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Di Matteo A, Mankia K, Nam JL, Cipolletta E, Garcia-Montoya L, Duquenne L, Rowbotham E, Emery P. In anti-CCP+ at-risk individuals, radiographic bone erosions are uncommon and are not associated with the development of clinical arthritis. Rheumatology (Oxford) 2021; 60:3156-3164. [PMID: 33415335 DOI: 10.1093/rheumatology/keaa761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/08/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To investigate the prevalence, distribution and predictive value for the development of inflammatory arthritis (IA) of conventional radiography (CR) bone erosions (BE) in anti-CCP positive (CCP+) at-risk individuals with musculoskeletal (MSK) symptoms but without clinical synovitis. METHODS Baseline CR of the hands and feet of 418 CCP+ at-risk individuals were analysed. The presence of US-BE was explored in the anatomical areas in which CR-BE were reported. Hands and feet CR at the time of progression were analysed in a subset of individuals who developed IA (73/123, 59.3%). Logistic regression analyses were performed to calculate the predictive value of baseline CR-BE for the development of IA in 394 CCP+ individuals with ≥1 follow-up visit. RESULTS BE were detected in 17/418 (4.1%) CCP+ at-risk individuals (median Simple Erosions Narrowing Score-BE = 2.0, IQR: 1.0-2.0; median Sharp van der Heijde score-BE = 4.0, IQR: 3.0-8.5), most frequently in the foot joints (11/17, 64.7% individuals). A total of 123/394 (31.2%) CCP+ at-risk individuals developed IA; 7/17 (41.2%) with, and 116/377 (30.8%) without BE on CR (P = 0.37). US-BE were found in 4/7 (57.1%) individuals with CR-BE who developed IA, but only in 1/10 (10.0%) who did not. At the time of progression, new BE were detected in 4/73 (5.5%) CCP+ individuals on repeated CR. In the regression analyses, baseline CR-BE were not predictive for the development of IA. CONCLUSIONS In CCP+ at-risk individuals with MSK symptoms, CR-detected BE are uncommon and do not predict the development of IA.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, 'Carlo Urbani' Hospital, Ancona, Italy
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, 'Carlo Urbani' Hospital, Ancona, Italy
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Rowbotham
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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What Is the Value of Ultrasound in Individuals 'At-Risk' of Rheumatoid Arthritis Who Do Not Have Clinical Synovitis? Healthcare (Basel) 2021; 9:healthcare9060752. [PMID: 34207207 PMCID: PMC8233794 DOI: 10.3390/healthcare9060752] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 12/22/2022] Open
Abstract
The identification of biomarkers that help identify individuals at imminent risk of progression to rheumatoid arthritis (RA) is of crucial importance for disease prevention. In recent years, several studies have highlighted the value of musculoskeletal (MSK) ultrasound (US) in predicting progression to inflammatory arthritis (IA) in individuals ‘at-risk’ of RA. These studies have highlighted the following main aspects: first, in RA-related autoantibody-positive individuals, MSK symptoms seem to develop before ‘sub-clinical’ joint inflammation occurs on US. Second, the detection of ‘sub-clinical’ synovitis (and/or bone erosions) greatly increases the risk of IA development in these ‘at-risk’ individuals. US has a potential key role for better understanding the ‘pre-clinical’ stages in individuals ‘at-risk’ of RA, and for the early identification of those individuals at high risk of developing IA. Further research is needed to address questions on image analysis and standardization. In this review, we provide an overview of the most relevant studies which have investigated the value of US in the prediction of RA development in individuals ‘at-risk’ of RA who have MSK symptoms, but no clinical evidence of IA. We highlight recent insights, limitations, and future perspectives of US use in this important population.
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Yago T, Asano T, Fujita Y, Migita K. Familial Mediterranean fever phenotype progression into anti-cyclic citrullinated peptide antibody-positive rheumatoid arthritis:a case report. Fukushima J Med Sci 2020; 66:160-166. [PMID: 33162488 PMCID: PMC7790467 DOI: 10.5387/fms.2020-07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Familial Mediterranean fever (FMF) is caused by dysfunction of the MEFV gene product, pyrin. Here we report a case of FMF phenotype which developed into rheumatoid arthritis (RA), based on a positive result for anti-cyclic citrullinated peptide (CCP) antibody (Ab). A 42-year-old woman presented to our clinic with more than 6 months of intermittent arthralgia in the wrists, feet, and fingers associated with menstruation. No fever was reported and there was no family history of FMF or other autoimmune diseases. Laboratory tests revealed elevated C-reactive protein (CRP) and rheumatoid factor (RF). Tests for autoantibodies including anti-CCP Ab, antinuclear Ab, and anti-DNA Ab were all negative. Genetic analysis identified an R304R homozygous mutation in MEFV; however, the pathological significance is unclear because this mutation does not cause amino acid substitution. We diagnosed incomplete FMF phenotype despite the lack of fever due to periodic arthritis, lack of autoantibodies, and complete resolution of arthritis following colchicine treatment within a day. Several months later, increased stiffness and arthralgia persistently occurred in finger joints on both sides. Ultrasonography revealed synovitis at the metacarpophalangeal and metatarsophalangeal joints. Laboratory analysis revealed the patient to be positive for anti-CCP Ab. Therefore, we finally diagnosed RA. Her arthritis diminished following administration of methotrexate and salazosulfapyridine. We consider the possibility that pyrin dysfunction may have affected the acquired immunity, contributing to the onset of RA as an autoimmune disease. This is an interesting case of equivalent FMF progressing into RA and will be valuable to raise awareness of a continuum from autoinflammatory to autoimmune disease.
