PsA) in patients with psoriasis (PsO) according to different treatments for their skin: topics/no treatment, conventional disease-modifying antirheumatic drugs (DMARDs) (cDMARDs) or biological DMARDs (bDMARDs).

METHODS

Patients with PsO without PsA followed at a university hospital were included in this retrospective cohort study. Patients were classified according to their treatment in topics (topics, phototherapy or no treatment), cDMARDs (methotrexate and cyclosporine) and bDMARDs (tumour necrosis factor inhibitors (TNFi), interleukin 17 inhibitors (IL-17i) and IL-12-23i ((interleukin (IL) 12/IL-23 inhibitor))) groups. Incident cases of PsA were attributed to one treatment if developed during the administration of that treatment. A Cox proportional hazards model was used to evaluate the adjusted risk of PsA development by treatment group.

RESULTS

1719 patients with PsO contributed a total of 14 721 patient/years (py). 1387 (81%) patients were in the topics, 229 (13%) in cDMARDs and 103 (6%) in the bDMARDs group. During follow-up, 239 patients (14%) developed PsA (231 under topics, six under cDMARDs and two under bDMARDs). Global incidence was 1.6 per 100 py. The risk of developing PsA in patients with PsO treated with bDMARDs was significantly lower (incidence rate ratio (IRR)=0.26; 95% CI 0.03 to 0.94; p=0.0111), compared with topics, but not compared with cDMARDs (IRR=0.35; 95% CI 0.035 to 1.96; p=0.1007). Adjusted Cox proportional hazards regression analysis showed that male sex, nail involvement and higher body max index were associated with increased risk of developing PsA, while biologics use was protective (HR: 0.19; 95% CI 0.05 to 0.81).

CONCLUSION

Treatment with biologics in patients with PsO reduced the risk of PsA development.

A standardized sonographic analysis of nails in psoriatic arthritis and healthy controls: Feasibility, reliability, diagnostic performance, and demographic and clinical associations

OBJECTIVES

Subunits of the nail can be evaluated by nail ultrasonography (NUSG). The purposes of this study are to document NUSG properties (both nail-based and participant-based evaluations) in patients with psoriatic arthritis (PsA) and healthy controls and to explore the final scorings.

METHODS

After the literature review and a pilot study, a consensus was reached to evaluate 12 nails and 5 parameters by NUSG: nail plate impairment (NPI), nail plate thickness (NPT), nail bed thickness (NBT), nail thickness (NT), and Doppler activity (DA); further, scorings for each parameter (NPIs, NPTs, NBTs, NTs, and DAs) were calculated. Group comparisons and diagnostic performances (with ROC curve analysis) were applied to both parameters and scorings. Final scorings to predict PsA diagnosis among the NUSG scorings were reached by regression analysis. Feasibility, reliability, and clinical associations of the scores were also performed.

RESULTS

Sixty-four patients with PsA and 26 controls (3240 baseline images) were assessed. The most affected nails, PsA/control comparisons, and the ROC analysis varied among the nails, within the higher values of PsA; therefore, 12 nails remained in the scorings. Participant-based scorings showed better content and diagnostic performances than the nail-based. Diagnostic performances, feasibility, reliability, and regression analysis of the scorings documented that NPIs, NTs, and DAs were the best. Some demographics, employee status, hemoglobin, and disease activity of the participants were associated with them.

CONCLUSIONS

The NUSG Index (NUSGI) including NPIs, NTs, and DAs is a feasible, reliable, and discriminative method to predict PsA diagnosis, with its rich content. Clinicaltrials.gov-ID: NCT04718428.

Accuracy of Physical Examination to Detect Synovial and Extra-Synovial Pathologies in Psoriatic Arthritis in Comparison to Ultrasonography

