Enthesitis-related arthritis: monitoring and specific tools

Abstract Objective: In this article, the authors aimed to review the different tools used in the monitoring of enthesitis-related arthritis. Sources: The authors performed a literature review on PubMed, Google Scholar, and Scopus databases. The dataset included the original research and the reviews including patients with enthesitis-related arthritis or juvenile spondylarthritis up to October 2020. Summary of finding: Enthesitis-related arthritis is a category of juvenile idiopathic arthritis. It is characterized by the presence of enthesitis, peripheral arthritis, as well as axial involvement. The only validated tool for disease activity measurement in juvenile idiopathic arthritis is the Disease Activity Score: It has proven its reliability and sensitivity. Nevertheless, due to an absence of validated evaluation tools, the extent of functional impairment, as well as the children and parents' perception of the disease, could not be objectively perceived. Despite the great progress in the field of imaging modalities, the role they play in the evaluation of disease activity is still controversial. This is partially due to the lack of validated scoring systems. Conclusion: Further work is still required to standardize the monitoring strategy and validate the outcome measures in enthesitis-related arthritis.

Clinical significance of group A streptococcal infection in pediatric patients with enthesitis related arthritis / 中华风湿病学杂志

Objective:To demonstrate the clinical significance of group A streptococcal infection (GAS) in patients with enthesitis related arthritis (ERA).Methods:A retrospective study was conducted on ERA (136) and PolyRF-/Oligo juvenile idiopathic arthritis (JIA) (272) patients in Beijing Children's Hospital from 2016 to 2018. Anti-streptococcal hemolysin "O" (ASO) was tested and documented in all patients. The infection rate of GAS was compared between patients with ERA and PolyRF-/Oligo JIA. Patients with ERA were divided to two groups according to the result of ASO (ASO positive and ASO negative). All the clinical data were documented and compared within the two groups. The statistical methods used mainly include t test, rank sum test, chi-square test, and Spearman correlation analysis.Results:The GAS infection rate of patients with ERA was higher than patients with PolyRF-/Oligo JIA (17.6% vs 9.5%, χ2=5.52, P=0.019). In ERA patients, clinical data were analyzed, and a statistical significant difference was observed in the presence of human leukocyte antigen (HLA)-B27 between ASO positive and ASO negative group [75.0%(18/24) vs 49.1%(55/112), χ2=5.329, P=0.021]. Statistical differences were found in Patrick's sign positive rate between the two groups [100%(24/24) vs 67.0%(75/112), χ2=10.61, P=0.001]. There was statistically significant difference between the two groups regarding the radiogr-aphic grading at the sacroiliac joint. More patients with positive ASO had grade Ⅲ damage at the sacroiliac joint compare to patients with negative ASO [68.2%(15/22) vs 28.4%(29/102), χ2=12.49, P<0.001]. The logarithmic of the ASO was slightly correlated with the radiographic grade of sacroiliac joint ( r=0.26, P=0.005). Conclusion:Patients with ERA are prone to be infected by GAS. It's probably related to HLA-B27 postivity for antigen presentation. Patients who were infected by GAS fre-quently have sacroiliac joint involvement, and tend to be more sever. This indicates that GAS may play an important role in the pathogenesis of sacroiliac joint destruction.

Clinical value of high frequency ultrasound in the early screening subclinical psoriatic arthritis / 中华超声影像学杂志

Objective:To explore the significance of enthesitis in psoriasis(PsO) and the value of high-frequency Doppler ultrasound (HDUS) in screening potential subclinical psoriatic arthritis(PsA) patients through enthesitis; Designing the semi-quantitative score of enthesitis explore the value of semi-quantitative score in evaluating the degree of joint structure damage and improving the curative effect in patients with subclinical PsA.Methods:Clinical and sonographic data were collected in 125 PsO patients and 50 osteoarthritis (OA) patients who attended hospital from January 2019 to March 2021, and healthy controls (HC) recruited during the same period. The prevalence of enthesitis of distal interphalangeal joint (DIP) of psoriasis patients, osteoarthritis patients and HC was compared. Meanwhile the semi-quantitative scoring system for ultrasound-guided enthesitis was designed, and the correlation between the severity of enthesitis and clinical score was analyzed. The correlation between psoriasis nail and enthesitis of extensor tendon of DIP finger was also analyzed.Results:The significant difference was found in the prevalence of enthesitis of DIP among PsO group, OA group and HC group (all P<0.001); There was a significant difference in the severity of enthesitis of DIP in PsO group before and after treatment ( P<0.001); In PsO group, the correlation between the severity of enthesitis of DIP and Psoriasis Area and Severity Index(PASI)score was moderate ( rs=0.538, P<0.001), and highly correlated with Nail Psoriasis Severity Index (NAPSI) scores( rs=0.877, P<0.001). There was a significant difference in the incidence of enthesitis between the patients with psoriasis nail and the patients without that ( P<0.001). The prevalance of enthesitis of nail disease free fingers was also found significantly different between PsO group and HC group( P<0.001). Conclusions:Enthesitis is a prominent characteristic of PsO.And the semi-quantitative scores designed in this research are in satisfied consistence with the clinical scores, and could be used to evaluate subclinical PsA structural damage.Furthermore, it is possible that the enthesitis of DIP is a relatively independent process from the nail disease.

