Knee joint synovitis in Behçet's disease: a sonographic study.

OBJECTIVE: The aim of this study was to investigate, using ultrasound (US), knee involvement in patients with Behçet's disease (BD). METHODS: Knee US was performed in 30 unselected Italian BD patients. Signs of arthritis (joint effusion, synovial proliferation) and presence of bone erosions and Baker's cysts were recorded. Power Doppler evaluation was performed. A semi-quantitative score was used for each structure examined, whereby 0 was to indicate the absence of any change and score from 1 to 3 the presence of mild to severe changes. A sum of the single scores was obtained. Disease activity was evaluated to identify the correlation with the US modifications. RESULTS: Twenty (66.6%) patients had symptomatic articular involvement and US showed knee involvement in 18 of them (60%). Synovial proliferation was detected in 14 (46%, positive power Doppler in 4), joint effusion in 14 (46%), bone surface erosions in 3 (10%). Four patients, asymptomatic for joint involvement, showed US alterations. Eleven patients showed a total score between 1 and 3, while the other 7 had a score between 4 and 6. Subjects with a higher US score presented an increased prevalence of acneiform skin lesions with respect to the group with US score 1-3. Statistical analysis showed a positive correlation between disease activity and US score in group 2 (p=0.04). CONCLUSION: This study confirms that peripheral joint involvement represents an important clinical aspect in italian BD patients and US evaluation is useful for the detection of this aspect.

Wrist joint involvement in systemic lupus erythematosus. An ultrasonographic study.

OBJECTIVE: To define joint alterations in the wrists of patients with systemic lupus erythematosus (SLE) by ultrasonography (US). METHODS: Fifty-two wrists of 26 SLE patients and 30 wrists of 15 healthy controls were evaluated using US by two different experienced operators, blinded to the clinical data. A 14 MHz linear probe was used. Power Doppler (PD) was applied to evaluate the presence of synovial neoangiogenesis as a parameter of active local synovitis. The findings were correlated to the clinical evaluation, serological systemic disease activity parameters (ESR, C3 levels) and the SLE-disease activity score (SLEDAI). Statistical analysis was performed by the EPISTAT program. RESULTS: Signs of synovitis were found in 22 wrists (42.3%). Synovial proliferation was present in 10 joints (19.2%), PD positivity in 5 (9.6%) and joint effusion in 13 (25%). Erosions were present in both wrists (3.8%) of one patient. Signs of tenosynovitis of one or more tendons were shown in 23 cases (44.2%). Ganglia were found in 2 joints (3.8%). Changes of the median nerve, joint dislocations, tendons' ruptures, cysts and nodules were never detected. In 14 wrists (26.9%) no alterations were found. There was no correlation between sonographic findings and clinical, laboratory and indexes signs of disease activity. In the control group the only alteration found was tenosynovitis in 1 joint (p < 0.0001). CONCLUSION: US proved to be an useful technique to detect wrist joint alterations in SLE. These findings may help the physician to modulate treatment strategies and to perform a low cost monitoring of joint disease activity.

Joint sonography in asymptomatic patients with HCV correlated hepatitis.

OBJECTIVES: Many different articular symptoms may appear in patients with HCV hepatitis, but in a relatively large number of patients no rheumatic symptoms are present. This sonographic study was undertaken to detect the possible presence of early articular changes in HCV patients without any rheumatic manifestations. METHODS: The knee, hip and shoulder were evaluated in a cohort of 29 consecutive HCV patients without any rheumatic symptoms. Results were compared with those obtained by the evaluation of 29 healthy subjects who were negative for markers of HCV and HBV infections. RESULTS: Results showed the presence of alterations in 96.5% of the patients, with significant differences in comparison to controls (p < 0.0001). Slight inflammatory changes were found in all the joints examined. The knee was involved in 79.3% of the cases, the hip in 27.6% and the shoulder in 89.6%. CONCLUSIONS: Our preliminary study shows the presence of joint changes in the majority of cases. To the best of our knowledge this is the first ultrasonographic study to focus on joint evaluation in patients with HCV hepatitis. Broader epidemiological and virological investigations, in particular for the HCV subtype and HLA genotype, will be required to elucidate the relationship between HCV infection and rheumatic symptoms.

