Updating the use of the Madrid Sonographic Enthesis Index (MASEI): a systematic review of the literature

Prevalence of spondyloarthritis in inflammatory bowel disease according ASAS and ultrassonography and its correlation with plasma calprotectin

BACKGROUND

Enteropathic spondyloarthritis is underdiagnosed and inflammatory biomarkers and ultrasonography (US) could be useful for screening inflammatory bowel disease (IBD) patients. The objective of this study was to evaluate the prevalence of spondyloarthritis (SpA) in IBD patients, according to the Assessment of SpondyloArthritis International Society (ASAS) criteria and the correlation of results of US of entheses and joints with plasma calprotectin levels.

METHODS

This was an observational cross-sectional study. Patients from the IBD outpatient clinic of a reference center were evaluated according to ASAS criteria classification, results of US of entheses and joints, and inflammatory biomarker measurements (erythrocyte sedimentation rates, C-reactive protein levels, fecal and plasma calprotectin levels). A p value lower than 0.05 was considered significant.

RESULTS

A total of 30.5% of the studied sample (n = 118) of patients with IBD presented at least one inflammatory musculoskeletal manifestation. The overall prevalence of enteropathic SpA was 13.55%, with 10.16% axial SpA and 4.23% peripheral SpA according to the ASAS criteria. A total of 42.1% of patients had an MASEI score greater than 18, 35.2% had synovitis, and 14.7% had tenosynovitis on US, increasing the frequency of diagnosis of enteropathic SpA to 22.8%. Plasma calprotectin levels were similar to those in healthy controls, and correlated only with the fecal calprotectin level (p 0.041).

CONCLUSIONS

A total of 13.5% of patients met the criteria in accordance with the ASAS criteria for enteropathic SpA, which increased to 22.8% with the addition of US. The prevalence of enthesitis, synovitis and tenosynovitis by US of symptomatic joints and entheses were 42%, 35% and 14.7% respectively. Plasma calprotectin was correlated with fecal calprotectin but not with inflammatory biomarkers or US or ASAS criteria.

The identification of association between ultrasonographic enthesitis and the ASAS Health Index in patients with axial spondyloarthritis

This study aimed to evaluate association between the entheseal abnormalities in ultrasound and the Assessment of Spondyloarthritis International Society Health Index (ASAS HI) in patients with axial spondyloarthritis (axSpA). Seventy-four patients with axSpA were enrolled in this study. Ultrasonographic evaluation of entheses was performed by a blinded rheumatologist with the Madrid Sonographic Enthesitis Index (MASEI). The MASEI total score and the MASEI sub-scores (e.g., structural damage and activity scores) were calculated. The ASAS HI and the other SpA tools (e.g., Bath Ankylosing Spondylitis Disease Index, the Ankylosing Spondylitis Disease Activity Score) were used to evaluate patients' health and disease activity. Correlation and multivariate linear regression analyses were performed to assess the relationship between the MASEI and the ASAS HI. The mean score of the ASAS HI was 7.7 ± 4.6. The MASEI total score was calculated as 8.4 ± 6.8, while the mean MASEI-activity was 4.7 ± 3.6 and the mean MASEI-structural damage was 3.8 ± 4.5. There was no correlation between ASAS HI and MASEI total scores (r = 0.11, p = 0.34). However, the ASAS HI had a positive correlation with the MASEI-activity (r = 0.49, p < 0.001) and had a low negative correlation with the MASEI-structural damage (r = - 0.29, p < 0.05). In the linear regression model, the MASEI-activity and MASEI-structural damage were significantly related to the ASAS HI (β = 0.72 and - 0.58, respectively; R² = 0.53 p < 0.001). This study reported that the ASAS HI score was more negatively affected by active entheseal lesions rather than structural lesions. We suggest adding the entheses evaluation with ultrasonography to other tools for monitoring the health status of patients with axSpA.

Entheseal Involvement in Spondyloarthritis (SpA) and Gout: An Ultrasound Comparative Study

Objective

To compare the assessment of entheses in subjects with spondyloarthritis (SpA) with patients with gout by the Madrid Sonographic Enthesis Index (MASEI).

Method

This cross-sectional study includes videos of entheses evaluated by ultrasound (US) of 30 patients with SpA diagnosed according to the ASAS criteria and 30 patients with gout established by the presence of monosodium urate crystals. Entheses were evaluated for MASEI in 2 Institutes located in two different countries. Demographic and clinical data were registered. Total MASEI score, MASEI-inflammatory, and MASEI-chronic damage were analyzed. Comparisons between groups were obtained by chi-square test and Student's t-test. An inter-reading US reliability was realized.