Benefit of ultrasound in the phenotype recognition of psoriatic arthritis / 北京大学学报(医学版)

OBJECTIVE@#To explore the difference in phenotype recognition of PsA patients in two clinical scenarios, physical examination with and without ultrasound assessment.@*METHODS@#PsA patients who visited the rheumatology and clinical immunology department of Peking University First Hospital between January 2010 and October 2020, with complete data of clinical and ultrasound assessment were enrolled. The phenotypes were first identified based on physical examination only, and then combined with enthesitis and dactylitis shown on power doppler and gray-scale ultrasound. The phenotype groupings without and with ultrasound assessment were presented with Wayne diagram. The distributions of different clinical phenotypes were compared by using χ2 test or Fisher's exact test. The differences of clinical phenotypes with and without ultrasound assessment were compared by using Wilcoxon signed rank test.@*RESULTS@#A total of 227 patients with PsA were enrolled with one or more clinical domains. Physical examination revealed that psoriasis was in 209 (92.1%, 209/227) patients, nail involvement in 98 (43.2%, 98/227) patients, peripheral arthritis in 219 (96.5%, 219/227) patients, axial involvement in 25 (11.0%, 25/227) patients, dactylitis in 80 (35.2%, 80/227) patients, and enthesitis in 18 (7.9%, 18/227) patients. Besides 18 patients with clinical enthesitis, ultrasound scan revealed acute enthesitis in 80 patients, with hypoechogenicity (55 cases), tendon thickening (62 cases), and presence of Doppler signals (48 cases). Similarly, dactylitis on ultrasound was found in 18 patients besides those patients with clinical dactylitis. Compared with the phenotypes recognized based on physical examination only, the additional ultrasound assessment revealed that the most common phenotypes, peripheral arthritis was significantly less frequently recognized (49.8% vs. 27.8%, P < 0.001), however on the other hand, the proportion of the patients with peripheral arthritis and enthesitis was significantly increased (4.4% vs. 18.1%, P < 0.001). The phenotype of peripheral arthritis combined with enthesitis, and dactylitis was also dramatically increased (1.8% vs. 17.6%, P < 0.001).@*CONCLUSION@#Ultrasound is a useful tool to identify enthesitis and dactylitis. With the aid of ultrasound assessment, rheumatologists can better identify the lesions of PsA, accurately identify the phenotypes, and further guide the subsequent treatment.

Sacroiliitis in children and adolescents with familial Mediterranean fever

Abstract Background: Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by recurrent episodes of fever and serositis. Sacroiliitis can be observed in some FMF patients. This study aimed to compare the demographic, clinical, and laboratory findings, and treatment in children with FMF and sacroiliitis, and children with juvenile spondyloarthropathy (JSpA). Methods: In total, 1687 pediatric FMF patients that were followed-up between May 2010 and June 2020 were evaluated retrospectively. Among them, those with sacroiliitis ( n = 63) were included in the study and compared to patients with JSpA ( n = 102). Results: The study included 63 FMF patients with sacroiliitis (38 males [60.3%] and 25 females [39.7%]) with a mean age of 15.2 ± 4.1 years. Mean age at symptom onset was 7.2 ± 5.05 years and mean age at diagnosis was 9.74 ± 4.67 years. The most common mutation in the FMF patients was M694V/M694V ( n = 22). Patients were diagnosed with sacroiliitis with a mean of 12 months (range: 6-36 months) after the diagnosis of FMF. Among the FMF patients, 28 (44.4%) had enthesitis, 23 (36.5%) had heel pain, and 11 (17.4%) had low back pain. The study also included 102 JSpA patients (90 males [88.2%] and 12 females [11.8%]). Mean age of patients with JSpA was 16.1 ± 2.8 years. As compared to 102 JSpA patients, patients with FMF and sacroiliitis had higher acute phase reactants, whereas HLA- B27 positivity rate was lower. In addition, axial involvement rate was higher in the JSpA patients. Conclusion: Sacroiliitis is a common co-morbidity in FMF patients. The phenotypic features of these patients are different from patients with JSpA.

