Ultrasonography and detection of subclinical joints and tendons involvements in Systemic Lupus erythematosus (SLE) patients: A cross-sectional multicenter study

Examining the clinical and radiological landscape of rhupus: navigating the challenges in disease classification

Rhupus, in the broad sense, refers to an overlap between rheumatoid arthritis (RA) and lupus. However, there is a paucity of data on the appropriate diagnostic/classification criteria that should be used to define rhupus. Hence, we undertook this narrative review to analyze the clinical characteristics, radiology, and treatment with a focus on diagnostic challenges and defining features of rhupus. The databases of Medline/PubMed, Scopus, and DOAJ were searched for relevant articles using the following keywords: ("Rhupus"), ("lupus" AND "erosive" AND "arthritis"), and ("lupus" AND "rheumatoid arthritis" AND "overlap"). Studies have used a variety of classification criteria for rhupus of which a combination of the latest classification criteria for RA and lupus along with positive anti-cyclic citrullinated peptide, anti-Smith, and anti-dsDNA antibodies seem most relevant. The majority of rhupus cohorts report the onset of the disease as RA (two-thirds of rhupus patients) followed by the development of features of lupus at an average interval of 3-11.3 years. The radiographic features and distribution of erosions are similar to RA. However, ultrasonography and MRI reveal erosions in pure lupus related arthritis as well. This makes the reliability of radiologic tools for the evaluation of rhupus supportive at the most. Extra-articular features in rhupus are mild with major organ involvement in the form of neuropsychiatric lupus and lupus nephritis being rare. We have further discussed the fallacies of the various classification criteria and proposed a theme for classifying rhupus which needs to be tested and validated in future studies. Our current state of understanding supports rhupus as an overlap of SLE and RA with articular disease similar to RA with the extra-articular disease being milder than SLE. Developing standardized classification criteria for rhupus will help in the early diagnosis and prevention of articular damage in patients with rhupus.

Effect of low-level gallium aluminum arsenide laser therapy on the chewing performance and pain perception of patients with systemic lupus erythematosus: A randomized controlled clinical trial

OBJECTIVE

To evaluate the effect of low-level laser therapy (LLLT) on pain intensity (PI) and chewing performance (CP) in systemic lupus erythematosus (SLE) patients with myogenic temporomandibular disorder (TMD).

METHODS

Ninety-one patients were randomly allocated to three groups: Group L (intervention), Group P (placebo), and Group C (control). Outcomes were PI (assessed with visual analog scale (VAS)) and CP (assessed with the geometric mean diameter (GMD) of crushed test food). Measurements were performed at T0 (before the LLLT), T1 (immediately after the LLLT), and T2 (1-month follow-up). Data were analyzed using Generalized Linear Models, Kruskal-Wallis, and Friedman tests.

RESULTS

For T1 and T2, Group L demonstrated the lowest values for both GMD (6283.7 ± 257.2 µm; 6382.7 ± 303.7 µm) and VAS (5;6) (p < 0.001).

CONCLUSION

LLLT was an effective therapeutic approach in reducing pain and improving CP for one month in SLE patients with myogenic TMD.

Subclinical synovitis impact on the progression of lupus joint disease: A 10-year longitudinal multicenter study

OBJECTIVE

To determine the effect of subclinical synovitis on the progression of joint disease in a cohort of patients with systemic lupus erythematosus over a mean follow-up of 10 years.

METHODS

A longitudinal follow-up of 96 patients diagnosed with lupus was performed. All patients were considered clinically free of joint disease or with minimal joint impairment at baseline and were studied through ultrasound study of their dominant hand to assess the prevalence of subclinical synovitis. Now, over 10 years after we contacted them and reviewed their evolution to determine the impact of had or had not been diagnosed with subclinical synovitis in their current joint condition.

RESULTS

Thirty-one of the 91 reached patients developed clinical progression in their joint manifestations (at least one ordinal degree of worsening). Of these, 23 (74,9%) had demonstrated subclinical synovitis at baseline. In the group of patients who did not progress clinically, 46 (76,6%) did not have this finding at the start of follow-up (p < .01, OR 9,44 95%CI 3,46-25,74). The patients in whom clinical progression was demonstrated had worse combined ultrasound scores than the rest of the patients: 6,41 SD 1,45 vs. 1,15 SD 0,97 (p < .01).