Sonographic study of painful shoulder.

OBJECTIVE: To identify sonographically the site and entity of alterations in a high number of patients with shoulder pain. METHODS: Two different experienced operators (both rheumatologists), who were blinded to the clinical data, performed sonographic examinations on 528 shoulders of 425 consecutive patients with painful shoulder and in both shoulders of 198 control subjects. They carried out ultrasound examinations separately using a 7.5 MHz linear transducer. Investigation included the long head of the biceps tendon, the supraspinatus tendon, infraspinatus tendon, subscapularis tendon, acromioclavicular joint, glenohumeral joint, subacromial-subdeltoid bursa, subscapularis bursa, and finally identification of calcifications. Before the ultrasonographic exam, a third experienced rheumatologist performed a physical examination in all patients using specific tests of movement for evaluation of the long head of biceps tendon, the supraspinatus tendon, infraspinatus tendon, subscapularis tendon, and acromioclavicular joint. RESULTS: Sonographic alterations were found in a total of 94.1% of patients. The structure most frequently involved was the supraspinatus tendon (64.6%). The long head of the biceps tendon (48.1%) and the acromioclavicular joint (51.5%) were also frequently involved. Different types of alterations in the various structures were detected. Significant differences were found with respect to controls. A high sensitivity and specificity of sonography was demonstrated compared to physical examination. CONCLUSIONS: Sonography evaluates accurately the single anatomic structures of the shoulder and identifies both the site and type of changes in patients with painful shoulder. The high sensitivity/specificity, non-invasiveness and low costs of this technique justify its routine utilisation in clinical rheumatological practice.

Knee joint synovitis in Sjögren's syndrome. Sonographic study.

Ultrasound detects effusion and synovial proliferation caused by synovitis. The study was undertaken to evaluate the signs of synovitis in patients with primary Sjögren's Syndrome (SS). Joint effusion was detected and synovial thickness was measured in the suprapatellar synovial bursa. Results have been compared with those obtained by sonographic assessment of knee joint in patients with secondary SS and RA. with secondary SS and connective tissue diseases, with RA, and in healthy subjects. Synovial thickening was demonstrated in all the diseases (higher grades of thickening were found in secondary SS with RA and in RA). Joint effusion was present with significantly higher frequency in secondary SS with RA and in RA. Results demonstrated signs of slight synovitis in primary SS. More severe synovitis was found both in secondary SS with RA and in RA. This is the first sonographic study demonstrating slight synovitis in primary SS.

Sonography in the study of metatarsalgia.

OBJECTIVE: To identify sonographically the changes of the forefoot in patients with metatarsalgia. METHODS: Sonography of the foot was performed in 112 patients with metatarsalgia and in 50 healthy controls. Metatarsophalangeal (MTP) joints, intermetatarsal web spaces, flexor and extensor tendons, and plantar aponeurosis were examined. RESULTS: Sonography showed intermetatarsophalangeal bursitis in 20.5% of cases, Morton's neuroma in 15.2%, and effusion of MTP joints in 11.7%. CONCLUSION: Sonography gives useful information about the possible alteration responsible for metatarsalgia.

Power Doppler sonography in knee arthritis--a pilot study.

