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.

Diagnostic value of semi-quantitative grading of musculoskeletal ultrasound in wrist and hand lesions of subclinical synovitis in rheumatoid arthritis

We used semi-quantitative grading of musculoskeletal ultrasound to evaluate wrist and hand lesions of subclinical synovitis, in order to make earlier diagnosis of rheumatoid arthritis. A total of 164 patients were included in this study. Physical examination and ultrasound examination were used to evaluate 30 joints of the wrist and hand. According to the clinical symptoms, the patients were divided into subclinical synovitis (SS) group and clinical synovitis (CS) group. The wrist and hand joints of patients with rheumatoid arthritis between the two groups were evaluated by semi-quantitative grading of musculoskeletal ultrasound, including synovitis, Power Doppler signal, joint effusion and bone erosion. We found that the total score of semi-quantitative ultrasound, synovitis score and Power Doppler signal score in the SS group were lower than those in the CS group (P<0.05). There was no significant difference in joint effusion score and bone erosion score (P>0.05). In the analysis of laboratory examination, the value of anti-RA33 antibody and ESR of SS group were decreased than that of CS group, with statistically significant difference (P=0.004), while that of RF, AKA and CCP had no significant difference between the two groups (P>0.05). In this study, the author also compared the tenosynovitis between the two groups. There was statistically significant difference (P=0.033). In conclusions, semi-quantitative grading of musculoskeletal ultrasound has certain diagnostic value for the diagnosis of subclinical synovitis in wrist and hand lesion.

Rheumatoid Arthritis Relapse and Remission - Advancing Our Predictive Capability Using Modern Imaging

Clinical remission has become an achievable target for the majority of patients with rheumatoid arthritis, but subclinical inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) has been demonstrated to be frequent in patients in clinical remission. Subclinical synovitis has been shown to be linked to both subsequent structural damage progression and a risk of flare, demonstrating that subclinical synovitis represents incomplete suppression of inflammation and questions whether it is appropriate only to use clinical composite scores as treatment target in clinical practice. Maintaining a state of remission has proven important as sustained clinical remission impacts long-term outcome regarding joint damage progression, physical function and quality of life. Treating subclinical inflammation has been attempted and has led to more frequent strict clinical remission and better physical function, but also to more adverse events. Thus, an overall benefit of incorporating imaging goals in treat-to-target strategies has not been documented. However, in patients in clinical remission on biological disease-modifying anti-rheumatic drugs, both ultrasound and MRI may aid in the clinical decision regarding whether drug tapering or even discontinuation should be attempted.

Prevalence of subclinical synovitis of the hand in patients with systemic lupus erythematosus

OBJECTIVES

To determine the prevalence of subclinical synovitis in Lupus patients without peripheral joint symptoms, in those with arthralgias without arthritis and those with episodic arthritis but without radiological structural damage.

METHODS

We conducted a multicentre cross-sectional study. Patients with lupus from those three categories were recruited to take part in a greyscale ultrasound scan performed by an expert blinded rheumatologist. Data from a historical control group from a previous study was also included for comparisons. Images were assessed separately in order to determine the presence and level of synovitis following Eular recommendations.

RESULTS

Ninety-six patients (88.5% female) with an average age of 40 ± 6.2 years old, were included. SLICC/ACR score was 0.6 ± 0.3 in the group without joint symptoms (group 0), 0.8 ± 0.3 in the group with arthralgias (group I) and 1.1 ± 0.4 in the group with episodic arthritis. The global prevalence of subclinical synovitis was 38.5%. In group 0, that prevalence was 30%. The time since onset of symptoms of patients with subclinical synovitis was longer than the rest of the patients (9.4 ± 2.2 vs 6.5 ± 4.0 years, P < 0.001). No other remarkable association was founded with clinical features of the disease.

CONCLUSIONS

This is the first study focused on subclinical synovitis in patients with lupus. Other previous studies had included patients with different levels of arthropathy. Subclinical synovitis does exist in lupus patients in over a third of patients. Its meaning remains unclear and must be a topic of further studies.

Bilateral brachial synovial cysts in systemic juvenile idiopathic arthritis: Case report and literature review

Aim

To review the clinical features of brachial synovial cyst.

Method

A case of bilateral brachial synovial cysts is described in a child suffering from systemic juvenile idiopathic arthritis during a relapse. Magnetic resonance imaging and ultrasonography were conducted to further evaluate the nature of the cysts. The case is compared with known cases in a literature review.

Results

Review of the literature showed that brachial synovial cysts occur most commonly in systemic juvenile idiopathic arthritis. It is considered that uncontrolled systemic inflammation and recurrent disease activity might be the cause of synovial cysts.

Conclusion

Brachial synovial cyst is a rare manifestation of juvenile idiopathic arthritis. Uncontrolled systemic inflammation inducing chronic damage to joint structure may be the primary cause of synovial cyst formation.