CONCLUSIONS

The finding of subclinical synovitis in patients with systemic lupus erythematosus is associated with the development of joint disease progression both clinically and ultrasonographically.

Musculoskeletal involvement in systemic lupus erythematosus: a contrast-enhanced magnetic resonance imaging study in 107 subjects

OBJECTIVE

Joint involvement in SLE is the most frequent manifestation and shows a wide heterogeneity. It has not a valid classification and it is often underestimated. Subclinical inflammatory musculoskeletal involvement is not well known. We aim to describe the prevalence of joint and tendon involvement in hand and wrist of SLE patients, either with clinical arthritis, arthralgia or asymptomatic and compare it with healthy subjects using contrasted MRI.

METHODS

SLE patients fulfilling SLICC criteria were recruited and classified as follows: group (G) 1: hand/wrist arthritis, G2: hand/wrist arthralgia, G3: no hand/wrist symptoms. Jaccoud arthropathy, CCPa and RF positivity, hand OA or surgery were excluded. Healthy subjects (HS) were recruited as controls: G4. Contrasted MRI of non-dominant hand/wrist was performed. Images were evaluated following RAMRIS criteria extended to PIP, Tenosynovitis score for RA and peritendonitis from PsAMRIS. Groups were statistically compared.

RESULTS

A total of 107 subjects were recruited (G1: 31, G2:31, G3:21, G4:24). Any lesion: SLE patients 74.7%, HS 41.67%; P 0.002. Synovitis: G1: 64.52%, G2: 51.61%, G3: 45%, G4: 20.83%; P 0.013. Erosions: G1: 29.03%; G2: 54.84%, G3: 47.62%; G4: 25%; P 0.066. Bone marrow oedema: G1: 29.03%, G2: 22.58%, G3: 19.05%, G4: 0.0%; P 0.046. Tenosynovitis: G1: 38.71%; G2: 25.81%, G3: 14.29%, G4: 0.0%; P 0.005. Peritendonitis: G1: 12.90%; G2: 3.23%, G3: 0.0%, G4: 0.0%; P 0.07.

CONCLUSION

SLE patients have a high prevalence of inflammatory musculoskeletal alterations confirmed by contrasted MRI, even if asymptomatic. Not only tenosynovitis but peritendonitis is also present.

Improving measures of disease activity in systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a multisystem disease with varied manifestations and course. Variation in presentation among patients, and within the same patient, there may be varied manifestations over time. It has been difficult to measure the extent of disease activity accurately. Several investigators and groups have developed definitions of disease activity and methods to measure it. Consequently, there are currently several instruments to measure disease activity as well as damage in patients with SLE.

AREAS COVERED

This review covers currently available evidence on measures of disease activity in SLE. It discusses potential avenues for further development of new measures and the refinement of existing tools to improve disease activity measures in research and clinical care settings.

EXPERT OPINION

Given the complexity and heterogeneity of the disease, further work and tools are needed to assess disease activity better. Organ-specific measures for cutaneous, renal, and joint manifestations are needed for a detailed assessment of disease activity in conjunction with the use of disease generic tools (e.g. SLEDAI). New tools such as the SLE Disease Activity Index-Glucocorticoid Index (SLEDAI-2 KG) incorporating glucocorticoid doses to describe disease activity, SLE-DAS and SLEDAI-2 K RI-50 to record partial improvements could also be helpful.

Contribution of Ultrasound in Current Practice for Managing Juvenile Idiopathic Arthritis

The interest and application of musculoskeletal ultrasound (MSUS) in juvenile idiopathic arthritis (JIA) are increasing. Numerous studies have shown that MSUS is more sensitive than clinical examination for detecting subclinical synovitis. MSUS is a well-accepted tool, easily accessible and non-irradiating. Therefore, it is a useful technique throughout JIA management. In the diagnostic work-up, MSUS allows for better characterizing the inflammatory involvement. It helps to define the disease extension, improving the classification of patients into JIA subtypes. Moreover, it is an essential tool for guiding intra-articular and peritendinous procedures. Finally, during the follow-up, in detecting subclinical disease activity, MSUS can be helpful in therapeutic decision-making. Because of several peculiarities related to the growing skeleton, the MSUS standards defined for adults do not apply to children. During the last decade, many teams have made large efforts to define normal and pathological US features in children in different age groups, which should be considered during the US examination. This review describes the specificities of MSUS in children, its applications in clinical practice, and its integration into the new JIA treat-to-target therapeutic approach.