We aimed to explore the accuracy of physical examination (PE) to detect the synovial and extra-synovial pathologies in psoriatic arthritis (PsA) in comparison to ultrasonography (US). Twenty-nine PsA patients with hand pain were included in the study. A detailed PE of the hands was performed and US scans were performed for the joints, extensor and flexor tendons, and entheses of the second to fifth fingers of both hands. The agreement between PE and US findings was calculated. The strongest agreement for the joints was between "swollen joints" and power Doppler (PD) signals in the metacarpophalangeal (MCP) joints and grey scale synovitis in the proximal interphalangeal (PIP) joints. The agreement of tender entheses on PE and inflammation on US (hypoechogenicity, thickening, and/or PD signals) was poor for both extensor (Kappa = -0.027, Prevalence Adjusted and Bias Adjusted Kappa (PABAK) = 0.344) and flexor compartments (Kappa = 0.039, PABAK = 0.569). Similar to enthesitis, comparison of any PE and US findings showed a poor agreement at the extensor and flexor tendon regions (extensor: Kappa = 0.123, PABAK = 0.448, and flexor: Kappa = 0.171, PABAK = 0.431). Our study showed that there was a poor to fair agreement of PE and US findings of hands. US can add value when determining the source of pain in PsA in the small joints.

Ultrasound assessment in psoriatic arthritis (PsA) and psoriasis vulgaris (non-PsA): which sites are most commonly involved and what features are more important in PsA?

Background

The aim of this study was to find out the most commonly involved sites and the most important ultrasonic features in psoriatic arthritis (PsA).

Methods

In total, 120 PsA patients and 320 psoriasis vulgaris (non-PsA) patients were assessed by grayscale and power Doppler (PD) ultrasound (US). Joints, tendons, enthesis, and bursa changes were observed. Weights of affected anatomical sites of PsA patients (overall weights >90%) were calculated. Affected anatomical sites between PsA and non-PsA patients were compared. Ultrasonic features of joint, tendon, entheses, and bursa changes between PsA and non-PsA patients were also compared. Finally, the test performance of ultrasonic features for the diagnosis of PsA was calculated.

Results

The anatomical sites with the highest weights were the Achilles tendon, quadriceps tendon, and knee; weights of these anatomical sites were all more than 5%. Among the affected anatomical sites of PsA patients, most of the anatomical sites were more greatly affected in the PsA patients than in the non-PsA patients (all P<0.05). The comparison of the affected Achilles tendon, quadriceps tendon, MTP1, subacromial-subdeltoid bursa, MCP4, and MCP3 showed no significance between PsA and non-PsA patients (all P>0.05). Joint synovial thickening, joint PD signal grades, joint bone erosions, tendon sheath synovial thickening, tendon sheath PD signals, enthesis bone erosions, and enthesis PD signals in PsA patients were higher than in non-PsA patients (all P<0.05). Joint PD signal grades, joint bone erosions, enthesis bone erosions, and enthesis PD signals showed the highest specificities, which were 96.06%, 95.15%, 96.93%, and 94.63% respectively.

Conclusions

The most common involvement sites of PsA were the Achilles tendon, quadriceps tendon, and knee, and some sites in non-PsA patients were also highly involved. The most important features in PsA included joint PD signal grades, joint bone erosion, entheses bone erosions, and entheses PD signals in US assessment.

Reactive arthritis secondary to Hafnia alvei enterocolitis

Diagnosis of postenteritic reactive arthritis (ReA) is a challenge and might have a broad range of differential diagnoses. A 50-year-old man was referred to our attention because of persistent inflammatory low back pain and asymmetric oligoarthritis. The clinical history was positive for diarrhoea in the previous 3 months. Inflammatory bowel disease, Whipple and celiac diseases were carefully excluded. In addition, serology, stool cultures, biopsies from the upper gastrointestinal tract yielded negative results for infections. A presumptive diagnosis of ReA was done and a non-steroidal anti-inflammatory drug trial prescribed. Persistence of symptoms prompted us for a second look of the colon. Biopsy collected from the terminal ileum were cultured and surprisingly colonies of Hafnia alvei, a rod-shaped Enterobacteriaceae, were detected. Treatment with ciprofloxacin leads to fast symptoms resolution. Although enterocolitis from H. alvei has been rarely reported, the culture of intestinal specimens might be recommended in the work-up of patients with suspected postenteritic ReA.

DAPSA and ultrasound show different perspectives of psoriatic arthritis disease activity: results from a 12-month longitudinal observational study in patients starting treatment with biological disease-modifying antirheumatic drugs

Objectives

Disease Activity index for PSoriatic Arthritis (DAPSA) (sum score 68/66 tender/swollen joint counts (68TJC/66SJC), patient’s global assessment, pain and C-reactive protein (CRP)) is recommended for clinical assessment of disease activity in patients with psoriatic arthritis (PsA). Ultrasound (US) (grey scale (GS) and power Doppler (PD)) detects inflammation in joints and extra-articular structures. The present objectives were to explore the longitudinal relationships between DAPSA, clinical assessment as well as patient-reported outcome measures (PROMs) with US in patients with PsA initiating biological DMARDs and the associations between DAPSA and US remission.