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Affiliation(s)
- Toru Yago
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
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4
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Ranganath VK, Hammer HB, McQueen FM. Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI. Best Pract Res Clin Rheumatol 2020; 34:101593. [PMID: 32988757 DOI: 10.1016/j.berh.2020.101593] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.
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Affiliation(s)
- Veena K Ranganath
- University of California, David Geffen School of Medicine, Los Angeles, USA.
| | - Hilde B Hammer
- Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
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Di Matteo A, Mankia K, Wakefield RJ, Emery P. Which joints and what pathological findings should be evaluated on ultrasound in CCP+ at-risk individuals? The fifth MTP joint for bone erosions is a good starting point. Response to: 'Pisotriquetral arthritis: 'forgotten' joint in ultrasound imaging of the wrist' by Becciolini et al. Ann Rheum Dis 2020; 81:e98. [PMID: 32513649 DOI: 10.1136/annrheumdis-2020-218036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Andrea Di Matteo
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK.,Clinica Reumatologica, Dipartimento di Scienze Cliniche e Molecolari, Universita Politecnica delle Marche, Ancona, Italy
| | - Kulveer Mankia
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Richard J Wakefield
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Paul Emery
- University of Leeds Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Leeds, UK .,NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
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Boylan M. Should ultrasound be used routinely in the diagnosis of rheumatoid arthritis? Ir J Med Sci 2019; 189:735-748. [PMID: 31646431 DOI: 10.1007/s11845-019-02096-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/04/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION A growing body of evidence indicates the benefits of early diagnosis of rheumatoid arthritis (RA) and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDS) in terms of relieving symptoms, improving prognosis, and reducing long-term complications. There is however some controversy over the most beneficial method of imaging in providing accurate early diagnosis. Though current practice favours clinical and radiological assessment, this is increasingly supplemented by ultrasound techniques (and, to a lesser extent, CT and MRI scanning). While EULAR and ESSR favour the use of ultrasonography (US) as the first-line investigation in cases of suspected RA, a recent NICE review upholds the traditional place of plain film radiographs of hands and feet to detect erosions as early signs of synovitis. This review considers the evidence for US in the early diagnosis of RA and the case for it becoming the primary assessment modality in rheumatology clinics. AIMS This paper aims to assess the current literature on the efficacy of ultrasonography in diagnosing early RA, by comparing US with alternative imaging modalities. The goal is to propose the most appropriate method of diagnosis to improve early initiation of DMARD treatment for optimum disease outcomes. METHODS Searches for related studies and review articles were carried out using electronic databases and hand searches. Additional references were gleaned from the bibliographies of included papers. Related articles and pop-outs from PubMed were also used. The search was refined in PubMed, by only using reviews which were written in English and published in past 10 years and had full free text available. RESULTS This review confirms that US has a high level of sensitivity in diagnosing RA (and hence a low risk of missing cases of RA which might benefit from early treatment with DMARDs). It also has a high level of specificity (and hence a low risk of falsely diagnosing somebody with RA who may suffer adverse effects of DMARD therapy). US is already widely available and well accepted by clinicians and patients. It does not involve exposure to radiation and can be readily delivered by appropriately trained staff. CONCLUSION This review of relevant studies indicates that US should become accepted as the investigation with the most favourable balance of benefits to risks in the early diagnosis of RA. Given the continuing controversy surrounding studies of different imaging techniques in RA, further research into the diagnostic role of US in RA is indicated.
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Affiliation(s)
- Maria Boylan
- Graduate Entry Medical School, University of Limerick - Faculty of Education & Health Services, Limerick, V94 T9PX, Ireland.