The frequency and characteristics of ultrasonographic ankle joint involvement in systemic lupus erythematosus: A prospective cross-sectional single-center study

The involvement of ankles in systemic lupus erythematosus (SLE) has not been widely studied. The aim of our prospective study was to determine the characteristics of the ankle joint and tendon involvement in SLE using ultrasound (US) as an imaging modality. Sixty consecutive patients with SLE underwent a detailed clinical evaluation and US examination. Gray-scale and power Doppler US of the bilateral tibiotalar (TT) joints, subtalar (ST) joints, and ankle tendons were performed using a multiplanar scanning technique. Joint effusion, synovitis, tenosynovitis, enthesitis, and vascularization were assessed according to the OMERACT recommendations. The Total Ankle Ultrasound Score (TAUSS) was calculated as the sum of the grades of joint effusion and synovial hypertrophy for both TT and ST joints bilaterally (ranging from 0-24) and power Doppler activity was assessed separately. Finally, US findings were correlated with physical evaluation, laboratory parameters, and SLE activity scores. US ankle joint involvement was present in 32/60 (53.3%) patients. TT joints were affected in 26 (43.3%) and ST joints in 16 (26.7%) patients. Thirteen (21.7%) patients had US tendons and/or enthesal involvement. TT joint effusion was the most frequent finding, present in 55/240 (22.9%) examined joints, followed by synovial hypertrophy detected in 18/240 (7.5%) joints. The median (interquartile range; range) TAUSS of the US-affected joints was 1 (0-2; range 1-10). There were no significant correlations between US findings and inflammatory parameters or serological parameters of disease activity, but we found a weak positive correlation between TAUSS and the European Consensus Lupus Activity Measurement (r = 0.281, P = .029). This study revealed a high prevalence of pathological US ankle changes in patients with SLE and a positive correlation between ankle US involvement and disease activity score (European Consensus Lupus Activity Measurement).

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Ultrasound to identify systemic lupus erythematosus patients with musculoskeletal symptoms who respond best to therapy: the US Evaluation For mUsculoskeletal Lupus longitudinal multicentre study

OBJECTIVES

To determine whether SLE patients with inflammatory joint symptoms and US synovitis/tenosyovitis achieve better clinical responses to glucocorticoids compared with patients with normal scans. Secondary objectives included identification of clinical features predicting US synovitis/tenosynovitis.

METHODS

In a longitudinal multicentre study, SLE patients with physician-diagnosed inflammatory joint pain received intramuscular methylprednisolone 120 mg once. Clinical assessments, patient-reported outcomes and bilateral hand/wrist USs were collected at 0, 2 and 6 weeks. The primary outcome (determined via internal pilot) was the early morning stiffness visual analogue scale (EMS-VAS) at 2 weeks, adjusted for baseline, comparing patients with positive (greyscale ≥2 and/or power Doppler ≥1) and negative US. Post hoc analyses excluded FM.

RESULTS

Of 133 patients, 78 had a positive US. Only 53 (68%) of these had one or more swollen joint. Of 66 patients with one or more swollen joint, 20% had a negative US. A positive US was associated with joint swelling, symmetrical small joint distribution and serology. The primary endpoint was not met: in the full analysis set (N = 133) there was no difference in baseline-adjusted EMS-VAS at week 2 [-7.7 mm (95% CI -19.0, 3.5); P = 0.178]. After excluding 32 patients with FM, response was significantly better in patients with a positive US at baseline [baseline-adjusted EMS-VAS at 2 weeks -12.1 mm (95% CI -22.2, -0.1); P = 0.049]. This difference was greater when adjusted for treatment [-12.8 mm (95% CI -22, -3); P = 0.007]. BILAG and SLEDAI responses were higher in US-positive patients.