We compared power Doppler sonography to laboratory indices of disease activity in patients with knee arthritis to determine the clinical relevance of hypervascularity. Eight healthy volunteers and 22 patients with symptoms and signs of knee arthritis were studied. Presence or absence of hypervascularity, synovial thickening, effusion, and Baker's cysts were recorded. Disease activity was measured by erythrocyte sedimentation rate, c-reactive protein, alpha2-globulins, sideremia, hemoglobinemia, and serum white cell count. Various grades of synovial hyperemia were found in 12/22 cases. Patients with and without synovial hypervascularity showed statistically significant differences in age (P=0.017), erythrocyte sedimentation rate (ESR) (P = 0.039), hemoglobinemia (P = 0.009), and sideremia (P = 0.012). Power Doppler sonography is able to demonstrate synovial hyperemia, which is correlated with some laboratory indices of inflammation.

[Rheumatoid arthritis: frequency of hospitalization and evaluation of economic burden] / Artrite reumatoide: stima della frequenza dei ricoveri e valutazione dei costi della malattia.

About 10% of the Italian general population is affected by rheumatic diseases (RD). Due to their chronic and disabling nature, RD are cause of an annual economic burden evaluated in about 17,000 billions italian lire. In Italy, rheumatoid arthritis (RA) affects nearly 400,000 people. One hundred RA patients answered to a questionnaire concerning hospitalization during the first ten years of disease. Seventy-two patients needed hospitalization with a total of 147 hospital admissions. Eleven patients were admitted thrice to the hospital, 53 patients twice, and 8 patients only once with a mean number of hospital admissions per patients of 1.8. Hospitalization costs were calculated on the basis of the cost of the DRG for RA and inferred for the total population of Italian RA patients. The result was about 350 billions italian lire. Two methods were used in order to evaluate the economic impact of RA including both direct and indirect costs. First, internationally accepted criteria for cost assessment were applied to the Italian system. Second, different evaluations were performed by the authors. With the first method, direct and indirect costs were 3,000 and 3,500 billions Italian lire, respectively. With the second method, based on a more precise assessment of costs including the costs of wager from a reduction or cessation of work, the total costs for RA was between 3,100 and 3,600 billions Italian lire. Since psychological and social problems often influence patients with RA in relation to their families and society, the issue of intangible costs has also been addressed.

[Brucellar spinal abscess. Case report] / Ascesso spinale brucellare. Descrizione di un caso.

Brucellosis is a zoonosis commonly present in many areas of the world; in some Mediterranean countries it is endemic. The disease is usually transmitted to humans by ingestion of contaminated food; rarely it may be transmitted either by direct penetration through skin lesions or conjunctival mucosa or even by inhalation of aerosols. The disease may be asymptomatic, but in some occasions acute or chronic symptoms are present. Among localised forms of the disease spinal involvement is rare but it should be suspected in many Mediterranean areas where brucellosis is endemic. In particular, the extension of the brucellar abscess within the epidural space with contemporaneous muscular involvement is unusual. The authors report a case of a patient with multiple spinal brucellar abscesses of exceptional dimensions, extending in the epidural space and within paravertebral and psoas muscles and causing compression of the lumbar nerve roots. The exact localisation and extension of the abscess have been accurately defined by MRI.

Usefulness of high resolution US in the evaluation of effusion in osteoarthritic first carpometacarpal joint.

OBJECTIVE: The aim of this study is to provide a reproducible and quantitative sonographic method for evaluation of effusion in the first carpometacarpal joint in osteoarthritis. METHODS: High resolution sonography of the carpometacarpal joint of the thumb was carried out in 20 normal joints and in 57 joints from patients with osteoarthritis. A 10 MHz transducer was used. RESULTS: The articular cavity appeared as a hypoechoic triangular area. In normal joints the mean values obtained by measuring the distance between the apex and the base of the triangle was 2.89 mm (SD 0.22). In osteoarthritic joints it was significantly increased (p<0.001). The authors assert that the presence of effusion is very likely if the value is >3.33 mm (mean+2 SD). CONCLUSIONS: Sonography provides useful, reproducible, and quantitative data for detection of effusion within the first carpometacarpal joint.

A morphological study of bone and articular cartilage in ochronosis.