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van Beers-Tas MH, Blanken AB, Nielen MMJ, Turkstra F, van der Laken CJ, Meursinge Reynders M, van Schaardenburg D. The value of joint ultrasonography in predicting arthritis in seropositive patients with arthralgia: a prospective cohort study. Arthritis Res Ther 2018; 20:279. [PMID: 30567606 PMCID: PMC6300036 DOI: 10.1186/s13075-018-1767-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/12/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The value of joint ultrasonography (US) in the prediction of clinical arthritis in individuals at risk of developing rheumatoid arthritis (RA) is still a point of debate, due to varying scanning protocols and different populations. We investigated whether US abnormalities assessed with a standard joint protocol can predict development of arthritis in seropositive patients with arthralgia. METHODS Anti-citrullinated protein antibodies and/or rheumatoid factor positive patients with arthralgia, but without clinical arthritis were included. US was performed at baseline in 16 joints: bilateral metacarpophalangeal 2-3, proximal interphalangeal 2-3, wrist and metatarsophalangeal (MTP) joints 2-3 and 5. Images were scored semi-quantitatively for synovial thickening and for positive signs on power Doppler (PD). Association between US abnormalities and arthritis development at the joint and at the patient level was evaluated. Also, we investigated the added value of US over clinical parameters. RESULTS Out of 163 patients who underwent US examination, 51 (31%) developed clinical arthritis after a median follow-up time of 12 (interquartile range 5-24) months, of which 44 (86%) satisfied the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA. US revealed synovial thickening and PD in at least one joint in 49 patients (30%) and 7 patients (4%), respectively. Synovial thickening was associated with both development and timing of clinical arthritis in any joint (patient level) when MTP joints were excluded from the US assessment (odds ratio 6.6, confidence interval (CI) 1.9-22), and hazard ratio 3.4, CI 1.6-6.8, respectively, with a mean time to arthritis of 23 versus 45 months when synovial thickening was present versus not present). There was no association between US and arthritis development at the joint level. Predictive capacity was highest in the groups with an intermediate and high risk of developing arthritis based on a prediction rule with clinical parameters. CONCLUSIONS Synovial thickening on US predicted clinical arthritis development at the patient level in seropositive patients with arthralgia when MTPs were excluded from the US assessment. Positive PD signs were infrequently seen in these at-risk individuals and was not predictive. In patients at intermediate risk of RA, US may help to identify those at higher risk of developing arthritis.
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Affiliation(s)
- Marian H van Beers-Tas
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands.
| | - Annelies B Blanken
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
| | - Mark M J Nielen
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118-124, 3513 CR, Utrecht, The Netherlands
| | - Franktien Turkstra
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
| | - Conny J van der Laken
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - Marlies Meursinge Reynders
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center
- Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Zhang YH, Li K, Xiao J, Zhang HD, Zhang XY. Comparison of Ultrasound, Radiography, and Clinical Investigations in the Diagnosis of Early Rheumatoid Synovitis in Patients with Nonspecific Musculoskeletal Symptoms: A Multicenter Cross-Sectional Study. Med Sci Monit 2018; 24:4372-4378. [PMID: 29939979 PMCID: PMC6048998 DOI: 10.12659/msm.908755] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Early diagnosis and treatment of rheumatoid synovitis can reduce the progression of rheumatoid arthritis (RA). However, in the early stages of rheumatoid synovitis, patients may only have non-specific musculoskeletal symptoms, and plain film radiographs may not detect early synovial changes. The aim of this study was to compare the sensitivity and specificity of ultrasound with radiography, and clinical investigations in the detection of rheumatoid synovitis in patients presenting with nonspecific musculoskeletal symptoms. MATERIAL AND METHODS This was a non-randomized, cross-sectional, clinical study that included 189 patients who had nonspecific musculoskeletal symptoms. All patients underwent clinical investigations, postero-anterior and dorsal radiographic imaging, and bilateral grey-scale ultrasound examinations of the third and second metacarpophalangeal (MCP) joints, the third and the second proximal interphalangeal (PIP) joints, the second and the fifth metatarsophalangeal (MTP) joints, and the wrist. RESULTS There was no clear predictive value for detection of early synovitis by clinical investigations alone. Plain film radiography of patients only provided accurate information of joint erosions but less information for synovitis. Grey-scale ultrasound was more effective at detecting early synovitis compared with clinical investigations (p=0.00015; q=4.548) and compared with plain film radiography (p=0.0002; q=4.537), and quantified the synovial changes. The predictive values of plain film radiography and clinical investigations had 0.43 and 0.24 sensitivity and 0 specificity compared with ultrasound. CONCLUSIONS The findings of this study support the use of grey-scale ultrasound in the detection of early rheumatoid synovitis of the fingers and the wrist.
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Affiliation(s)
- Ying-Hua Zhang
- Department of Ultrasonography, Jining No. 1 Peoples' Hospital, Jining, Shandong, China (mainland)
| | - Kang Li
- Department of Bone and Joint Surgery, Heze Municipal Hospital, Heze, Shandong, China (mainland)
| | - Jing Xiao
- Department of Ultrasonography, Jining No. 1 Peoples' Hospital, Jining, Shandong, China (mainland)
| | - Hai-Dong Zhang
- Department of Functional Studies, Yanzhou Hospital of Traditional Chinese Medicine, Yanzhou, Shandong, China (mainland)
| | - Xiao-Yan Zhang
- Department of Ultrasonography, Rencheng District First Maternal and Child Health Care Hospital, Jining, Shandong, China (mainland)
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