Risk factors of uveitis in ankylosing spondylitis / 中华风湿病学杂志

Objective:To investigate the risk factors of uveitis in ankylosing spondylitis (AS).Methods:This retrospective study included 206 patients with AS who visited the department of rheumatology and immunology of People's Hospital of Xinjiang Uygur Autonomous Region between January, 2018 and December, 2018. Those patients with uveitis were enrolled in the uveitis group. AS patients without uveitis were included in the non uveitis group as control. The basic clinical data, laboratory indexes and imaging data were analyzed retrospectively by t-test, Wilcoxon rank sum test, Chi square test and binary logistic regression. Results:Thirty-seven patients with uveitis and 169 patients without uveitis were included. Compared with the non uveitis group, patients with uveitis were older in age [(40±11) years vs (36±11) years, t=-2.06, P<0.05], longer in disease duration [10(5, 16) years vs 5(2, 10) years, Z=-3.16, P<0.01], more peripheral arthritis [51.4%(19/37) vs 32.5%(55/169), χ2=4.66, P<0.05] and peripheral enthesitis [40.5%(15/37) vs 11.8%(20/169), χ2=17.34, P<0.01], and higher human leukocyte antigen (HLA)-B27 positive rate [100%(37/37) vs 85.8%(145/169), χ2=5.95, P=0.01]. However, there were no significant difference in gender, race, cervical tenderness, smoking history and volume, a positive family history of uveitis, a positive family history of AS and BMI. There was no significant difference in bloodplatelet (PLT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR). By the binary logistic regression analysis, we found that peripheral enthesitis [ OR(95% CI)=4.289(1.832, 10.040), P<0.01], and longer disease duration [ OR(95% CI)=1.072(1.014, 1.134), P<0.05] were independently related to AS related uveitis. Conclusion:This study suggests that the risk of uveitis is increased in AS patients with longer disease duration and peripheral enthesitis.

Artritis como debut de enfermedad inflamatoria intestinal en pediatría / Arthritis as clinical presentation of inflammatory bowel disease in children

La incidencia de enfermedad inflamatoria intestinal en la edad pediátrica se ha incrementado mundialmente en las últimas décadas. La forma de presentación puede ser diversa y, hasta en un 6-35 %, las manifestaciones extraintestinales pueden ser el debut; la artritis periférica es la más frecuente de estas. Una presentación atípica implica un retraso diagnóstico y, asociado a que el fenotipo de enfermedad inflamatoria intestinal es más grave en los niños, conlleva un incremento de las complicaciones intestinales y secuelas asociadas. Se presentan dos casos clínicos de enfermedad de Crohn cuya clínica inicial fue la claudicación de la marcha por una artritis periférica y una entesitis, respectivamente.

Inflammatory bowel disease in children has increased worldwide during the last decades. Clinical presentations are diverse and extraintestinal manifestations are the presenting sign in 6-35 % of patients, the most common of them being peripheral arthritis. An atypical clinical presentation results in diagnosis delay and, added to the greater seriousness of inflammatory bowel disease phenotypes in children, it entails more intestinal complications and sequelae. We describe two cases of inflammatory bowel disease with an initial symptom of lameness due to peripheral arthritis and enthesitis, respectively.