Methods

47 patients with PsA were examined at baseline and after 3, 6, 9 and 12 months. Assessments included 68TJC/66SJC, examiner’s global assessment (EGA), PROMs, CRP, erythrocyte sedimentation rate (ESR) and US GS and PD (48 joints, 10 flexor tendons, 14 entheses, 4 bursae). Clinical composite scores and PD sum scores (0=remission) were calculated. Longitudinal associations were explored by generalised estimating equations with linear and logistic regression.

Results

DAPSA was not longitudinally associated to PD. 66SJC, ESR, 28-joint Disease Activity Score, EGA and CRP were longitudinally associated with PD (p<0.001–0.03), whereas the pain-related components of DAPSA (68TJC and pain) as well as PROMs were not associated. At 6–12 months, remission was achieved in 29%–33 % of the patients for DAPSA and 59%–70 % for PD. The association between DAPSA and PD remission was not significant (p=0.33).

Conclusions

DAPSA was not associated with US inflammatory findings which indicates that DAPSA and US may assess different aspects of PsA activity.

Consensus on the management of patients with psoriatic arthritis in a dermatology setting

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis (PsO). Early diagnosis and prompt therapeutic intervention are crucial for limiting PsA progression and prevention of disability. Dermatologists are in a privileged position to detect early PsA. The management of patients with PsA in the dermatology setting is widely variable.

OBJECTIVE

To provide practical recommendations for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

METHODS

A consensus document was written by an expert panel composed by dermatologists (n = 12) and rheumatologists (n = 6). Eleven highly relevant questions were selected and elaborated with answers/statements based on a narrative literature review. The resulting document was discussed in a face-to-face meeting adopting a nominal group technique to reach consensus (i.e. 100% agreement) using the Delphi method.

RESULTS

A consensus was achieved in defining the following: the clinical characteristics differentiating inflammatory and non-inflammatory signs and symptoms of joint disease; the most important differential diagnoses of PsA in clinical practice; the most useful screening questionnaires, serum laboratory tests and imaging techniques for the detection of early PsA; the criteria for dermatologist to refer patients with PsO to rheumatologist; the criteria for the diagnosis of PsA; the selection of the indices that the dermatologist could use for measuring the activity and severity of PsA in clinical practice; when systemic steroids and/or intra-articular steroid injections are indicated in the treatment of PsA. Finally, systemic treatments including synthetic and biologic disease-modifying antirheumatic drugs to be considered for the treatment of PsA have been reported.

CONCLUSIONS

The implementations of these practical recommendations could be very helpful for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

Musculoskeletal ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review

Objective

To systematically review the role of musculoskeletal US in patients suffering from PsA or psoriasis (Pso) in terms of prevalence, diagnosis, prognosis, monitoring and treatment.

Methods

A systematic literature review was conducted through medical databases (MEDLINE via PubMed, Embase) and the grey literature up to September 2015 to inform a new study of the Musculoskeletal Ultrasound Study Group of the Italian Society for Rheumatology. All articles reporting data on musculoskeletal US in PsA or Pso were included and extracted according to the underlying clinical question.

Results

A total of 86 publications were included. The prevalence of US abnormalities showed a wide range for each examined feature (e.g. 37-95% for entheses thickness of the lower limbs). The performance of US for diagnosis of disease or elementary lesions was variable across studies, but no study evaluated the overall performance of US in addition to clinical findings for diagnosing PsA. Considering US in defining PsA and Pso prognosis, several works focused on US of entheses of lower limbs in Pso, while for the monitoring of PsA activity five different scoring systems were identified. Last, the results of the role of US in guiding intra-articular interventions were controversial for the clinical outcomes, but in favour of US for accuracy.

Conclusion

despite the recognized importance of US in the management of PsA and Pso, this review clearly demonstrated the need of pivotal research in order to optimize the use of US in the diagnosis and monitoring of psoriatic disease.