An ochronotic femoral head has been studied morphologically under the light and the electron microscope. Its articular cartilage showed the alterations already reported in the literature, mainly consisting of erosions of the surface, pigment accumulation in chondrocytes and intercellular matrix, chondrocyte degeneration, the formation of pigmented, calcified and uncalcified microshards, and the presence of granulation tissue with macrophagic cells. The changes in bone were less severe than those in cartilage. Pigment was present in the calcified matrix. This did not seem to disturb the organization of the bone tissue, although it was diffusely osteoporotic, perhaps because of limb disuse. The preservation of calcified matrix might depend on the fact that its collagen fibrils are encrusted by mineral substance, which avoids the dangerous effects that the deposition of ochronotic pigment induces in the fibrils of soft connective tissues. On the other hand, the newly formed osteoid matrix remains uncalcified for too short a time to be modified by the pigment. Diffuse or granular pigmentation was found in a few osteocytes, while several of them were condensed or reduced to cellular fragments. Bone resorption often occurred near these osteocytes. However, this did not seem to alter the degree of bone remodelling, possibly because of the relatively low numbers of degenerated or dead osteocytes. Pigment was also contained in the cytoplasmic vacuoles of otherwise active osteoclasts, whereas it was not found in osteoblasts. On the whole, ochronosis in bone seems to induce the same changes as in other connective tissues. However, their severity appears to be limited by calcification, which prevents modifications in collagen fibrils, and by bone remodelling, which to some extent eliminates the oldest, pigment-richest parts of the tissue.

Shoulder involvement in rheumatic diseases. Sonographic findings.

OBJECTIVE: To distinguish using shoulder sonography the different changes present in rheumatoid arthritis (RA), polymyalgia rheumatica (PMR), and periarticular disorders (PD) of soft tissue of the shoulder. METHODS: Ninety shoulders of patients with RA, 32 with PMR, 122 with PD, and 108 controls were studied sonographically, using a 7.5 MHz linear probe. The following structures were evaluated: long head of biceps tendon, supraspinatus, infraspinatus and subscapularis tendons, subacromial and subscapularis bursae, rotator cuff (thickness), calcifications, and glenohumeral and acromioclavicular joints. Statistical analysis was by Student's t test and chi-squared test. RESULTS: Involvement of long head of biceps tendon (peritendinous fluid collection, changes of thickness, and/or echotexture) was significantly different between RA and PMR and between PD and PMR. Alterations in thickness and/or fibrillar pattern were evaluated in rotator cuff tendons: supraspinatus tendon was involved with significant differences between PD and both RA and PMR; the changes of subscapularis tendon were present, with significant differences between PD and both the other groups; the alterations of infraspinatus tendon were not statistically different between the 3 groups. Effusion within bursae was present, with significant differences only between RA and PD. The mean thickness of rotator cuff was significantly different between controls (6.2 mm) and both PD (5.3 mm) and RA (5.8 mm), and between PMR (6 mm) and PD. Evaluation of effusion within the glenohumeral joint (capsule-bone distance) showed significant differences between controls (2.4 mm) and both RA (4.2 mm) and PMR (4 mm), between RA and PD (2.6 mm), and between PMR and PD. Calcifications were present only in PD (21.3%) and RA (6.7%), with significant differences. Effusion within the acromioclavicular joint was present in RA (35.5%) and PD (20.5%), with significant differences. CONCLUSION: Shoulder sonography showed involvement of all structures in RA, the prevalence of effusion in PMR, and involvement mainly of tendons in PD.

Sonographic findings in haemodialysis-related chronic arthropathy.