Correlation of enthesitis indices with disease activity and function in axial and peripheral spondyloarthritis: a crosssectional study comparing MASES, SPARCC and LEI

Abstract Background: The presence of enthesitis is associated with higher disease activity, more disability and incapacity to work and a poorer quality of life in spondyloarthritis (SpA). There is currently no consensus on which clinical score should be used to assess enthesitis in SpA. The objective of the present work was to compare the correlation of three enthesitis indices (MASES, SPARCC and LEI) with measures of disease activity and function in a heterogeneous population of patients with axial and peripheral SpA. Methods: A cross-sectional study was conducted in three Brazilian public university hospitals; patients fulfilling ASAS classification criteria for peripheral or axial SpA were recruited and measures of disease activity and function were collected and correlated to three enthesitis indices: MASES, SPARCC and LEI using Spearman's Correlation index. ROC curves were used to determine if the the enthesitis indices were useful to discriminate patients with active disease from those with inactive disease. Results: Two hundred four patients were included, 71.1% (N = 145) fulfilled ASAS criteria for axial SpA and 28.9% (N = 59) for peripheral SpA. In axial SpA, MASES performed better than LEI (p = 0.018) and equal to SPARCC (p = 0.212) regarding correlation with disease activity (BASDAI) and function (BASFI). In peripheral SpA, only MASES had a weak but statistical significant correlation with DAS28-ESR (rs 0.310 p = 0.05) and MASES had better correlation with functional measures (HAQ) than SPARCC (p = 0.034). Conclusion: In this sample composed of SpA patients with high coexistence of axial and peripheral features, MASES showed statistical significant correlation with measures of disease activity and function in both axial and peripheral SpA.(AU)

A study on comparison of gender-based prevalence and severity at presentation in spondyloarthritis in a tertiary care rheumatic center

Introduction: Spondyloarthritis (or spondyloarthropathy) is the overall name for a family of inflammatory rheumatic diseases that can affect the spine and joints, ligaments and tendons These diseases can cause fatigue and pain or stiffness in the back, neck, hands, knees, and ankles as well as inflammation of the eyes, skin, lungs, and heart valves While there is no course of prevention at this time treatment can reduce discomfort and delay the development of spinal deformities Aim of the study: The aim of the study was to differentiate gender difference at presentation of spondyloarthritis and to identify markers in determining the severity of disease Materials and methods: This was a prospective observational study conducted for a period of 6 months at Institute of Rheumatology, Government KAPV Medical College and MGM Government Hospital Totally 62 patients were included in the study 31 males and 31 consecutive females with features of spondyloarthritis per ASAS (Assessment of Spondyloarthritis international Society) at first presentation to our clinic were enrolled and their clinical characteristics were analyzed Results: On comparing disease activity and functional indices between males and females, mean BASDAI was 466±18 versus 498±194 (p=05), mean BASFI was 46±23 versus 48±23 (p=07), TN Tamil Selvam, VA Sowndhariya, NK Senthil Nathan A study on comparison of gender-based prevalence and severity at presentation in spondyloarthritis in a tertiary care rheumatic center IAIM, 2018; 5(12): 35-39 Page 36 mean BASMI was391±194 versus 418±206 (p=04) Out of 31 males, 17 were positive for HLA B27 and 6 out of 31 females were positive for HLA B27 (p=004) Conclusion: The pathogenesis of SpA is multifactorial and not yet fully understood Genetic factors (HLA-B27 and non– HLA-B27 related genes), inflammatory cytokines (eg TNF-alpha, IL-1, IL-6, IL-7, IL-17, and IL-23) and environmental triggers (infections, mechanical stress, abnormal intestinal microbiota) play an important role These different factors and their complex interaction can lead to activation of autoinflammation and autoimmunity and to the new bone formation Men are more prone to spondyloarthritis when compared with women

Enthesitis-related Arthritis

Enthesitis-related arthritis (ERA) is a disease predominantly affecting the joints and entheses of the lower extremities and has the potential to eventually affect the sacroiliac joints and spine evolving to juvenile ankylosing spondylitis. ERA is also characterized by rheumatoid factor seronegativity, paucity of antinuclear antibody, and a strong association with the human leukocyte antigen-B27. ERA accounts for a higher proportion of juvenile idiopathic arthritis (JIA) cases in the Asian population compared to other populations. Advances in the understanding of ERA pathogenesis continue to progress and have led to the development of new treatments targeting pro-inflammatory cytokines. In particular, tumor necrosis factor-α inhibitors have become a mainstay of therapy for patients in whom therapy with anti-inflammatory drugs and/or disease-modifying anti-rheumatic drugs are inadequate or contraindicated. Compared to other JIA subtypes, ERA is associated with a poorer quality of life, worse function, and a higher likelihood of ongoing active disease after the initial treatment. Because the current guidelines for the management of ERA is not considered separately from other categories of JIA, there is a need for treatment guidelines specific to ERA to improve the overall disease outcomes.

