Ultrasonographic detection of enthesitis and its relation to clinical manifestations among Egyptian systemic sclerosis patients

Background

Systemic sclerosis is a complex multi-systemic autoimmune disease with a wide range of its clinical manifestations; many systemic sclerosis (SSc) patients develop musculoskeletal manifestations during their course of illness. The aim of the study is to assess the prevalence of sonographically detected entheseal alterations in a case-control study of systemic sclerosis patients and to evaluate the relationship between the presence of these alterations and the clinical systemic manifestations. Patients and controls were evaluated using B mode and power Doppler ultrasonography to detect presence of enthesitis and were scored using Madrid Sonography Enthesitis Index (MASEI).

Results

In SSc patients, the MASEI score was significantly higher than in control (P < 0.0001). Enthesitis was more prevalent among SSc patients compared to healthy controls, SSc patients with enthesitis had significantly more prevalence of diffuse subtypes (P < 0.001).SSc patients had significantly more prevalence of interstitial pulmonary fibrosis (IPF) (P < 0.001), digital ulcers (P < 0.001), pulmonary hypertension (P < 0.001), and arthralgia and arthritis (P < 0.001). Regarding nailfold capillaroscopy pattern, late pattern was significantly more prevalent among patients with enthesitis (P = 0.008). Age, ESR level, and modified Rodnan skin score were predictors for MASEI score.

Conclusions

Ultrasound features of enthesopathy were frequently presented in systemic sclerosis patients. The enthesopathy was correlated with inflammation and disease complications.

Tofacitinib in the treatment of skin and musculoskeletal involvement in patients with systemic sclerosis, evaluated by ultrasound

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by fibrosis of the skin and internal organs, autoimmunity-driven damage and vasculopathy. The current approved disease-modifying treatments have limited efficacy, and treatment is guided toward alleviating organ complications. Thus, there is an unmet need for discovering new effective treatment options. There is recent evidence that the JAK/STAT signaling pathway is markedly activated in SSc patients. To assess the efficacy and safety of tofacitinib (TOF) on skin and musculoskeletal involvement as compared to methotrexate (MTX) in systemic sclerosis (SSc). In this 52-week pilot study, 66 patients with SSc were enrolled: 33 patients received 5 mg of oral TOF twice a day; 33 received 10 mg of MTX weekly. The proportion of dcSSc and lcSSc patients was similar (dcSSc: 42% TOF group and 36% MTX group; lcSSc: 58% TOF group and 64% MTX group). The primary outcome was the change in the modified Rodnan skin score (mRSS). Secondary outcomes included ultrasound (US) skin thickness and musculoskeletal involvement (US10SSc score). Digital ulcers (DUs) and adverse events (AEs) were documented through the treatment. Both groups had similar characteristics and medians on the outcome measures at baseline. At week 52, the TOF median mRSS was significantly lower than the MTX (p < 0.001) with a mean reduction of 13 points versus MTX 2.57. The mean percent improvement in the TOF group was 44% higher than in the MTX group. TOF median US skin thickness was significantly lower than MTX (p < 0.001), with a mean reduction of 0.31 mm versus 0.075 mm in the MTX group. The US10SSc median score was significantly lower in the TOF group (p = 0.002); mean reduction of 10.21 versus 5.27 in the MTX group. Healing of DUs with no new occurrences was observed in the TOF group. There was no significant difference between the groups in the number of AEs from baseline to week 52. TOF showed greater efficacy than MTX in reducing mRSS, skin thickness and musculoskeletal involvement in SSc and a satisfactory safety profile.

A narrative review of imaging in calcinosis associated with systemic sclerosis

Calcinosis is dystrophic calcification of the soft tissue which can lead to painful and debilitating disease. It is commonly seen in patients with systemic sclerosis (SSc). Imaging can assist in diagnosis, quantification of disease, and better pathophysiologic understanding of calcinosis. Traditionally, X-rays have been the most frequently used imaging modality for diagnosis; however, advances in ultrasound (US), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) have led to greater ability to characterize these lesions and surrounding structures. This narrative review aims to describe the use of imaging for calcinosis in patients with SSc. Key Points • Imaging is useful in the diagnosis of calcinosis, assessment of disease severity, and disease monitoring. • X-ray is commonly used and offers high sensitivity and specificity, but both ultrasound and CT-scans are alternatives when greater anatomic detail is sought regarding surrounding structures. • Investigational imaging modalities include dual energy CT-scans, cinematic rendering CT-scans, and PET- CT scans. • Conventional MRI scans have less sensitivity and specificity for detection of calcinosis.