Results

Patients with gout were older and had significantly more comorbidities than those with SpA. The total MASEI score was not significantly different among diseases (p = 0.07). MASEI-inflammatory was significantly more prevalent at the Achilles tendon in SpA, while the proximal patellar tendon was in gout. Power Doppler was higher in SpA compared to gout (p = 0.005). MASEI-chronic damage related to calcification/enthesophytes predominated in gout (p = 0.043), while calcaneal erosions did in SpA (p = 0.008). The inter-reader concordance was excellent (0.93, CI 95% 0.87–0.96, p = 0.001).

Conclusions

SpA and gout similarly involve entheses according to MASE, however, some inflammatory and chronic lesions differ significantly depending on the underlying disease and tendon scanned.

Doppler enthesitis: a potential useful outcome in the assessment of axial spondyloarthritis and psoriatic arthritis

OBJECTIVE

To analyse the frequency of power Doppler (PD) enthesitis in active axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients and its potential usefulness in clinical practice.

METHODS

A prospective multicentre cross-sectional study in patients with axSpA and PsA with active disease was undertaken. Patients underwent bilateral ultrasound (US) examination of the peripheral entheses according to the Madrid Sonographic Enthesis Index (MASEI). The MASEI and Outcome Measures in Rheumatology (OMERACT) PD enthesitis definitions were checked. An inter-reader analysis of recorded videos was performed to determine reliability.

RESULTS

Sixty-four consecutive patients were included. The mean DAS28 (3.9 ± 1.3) for peripheral involvement, mean BASDAI (5.6 ± 2.2) for axial involvement, and CRP values (10 ± 10.9) reflected moderate-high disease activity at baseline. The mean global MASEI score was 29.4 (± 11.4), and 55 patients (86%) scored ≥ 18 (proposed cut-off point to diagnose SpA). At the patient level, abnormal US findings consistent with at least one enthesis showing a PD signal were observed in 52 (81.3%) patients using the MASEI PD definition and 48 (75%) using the OMERACT PD definition, without significant variation between axSpA and PsA. The inter-reader reliability was excellent (kappa = 0.92 for MASEI PD and 0.86 for OMERACT PD).

CONCLUSIONS

PD enthesitis was found in the majority of patients with active axSpA and PsA, independent of axial or peripheral affectation. Both MASEI and OMERACT PD definitions were useful in detecting active enthesitis. These findings support the usefulness of a PD US evaluation of entheses in the assessment of axSpA and PsA. Key Points • PD enthesitis is a very common finding in patients with active axSpA and PsA • Both MASEI and OMERACT PD definitions are useful to detect active enthesitis • US enthesitis may reveal information in axSpA and PsA.

Ultrasound Imaging in Psoriatic Arthritis: What Have We Learnt in the Last Five Years?

Psoriatic arthritis (PsA) is a complex heterogeneous disease with multiple inter-related pathologies such as synovitis, enthesitis, tendinopathy, and dactylitis. Clinical assessment is limited in its detail to assess pathology, thus in recent years, ultrasound (US) has become more popular, given its high sensitivity to detect inflammatory arthritis and ability to inform clinical decisions. Although a qualitative technique, US findings can be graded semi-quantitatively for grayscale (GS) and power Doppler (PD). Synovitis is frequently present in inflammatory arthritis pathologies, and in PsA, recent evidence shows a propensity for tendon and entheseal lesions. The presence of flexor tenosynovitis and flexor tendon insertional enthesopathy at accessory pulleys is supportive of the “Deep Koebner” concept. Peri-tendinous inflammation—mutual to PsA or rheumatoid arthritis (RA), is associated with soft tissue oedema with PD signal frequently at the flexor tendon compartments in PsA. Research on enthesitis in PsA/PsO has improved understanding in subclinical and clinical PsA, explored associations with progression to PsA, and investigated links to prognosis assessment. Dactylitis is a pathognomonic PsA lesion where US has enhanced knowledge of the disease course and pathology of lesions such as: flexor tenosynovitis; synovitis; and soft tissue oedema. Increased US sensitivity has also brought innovation including promising automated ultrasound scanning techniques. So, what have we learnt in recent years and what are the unmet needs to focus future research initiatives in this disabling disease? This narrative review article assesses the neoteric evidence, bringing into context the knowledge gained and highlighting potential areas of research.