Clinical analysis of human leucocyte antigen-B27-positive enthesitis related arthritis in 70 children / 中华实用儿科临床杂志

Objective To investigate the clinical features,auxiliary examination,treatment and efficacy of human leucocyte antigen(HLA)-B27-positive enthesitis related arthritis (ERA).Methods The clinical manifestations,auxiliary examination,treatment and follow-up of HLA-B27-positive ERA diagnosed in the Children's Hospital of Chongqing Medical University from January 2007 to August 2017 were analyzed retrospectively.SPSS 19.0 software was used for data processing.Results A total of 70 children were enrolled,including 67 males and 3 females,and the average age of onset was(10.08 ± 2.67) years old.Clinical features:all of the 70 children had peripheral arthritis with or without enthesitis,and axial arthritis symptoms appeared in 24.3％ (17/70 cases) children,and 35.7％ (25/70 cases) children showed enthesitis.The onset of peripheral arthritis accounted for 87.1％ (61/70 cases),and all cases showed peripheral arthritis during the course of the disease,mostly the knees.Two cases were complicated with uveitis.Forty-seven cases (67.1％) were positive in Patrick test,and 9 cases(12.9％) had sacroiliac joint tenderness.The average Juvenile Arthritis Disease Activity Score with 27 joints (JADAS27) score was 20.12 ± 8.61.Twenty-seven cases (38.6％) had positive family history.Auxiliary examination:Erythrocyte sedimentation rate,C-reactive protein(CRP) and platelets increased in most children,and a few with leukocytosis increased slightly,nearly half of children with anemia mildly or moderately,and serum tumor necrosis factor-α(TNF-α),interleukin (IL)-6,IL-1β,IL-10 levels increased.Eighty-eight point six percent (31/35 cases) children had decreased bone mass;the positive rate of X-ray examination was 81.1％ (43/53 cases),including 5 cases of sacroiliac joint disease;the positive rate of uhrasonography was 81.5 ％ (44/54 cases);the positive rate of nuclear magnetic resonance (MRI) was 95.1％ (58/61 cases),including 30 cases (42.9％) of sacroiliitis.Treatment and outcome:Nonsteroidal antiinflammatory drugs (NSAIDs),disease modifying antirheumatic drugs (DMARDs),glucocorticoids,calcium and alfacalcidol were added,and 50.0％ (35/70 cases) patients had added TNF-α antagonist.The follow-up of all of the patients showed improvement in terms of clinical symptoms,laboratory tests and JADAS27 score after standard treatment.Conclusions It is difficult to diagnose but easy to misdiagnose because of the lack of specificity of ERA clinical symptoms.The improvement of imaging techniques,especially MRI,is helpful for the early diagnosis of ERA.To strengthen the understanding and management of ERA,and to grasp its clinical features,immunology and imaging features,help to make timely diagnosis and reasonable treatment,and to improve physical function and quality of life of patients,and to avoid or delay disability.

Seronegative Spondyloarthropathies

The seronegative spondyloarthropathies are a heterogenous groups of inflammatory diseases which may present with sacroilitis, inflammatory arthritis, spondylitis and enthesitis, as well as extra-articular manifestations of inflammation most commonly involving the eye, skin and gastrointestinal tract. There is a familial preponderance to these conditions, and an association with the HLA-B27 gene. The new ASAS classification system for these conditions aims to classify patients into 2 broad categories based on the predominant site of their symptoms. The diagnosis of early spondyloarthropathy relies on a detailed history and physical examination as radiographic changes occur late, and blood work-up may be normal. Management of these chronic diseases requires a holistic multidisciplinary approach with both pharmacological and non-pharmacological interventions in recent years, many newer therapies, especially biologic agents have become available for treatment of these conditions.

Does Painful Heels in Ankylosing Spondylitis Demonstrate Distinctive Features on Plain Radiographs: A Study of 104 Cases