CONCLUSION

In SLE patients without FM, those with a positive US had a better clinical response to therapy. Imaging-detected synovitis/tenosynovitis may be considered to decide on therapy and enrich clinical trials.

Erosive arthritis in systemic lupus erythematosus: not only Rhupus

Systemic lupus erythematosus (SLE)-related arthritis has been traditionally defined as non-erosive and is therefore considered a minor manifestation requiring a mild treatment. However, the concept of non-erosive arthritis in SLE has been challenged with the advent of sensitive imaging techniques, such as high-resolution ultrasound with power Doppler or magnetic resonance. The application of these new imaging tools has demonstrated that up to 40% of SLE patients with joint involvement can develop erosive damage. Thus, this more aggressive phenotype can be identified not only in patients overlapping with rheumatoid arthritis (RA). This issue has been considered for the first time in the classification criteria proposed by Systemic Lupus International Collaborating Clinics in 2012, in which the old definition of "non-erosive arthritis" was replaced with either synovitis or tenderness in two or more joints with morning stiffness, suggesting the possible presence of an erosive phenotype. Accordingly, the 2019 EULAR/ACR's SLE recommendations advise treatment with immunosuppressant or biological drugs for patients with RA-like moderate arthritis. As a result, several studies have investigated the presence of biomarkers associated with SLE erosive damage. A relevant role seems to be played by the autoantibodies directed against post-translational modified proteins: above all, a significant association has been observed with antibodies directed against citrullinated and carbamylated proteins. Conversely, the rheumatoid factor was not associated with this more aggressive SLE-related arthritis. Nonetheless, some pro-inflammatory factors have been associated with erosive damage in SLE patients. These results suggest new pathogenic mechanisms underlining erosive arthritis, only partially shared with RA. Hence, in the present narrative review, we summarized available data about erosive arthritis in SLE patients, in the light of its impact on therapeutic decisions.

Involvement of the wrist and hand joints and tendons in an Egyptian systemic lupus erythematosus cohort

Background

Systemic lupus erythematosus (SLE) patients often suffer hand function limitations even in the absence of symptoms related to joint or tendon disorders. Recent researches reported the presence of ultrasonographic (US) subclinical synovitis and tendon involvement in asymptomatic patients. We aimed to assess US patterns in SLE patients and determine their relationship with clinical assessment, disease activity and hand functional status using handheld dynamometry.

Results

We assessed 30 SLE patients (60 hands) using US; 21 (70%) patient had synovial hypertrophy, 8 (26%) showed a power Doppler (PD) activity, 6 (20%) had erosions and 11 (36.6%) had tendon US abnormality. Both patients with hand arthralgia/arthritis (symptomatic) and patients without arthralgia/arthritis (asymptomatic) had a statistically insignificant difference regarding the global synovitis score (p= 0.2) and disease activity (p= 0.3). However, the symptomatic group had a significantly increased number of joints with effusion (p= 0.04) and tendons involved (p= 0.04). The mean grip strength had a significant negative correlation with SLEDAI-2 K score (rs = − 0.4,p= 0.02) in the total patient group. In the asymptomatic group, a negative correlation was found between both mean grip (rs = − 0.5,p= 0.04) and pinch strength (rs = − 0.6,p= 0.01) with PD index, and mean pinch strength with the Jaccoud’s arthropathy index (rs = − 0.49,p= 0.05).

Conclusions

SLE patients may have higher subclinical synovitis, erosions and tendon involvement than expected, which may in turn reduce hand grip and pinch strength. Disease activity may also have a negative impact on the hand grip functional strength.

Need for Greater Attention to Joint Damage in Rhupus Patients: Results from an Ultrasound Study

Background

The aim of this study was to evaluate the prevalence of inflammation and bone destruction of hand joints in rhupus patients through ultrasound examination.

Material/Methods

Ten rhupus patients and 33 systemic lupus erythematosus (SLE) patients with hand arthropathy were recruited in this single-center study, and the clinical features and ultrasound manifestations of these patients were analyzed.