In 33 subjects receiving long-term haemodialysis sonographic examination of shoulders, hips and knees was performed. Changes of both joints and periarticular soft tissues were found in 60 shoulders, 16 hips and 42 knees. In the shoulder besides the presence of tenosynovitis and bursitis, even significant thickening of rotator cuff and increased distance between capsule and bone in transascellar scan were found. Also, in the hip the distance between capsule and bone was significantly increased. In the knee effusion was present in 14 cases and synovial hypertrophy in 20. Articular femoral cartilage was significantly thinned. Results obtained suggest the hypothesis of the presence of an important inflammatory component in the pathogenesis of arthropathy related to haemodialytic treatment. The production of cytokines by mononuclear cells stimulated by beta-2 microglobulin may cause the inflammatory response. Sonographic findings of alterations in 42 symptomless joints show the importance of this diagnostic method to begin an early therapy.

Time course of radiologic lesions in spinal hyperostosis: an osteoradiometric study.

The purpose of this study was to evaluate changes over time in the flowing spinal ossification characteristic of spinal hyperostosis. Thirty-two patients were studied. A QR-ORM osteoradiometry apparatus was used to measure variations in the surface area of the ossification on radiographs obtained after three, ten, and 20 years. The size of the ossification increased gradually in every case. Patients with a small ossification on the initial radiograph and younger patients were more likely to have larger ossification size increases over time; male gender and diabetes mellitus had a similar effect, although the differences were not significant, perhaps because of the small number of subjects. The magnitude of the ossification increase was not the same on the anteroposterior and lateral films at the various time points. The rate of ossification increase was slower in patients with long-standing disease or osteoporosis, although differences were not statistically significant. Over time, the density of the ossification increased, particularly near the vertebral bodies, perhaps as a result of transformation of fibrocartilage tissue into compact bone tissue.

Intra-articular somatostatin 14 reduces synovial thickness in rheumatoid arthritis: an ultrasonographic study.

Sixteen patients with RA (3 males, 13 females), diagnosed according to RA revised criteria, were selected and entered the study. They underwent six intra-articular injections of 750 mcg of SST14 at 15-day intervals. The thickness of the synovial membrane (SM) was measured with a 5-MHz linear sound with longitudinal and transversal scanning carried out on the upper patellar cavity. The contralateral knee was also assessed together with the injected knee in order to ascertain any systemic effect of the drug. A significant reduction of SM thickness was observed already at the first control (T3) in 14 out of 16 patients. At the 5th and 6th injections (T5 and T6) the reduction was still significant but to a lower extent. In 8 out of 16 cases a reduction of SM thickness was observed in the contralateral knee. Analysis of these data clearly shows that the intra-articular injection of SST14 is able to reduce the thickness of SM in patients with RA, and indicates that SST14 may directly reduce synovitis. This particularity has been detected in our work with a non-invasive technique such as the joint ultra-sound (US). In conclusion, our work confirms the efficacy of SST14 in the control of RA synovial hypertrophy and the reliability of US technique in the measurement of SM thickness.

[Intra-articular treatment with somatostatin 14 in rheumatoid arthritis]. / Trattamento endoarticolare con somatostatina 14 nell'artrite reumatoide.

19 patients with RA underwent six intraarticular injections of 750 micrograms of Somatostatin 14 in one knee at 15-day intervals. In all patients some clinical parameters were evaluated: articular function, pain on pressure, spontaneous pain, pain on movement, duration of morning stiffness. Also some laboratory parameters were examined: complete blood cell count, ESR and CRP. An overall and significant improvement of the symptomatology of the treated knee was seen in all patients especially after the 3rd infiltration and still more after the 5th. At follow up 3 months after the end of treatment 12 patients were controlled, 11 of these showed a persistence of the improvement. No side-effects were seen.

Rheumatoid nodules and cyclosporin A treatment.

The authors describe the appearance of rheumatoid nodules during cyclosporin A (CsA) therapy for RA. Their course was evaluated by sonography that revealed an increase in number and size of rheumatoid nodules. The relationship between CsA treatment and the onset of nodulosis is not clear and further studies are needed to assess the role of CsA treatment in the extra-articular manifestations of rheumatoid arthritis such as rheumatoid nodules.