OBJECTIVE: To investigate simple radiographic findings on painful heels in ankylosing spondylitis (AS). Heel radiography in most studies was from AS patients' non-painful heel. METHODS: Seventy AS patients (34 bilateral cases) with heel pain at the time digital radiographs were taken were studied. Standing lateral views (104 radiographs) of the heel were reviewed. Associations between radiologic abnormalities and disease duration and among various abnormal findings were analyzed. RESULTS: Ninety-six (93.4%) had radiographic abnormalities (82.7% in soft tissues/61.5% in bone). Abnormalities of bone only were observed in 9.6%, of the soft tissues only in 30.8%, and of both were 51.9%. These included Kager's triangle's blurring (77.9%), posterior soft tissue swellings near the Achilles tendon insertion (65.4%), obliterations of the retrocalcaneal recess (65.4%), erosions of the superior pole of the posterior calcaneus (31.7%), subplantar irregular spurs (20.2%), posterior traction spurs (16.3%), subplantar erosions (14.4%) and cortical thickenings of the inferior calcaneal body (5.8%). There was a significant association between swelling in the posterior soft tissue and obliteration of the retrocalcaneal recess (p<0.001). CONCLUSION: Digital radiography in AS is useful for observing not only bony lesions but also soft tissue abnormalities of the heel, particularly of the posterior heel. For assessing the symptomatic enthesitis of the Achilles, this simple and quick diagnostic tool is valuable when examining for soft tissues' alterations of the posterior heel.

Evaluación del dolor en el adulto mayor / Evaluation of the pain in older people

Resumen: Objetivo: Comparar las informaciones obtenidas del porcentaje verbal de mejoría declarada verbalmente con la escala visual analógica (EVA) en personas con edad menor y mayor o igual de 65 años. Pacientes y métodos: Fueron evaluados 95 individuos con dolor agudo en el hombro (entesitis). Fue solicitado en cada uno de ellos medir la intensidad del dolor a través de la EVA tras un tratamiento médico con infiltración de corticosteroide en el hombro; fueron examinados una semana después, con una nueva medición de la intensidad del dolor verbalmente. Enseguida, las informaciones fueron comparadas entre pacientes con edad mayor o igual y menor de 65 años. Resultados: Se utilizó una diferencia de hasta 10% en módulo (valor absoluto) entre el porcentaje verbalmente declarado y el calculado con base en las medidas declaradas en la EVA. En los sujetos < 65 años, la frecuencia de casos donde la variación entre el porcentaje de mejoría verbalmente declarado y el calculado excede 10% fue de 29.8%; entre las personas ≥ 65 años la discrepancia ocurrió en 60.95%. Conclusión: El análisis de este estudio utilizó distintos métodos descriptivos e inferenciales para investigar las hipótesis levantadas; dentro de las herramientas empleadas, una confirma la hipótesis sobre los individuos ≥ 65 años y nos lleva a recomendar que el uso de la EVA para este grupo etario sea realizado con cautela y orientación.

Abstract: Objective: To compare the information obtained of the percentage of improvement declared orally with the improvement marked in the visual analogical scale (VAS) in patients under and over 65 years of age. Patients and methods: Ninety-five individuals with acute shoulder pain (enthesitis) were evaluated. The subjects were requested to mark the pain intensity in the VAS before a treatment with corticosteroid injection in the shoulder and were evaluated again through the VAS one week after the procedure. They were also requested to declare orally the pain intensity. Then, the information was compared between patients aged under and over 65 years of age. Results: 29.8% of those younger than 65 years, and 60.95% of those older than that age presented more than 10% difference between orally stated and calculated pain relief percentage based on the VSA. Conclusion: The difference between the orally stated and the calculated pain relief percentage based on the VSA was significantly higher in the group of those older than 65 years. This finding proved that the VAS is a poor method to evaluate pain relief in the senior population.

MRI characteristics of enthesitis in peripheral ankylosing spondylitis / 实用医学杂志

Objective To explore the MRI findings of enthesitis in peripheral ankylosing spondylitis (AS). Methods We retrospectively reviewed the MRI obtained from 13 patients with clinically-diagnosed peripheral AS. MRI finding attributable to enthesitis could be visualized as tendon or ligament enthesitis, bone marrow edema (BME), synovitis, bursitis, tenosynovitis. Results MRI findings of knee showed enthesitis in 8 knees, mainly involved in the insertions of the quadriceps tendon at the upper patellar pole , the patellar ligament at the lower patellar pole and the tibial tubercle, BME in 8 knees, synovitis in 5 knees, bursitis in 3 knees, and tenosynovitis in 4 knees. MRI findings of ankle showed enthesitis in 3 ankles, involved in plantar insertion into calcaneus and Achilles tendon insertion into the calcaneus, BME in 1 ankle, and tenosynovitis in 3 ankles. Conclusion The lower extremities are more often involved in peripheral AS than the upper extremities. MRI characteristic of enthesitis may contribute to the diagnosis of peripheral AS early combined with HLA-B27.