Results

We discovered that rhupus patients were older (47.31±4.35 years vs. 38.58±2.50 years, P=0.040), had longer duration of disease (median 72 months vs. median 12 months, P=0.040), had a higher positive rate (70% vs. 10.71%, P<0.001), and had higher titers of anti-CCP antibody (42.633±14.520 vs. 2.121±0.970, P<0.001) than SLE patients with arthropathy. More importantly, the prevalence rates of synovial hyperplasia (90% vs. 42.42%, P=0.008), synovitis (90% vs. 18.18%, P<0.001), synovial hyperplasia (70% vs. 10.71%, P<0.001), and bone destruction (70% vs. 6.06%, P<0.001) were higher in rhupus patients than in SLE patients with arthropathy.

Conclusions

Rhupus patients are more prone to develop synovitis, synovial hyperplasia, and bone destruction. Therefore, more attention should be paid to protection of the joints in rhupus patients.

Defining inflammatory musculoskeletal manifestations in systemic lupus erythematosus

Objective

To define the prevalence and clinical associations of clinical and imaging definitions of synovitis in unselected SLE patients with musculoskeletal (MSK) symptoms.

Methods

112 patients with SLE (excluding RF and CCP positive patients); 88 consecutive with inflammatory MSK symptoms and 24 asymptomatic SLE controls were recruited. Patients had clinical assessment (BILAG, SLEDAI, joint counts, patient and physician visual analogue score), routine laboratory tests and US of two hands and wrists (synovitis and tenosynovitis, OMERACT definitions).

Results

Overall, 68% (60/88) of symptomatic patients had US inflammation (grey scale ⩾ 2 and/or PD ⩾ 1 or tenosynovitis) compared with 17% (4/23) of asymptomatic patients. In symptomatic patients, clinical inflammation was seen defined by BILAG A or B in 38% (34/88) or defined by the SLEDAI-MSK criterion in 32% (28/88). BILAG A/B had sensitivity (95% CI) of 56% (41, 69%) and specificity of 89% (72, 96%) for US-confirmed inflammation. SLEDAI-MSK criterion had sensitivity of 44% (31, 59%) and specificity of 89% (72, 96%). In patients with inflammatory symptoms, 27% (24/88) had subclinical inflammation (abnormal US but no clinically swollen joints) and 35% (31/88) had no clinical or US inflammation. Subclinical tenosynovitis and PD were associated with significantly higher IgG, physician visual analogue score, tender joint count.

Conclusion

In SLE patients with MSK symptoms, a large proportion of objective, clinically meaningful inflammation is only identifiable by US. The existing classification of MSK SLE using disease activity instruments based on joint swelling is inaccurate to guide patient selection for clinical trials, biologic therapy, or treat-to-target protocols.

Musculoskeletal Ultrasound in Systemic Lupus Erythematosus: Systematic Literature Review by the Lupus Task Force of the OMERACT Ultrasound Working Group

OBJECTIVE

To identify and synthesize the best available evidence on the application of musculoskeletal (MSK) ultrasound (US) in patients with systemic lupus erythematosus (SLE) and to present the measurement properties of US in different elementary lesions and pathologies.

METHODS

A systematic literature search of PubMed, Embase, and the Cochrane Library was performed. Original articles were included that were published in English between August 1, 2014, and December 31, 2018, reporting US, Doppler, synovitis, joint effusion, bone erosion, tenosynovitis, and enthesitis in patients with SLE. Data extraction focused on the definition and quantification of US-detected synovitis, joint effusion, bone erosion, tenosynovitis, enthesitis, and the measurement properties of US according to the OMERACT Filter 2.1 instruments selection.

RESULTS

Of the 143 identified articles, 15 were included. Most articles were cross-sectional studies (14/15, 93%). The majority of the studies used the OMERACT definitions for ultrasonographic pathology. Regarding the measurement properties of US in different elementary lesions and pathologies, all studies dealt with face validity, content validity, and feasibility. Most studies achieved construct validity. Concerning the reliability of image reading, 1 study (1/15, 7%) assessed both intraobserver and interobserver reliability. For image acquisition, 4 studies (4/15, 27%) evaluated interobserver reliability and none had evaluated intraobserver reliability. Criterion validity was assessed in 1 study (1/15, 7%). Responsiveness was not considered in any of the studies.

CONCLUSION

This literature review demonstrates the need for further research and validation work to define the involvement of US as an outcome measurement instrument for the MSK manifestations in patients with SLE.