Detection of subclinical synovial hypertrophy by musculoskeletal gray-scale/ power Doppler ultrasonography in systemic lupus erythematosus patients: A cross-sectional study

OBJECTIVE

Laboratory investigations are invasive methods. Magnetic resonance imaging (MRI) has a small field of view. Ultrasound can be performed at multiple parts of the body. The objective of the study was to find out subclinical synovial hypertrophy in systemic lupus erythematosus patients using gray-scale/power Doppler ultrasonography.

METHODS

A total of 247 systemic lupus erythematosus (without musculoskeletal involvement) patients from 21 February 2017 to 28 October 2018 were included in the cross-sectional study. Patients were subjected to physical examinations, laboratory tests, and gray-scale/power Doppler ultrasonography examinations. Synovial hypertrophy was confirmed if it was present in at least 4 out of 100 of the examined location sites. MRI examinations were performed for confirmation purposes. Spearman correlation was performed between imaging and laboratory investigations at the 99% confidence level.

RESULTS

No correlation was observed for results of synovial hypertrophy between physical examinations/laboratory tests and gray-scale/power Doppler ultrasonography examinations except erythrocyte sedimentation rate (r = 0.354). Cost of laboratory tests (315.47 ± 19.15 ¥/person) for subclinical synovial hypertrophy detection was higher than that of gray-scale/power Doppler ultrasonography examinations (135.47 ± 8.17 ¥/person, P <0.0001, q = 230.87). Results of gray-scale/power Doppler ultrasonography have a correlation with results of MRI (r = 0.34).

CONCLUSION

Only perform gray-scale/power Doppler ultrasonography examinations for regular maintenance of rheumatologic disease in systemic lupus erythematosus patients.

Performance of routine assessment of patient index data 3 (RAPID3) in monitoring disease activity of Chinese rheumatoid arthritis patients

AIM

To explore the performance of routine assessment of patient index data 3 (RAPID3) in reflecting disease activity in Chinese rheumatoid arthritis (RA) patients.

METHOD

The clinical data of 189 consecutive RA patients, including RAPID3 questionnaire, Disease Activity Score based on 28-joint count (DAS28), clinical disease activity index (CDAI) and simplified disease activity index (SDAI), and ultrasonography of hand and wrist joints were collected. The consistency between RAPID3 and DAS28, CDAI, SDAI in RA patients with different disease activities was performed by Spearman's correlations, kappa and/or weighted kappa coefficients.

RESULT

RAPID3 score was significantly associated with DAS28 and erythrocyte sedimentation rate (ESR), DAS28 with C-reactive protein (CRP), CDAI, SDAI (r = 0.797, 0.786, 0.784, and 0.760 respectively, P < 0.001 for all). RAPID3 was also significantly correlated with tender joint count, swollen joint count, ESR and CRP. The agreement of RAPID3 with DAS28 scoring systems was better in patients with moderate/high disease activity than those in remission/low disease activity. Ultrasonographic subclinical synovitis was presented in 42.3%-48.6% of patients in remission/low disease activity defined by various scoring criteria including RAPID3 with no significant difference observed (P = 0.22, >0.05).

CONCLUSION

RAPID3 showed good correlation with DAS28 scoring systems, especially in patients with moderate/high disease activity. RAPID3 is a reliable and convenient tool to monitor disease activity.

Ultrasonography-detected subclinical inflammation in patients with hand osteoarthritis and established rheumatoid arthritis: a comparison between two different pathologies using the same ultrasound examination protocol

OBJECTIVES

A recent review of ultrasound (US) studies in osteoarthritis (OA) showed very limited data about hand OA. Previous US studies in patients with OA described a degree of overlap between the US appearance of rheumatoid arthritis (RA) and OA joints. The present study aimed to assess the US features of subclinical inflammation in RA and hand OA, using the same US examination protocol.

METHODS

A retrospective, cohort study compared patients with established RA (n = 224) and hand OA (n = 73), with respect to several demographic, clinical, laboratory and US parameters. We used a 22-hand joint US examination protocol (wrists, metacarpophalangeal and proximal interphalangeal joints bilaterally - Outcome Measures in Rheumatology Clinical Trials [OMERACT] scoring system) for all patients.

RESULTS

Subclinical joint inflammation in the context of equivocal clinical examination was found in 9.6% of OA patients compared with 46.4% of RA patients (p = 0.0001), despite the fact that there was no significant difference between the degree of chronic joint swelling (synovial hypertrophy grades 2 and 3; p = 0.75 and p = 0.11, respectively). The presence of osteophytes was more common in patients with hand OA, as expected (p = 0.0001).

CONCLUSIONS

Our study findings reflected differences between the incidence and characteristics of subclinical inflammation in patients with RA and OA, which could be helpful in patients with an equivocal clinical examination or history of both diseases. Almost one in 10 patients with hand OA had active synovitis, while almost one in two patients with RA had uncontrolled inflammation in at least one joint.