The distinctive characteristics of ultrasonic imaging of enthesitis in spondyloarthritis patients / 中华内科杂志

Objective To explore the distinctive ultrasonographic characters of enthesitis in patients with spondyloarthritis (SpA) and evaluate the diagnostic value of ultrasonography in SpA by comparing ultrasonography of enthesis in the lower limbs of patients with SpA,rheumatoid arthritis (RA) and osteoarthritis(OA).Methods Entheses in the lower limbs (quadriceps tendon,proximal patellar ligament,distal patellar ligament,achilles tendon and plantar aponeurosis) were detected in SpA,RA,OA patients and health controls by ultrasonographic examination.Results A total of 46 SpA,23 RA and 12 OA patients were enrolled in this study,with 26 SpA and 7 RA patients complaining of heel pain(P ＜0.05).There were 126 enthesal sites(126/460,27.2％) were detected abnormal in SpA group,compared with 54 of 230 (23.5 ％) sites in RA group and 27 of 120 (22.5 ％) sites in OA group (P ＞ 0.05).Sixty five (70.7 ％) sites of the distal patellar ligaments were abnormal in SpA group,while that were 19(41.3％)in RA group(P ＜ 0.05)and 13 (54.2％)in OA group.Twenty six sites of tendon thickness and 22 sites of bone erosion in the distal patellar ligaments were found in SpA group,while only one site of each in RA group(P ＜ 0.05) and 4 sites of tendon thickness in OA group (P ＜ 0.05) were found.Tendon thickness,bursal synovitis and bone erosion coexisting in one distal patellar ligament indicated SpA,the sensitivity,specificity and the area under the curve (AUC) of which were 70.7％,65.5％ and 0.740,respectively.Conclusion Tendon thickness and bone erosion of entheses were more likely the distinctive ultrasonographic characters of enthesitis in SpA patients.Tendon thickness,bursal synovitis and bone erosion in the distal patellar ligament could be an ideal tool for SpA diagnosis.

Perfil epidemiológico da espondiloartrite de início juvenil comparada com a espondiloartrite de início na vida adulta em uma grande coorte brasileira / Epidemiologic profile of juvenile-onset compared to adult-onset spondyloarthritis in a large Brazilian cohort

Objetivo Analisar as características clínicas e epidemiológicas das espondiloartrites (EpA) de início juvenil (< 16 anos) e compará-las com um grupo de pacientes com EspA de início na vida adulta (≥ 16 anos). Pacientes e métodos Coorte prospectiva, observacional e multicêntrica com 1.424 pacientes com diagnóstico de EspA de acordo com o European Spondyloarthropathy Study Group (ESSG) submetidos a um protocolo comum de investigação e recrutados em 29 centros de referência participantes do Registro Brasileiro de Espondiloartrites (RBE). Os pacientes foram divididos em dois grupos: idade no início<16 anos (grupo EspAiJ) e idade no início ≥ 16 anos. Resultados Entre os 1.424 pacientes, 235 manifestaram o início da doença antes dos 16 anos (16,5%). As variáveis clínicas e epidemiológicas associadas com a EspAiJ foram: gênero masculino (p<0,001), artrite em membro inferior (p=0,001), entesite (p=0,008), uveíte anterior (p=0,041) e HLA-B27 positivo (p=0,017), em associação com escores mais baixos de atividade da doença (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI; p=0,007) e de capacidade funcional (Bath Ankylosing Spondylitis Functional Index – BASFI; p=0,036). A psoríase cutânea (p<0,001), a doença inflamatória intestinal (p=0,023), a dactilite (p=0,024) e o envolvimento ungueal (p=0,004) foram mais frequentes em pacientes com EspA de início na vida adulta. Conclusões Nessa grande coorte brasileira, os pacientes com EspAiJ se caracterizavam predominantemente pelo gênero masculino, envolvimento periférico (artrite e entesite), HLA-B27 positivo e escores de doença mais baixos. .

Objective To analyze the clinical and epidemiologic characteristics of juvenile-onset spondyloarthritis (SpA) (< 16 years) and compare them with a group of adult-onset (≥ 16 years) SpA patients. Patients and methods Prospective, observational and multicentric cohort with 1,424 patients with the diagnosis of SpA according to the European Spondyloarthropathy Study Group (ESSG) submitted to a common protocol of investigation and recruited in 29 reference centers participants of the Brazilian Registry of Spondyloarthritis (RBE – Registro Brasileiro de Espondiloartrites). Patients were divided in two groups: age at onset<16 years (JOSpA group) and age at onset ≥ 16 years (AOSpA group). Results Among the 1,424 patients, 235 presented disease onset before 16 years (16.5%). The clinical and epidemiologic variables associated with JOSpA were male gender (p<0.001), lower limb arthritis (p=0.001), enthesitis (p=0.008), anterior uveitis (p=0.041) and positive HLA-B27 (p=0.017), associated with lower scores of disease activity (Bath Ankylosing Spondylitis Disease Activity Index – BASDAI; p=0.007) and functionality (Bath Ankylosing Spondylitis Functional Index – BASFI; p=0.036). Cutaneous psoriasis (p<0.001), inflammatory bowel disease (p=0.023), dactylitis (p=0.024) and nail involvement (p=0.004) were more frequent in patients with adult-onset SpA. Conclusions Patients with JOSpA in this large Brazilian cohort were characterized predominantly by male gender, peripheral involvement (arthritis and enthesitis), positive HLA-B27 and lower disease scores. .

Diagnosis and management of psoriatic arthritis.

Psoriatic arthritis (PsA) is a multi-faceted disease marked by varying combinations of peripheral arthritis, dactylitis, spondylitis, and enthesitis. Rarely, recurrent uveitis occurs. Skin involvement may or may not exist. However, patients with nail psoriasis have a higher probability of developing PsA. Untreated patients have significant morbidity and mortality. Timely diagnosis and aggressive treatment of the disease can lead to lower morbidity. Drug therapy of PsA includes symptomatic therapy and therapy with disease-modifying anti-rheumatic drugs. Biologics are the only agents that address all the pathological changes, of this chronic condition.

Diagnosis and management of psoriatic arthritis.

Psoriatic arthritis (PsA) is a multi-faceted disease marked by varying combinations of peripheral arthritis, dactylitis, spondylitis, and enthesitis. Rarely, recurrent uveitis occurs. Skin involvement may or may not exist. However, patients with nail psoriasis have a higher probability of developing PsA. Untreated patients have significant morbidity and mortality. Timely diagnosis and aggressive treatment of the disease can lead to lower morbidity. Drug therapy of PsA includes symptomatic therapy and therapy with disease-modifying antirheumatic drugs. Biologics are the only agents that address all the pathological changes, of this chronic condition.

Patología inflamatoria de columna en niños y adolescentes / Inflammatory spine pathology in children and adolescents

Chronic inflammatory axial pain is an uncommon pediatric syndrome, brings a number of diseases affecting the axial skeleton. It is characterized by unknown etiology, with recognizing genetic susceptibility factors. The medical clinician should be performed to establish the diagnosis, making accurate therapy for long-term success and working to get a good quality of life. Current classifications established for children and young patients forms are limited by the pediatric medical short follow-up age. Two international classifications (a) International League of Associations for Rheumatology and (b) Classification of juvenile spondyloarthropathies Spondylarthropathy European group Study Group to achieve approximate diagnosis for pediatric rheumatology forms. The adult rheumatologist usually who will establish the definitive diagnosis and prognosis. The chronic inflammatory axial pain needs an unification of classification criteria for children and adults in order to facilitate the scientific communication and medical transition.

El dolor axial inflamatorio crónico es una entidad infrecuente en Pediatría, y agrupa una serie de patologías que afectan el esqueleto axial. este grupo de enfermedades son de etiología aún desconocida, reconociendo factores de susceptibilidad genética en ellas. Su importancia está en el enfoque que el clínico debe realizar para establecer el diagnóstico, realizar una terapia precoz para obtener buenos resultados a largo plazo y procurar que el paciente obtenga una buena calidad de vida. Las clasificaciones actuales establecidas para las formas infantojuveniles se ven limitadas por lo breve del periodo de seguimiento etario, además que se hace necesario aplicar dos clasificaciones internacionales (a) International League of Associations for Rheumatology y (b) Clasificación de Espondiloartropatías Juveniles del European Spondyloarthropathy Study Group para lograr el diagnóstico aproximado. Es necesario considerar que en muchos casos será el reumatólogo de adultos quien establecerá el diagnóstico y pronóstico definitivo. Se reconoce que este grupo de patología inflamatoria crónica requiere unificación de criterios de clasificación en niños y adultos para facilitar la comunicación científica y de transición.