Greater magnitude of entheseal microdamage and repair in psoriatic arthritis compared with ankylosing spondylitis on ultrasound.

Objectives: AS and PsA share clinical and immunological features centred on enthesitis. However, a strong association between PsA and preceding injury has been recognized. The aim of this study was to test the hypothesis that the entheseal damage seen by US is commoner in PsA patients than in AS patients. Methods: Seventy-nine AS and 85 PsA patients had US scans of 1640 entheses to calculate entheseal inflammation (hypoechogenicity, thickening and Doppler) and damage scores (calcifications, enthesophytes and erosions). Regression modelling was done to evaluate the effect of diagnoses on outcomes, controlling for age, gender, BMI, clinical enthesitis, HLA-B27, and anti-TNF use. Results: Both inflammation and damage scores on US were correlated with BMI (r = 0.392; r = 0.320) and age (r = 0.308; r = 0.538) (P < 0.001), and men had higher inflammation scores than women [12.3 (7.5) vs 8.9 (7.3), P = 0.001]. In multivariate analysis, despite similar (anti-TNF-treated patients) or slightly less inflammation (anti-TNF-naïve patients) in the PsA group, they had 4.22 times more US damage than their counterparts with AS. The difference was even higher in the anti-TNF-naïve patients (5.6 times). Conclusion: On US assessment, PsA patients have greater entheseal insertion damage scores compared with AS, suggesting potential differences in tissue repair, immunobiology or response to injury at insertions.

Limited reliability of radiographic assessment of spinal progression in ankylosing spondylitis.

Objectives: Conventional radiography is key to assessing AS-related spinal involvement and has become increasingly important given that spinal fusion may continue under biologic therapy. We aimed to compare the reliability of radiographic scoring of the spine by using different approaches to understand how different readers agree on overall scores and on individual findings. Method: Six investigators scored 68 plain radiographs of the cervical and lumbar spine of 34 patients with a 2-year interval, for erosions, sclerosis, squaring, syndesmophytes and ankyloses using the Spondyloarthritis Radiography (SPAR) module. The intraclass correlation coefficients were calculated compared with two gold standards. The reproducibility of each finding in 1632 vertebral corners and new syndesmophytes in each corner was calculated by kappa analysis and positive agreement rates. Results: The intraclass correlation coefficients mostly revealed good to excellent agreement with the gold standards (0.69-0.95). The kappa analysis showed worse agreement, being relatively higher for syndesmophytes (0.163-0.559) and ankylosis (0.48-0.95). Positive agreement rates showed that erosions were never detected at the same vertebral corner by two readers (positive agreement rate: 0%). The mean (range) positive agreement rates were 10.1% (0-27.7%) for sclerosis and 19.2% (0-59.7%) for squaring, and were higher for syndesmophytes [38.8% (21.4-62.5%)] and ankylosis [77.3% (64-95.3%)]. Conclusion: Our results show that there is a poor agreement on the presence of grade 1 lesions included in the Modified Stoke Ankylosing Spondylitis Spine Score-mostly for erosions and sclerosis-which may increase the measurement error. The currently used definitions of reliability have a risk of overestimating reproducibility.

Criteria sets for primary Sjogren's syndrome are not adequate for those presenting with extraglandular organ involvements as their dominant clinical features.

Patients with primary Sjogren's syndrome (pSS) may go undiagnosed or be misclassified due to the insidious nature and wide spectrum of the disease. The available several classification criteria emphasize glandular findings. We aimed to analyze the efficiency of various classification criteria sets in patients diagnosed on the clinical basis by expert opinion and to compare those pSS patients who fulfilled these criteria with those who did not. This is a multicenter study in which 834 patients from 22 university-based rheumatology clinics are included. Diagnosis of pSS was made on the clinical basis by the expert opinion. In this study, we only interviewed patients once and collected available data from the medical records. The European criteria, American-European Consensus Group (AECG) and American College of Rheumatology (ACR) Sjogren's criteria were applied. Majority of the patients were women (F/M was 20/1). The median duration from the first pSS-related symptom to diagnosis was significantly shorter in men (2.5 ± 2.3 vs 4.3 ± 5.9 years) (p = 0 < 0.016). When the European, AECG and ACR Sjogren's criteria were applied, 666 patients (79.9%) satisfied at least one of them. In total, 539 patients (64.4%) satisfied the European, 439 (52.6%) satisfied the AECG, and 359 (43%) satisfied the ACR criteria. Among the entire group, 250 patients (29.9%) satisfied all and 168 (20.1%) met none of the criteria. The rates of extraglandular organ involvements were not different between patients who met at least one of the criteria sets and those who met none. There is an urgent need for the modification of the pSS criteria sets to prevent exclusion of patients with extraglandular involvements as the dominant clinical features.

Can Pentraxin-3 be a Candidate Marker in the Follow-Up of the Patients With Behçet's Disease?

OBJECTIVES: This study aims to assess the level of pentraxin-3 (PTX-3) as an inflammatory marker and compare it with C-reactive protein (CRP) levels in patients with Behçet's disease (BD). PATIENTS AND METHODS: Forty-two patients with BD (15 males, 27 females; mean age 39.7±8.6 years; range 20 to 64 years) and 42 age- and sex- matched healthy controls (14 males, 28 females; mean age 40.8±8.2 year; range 25 to 60 years) were included in the study. Serum CRP and plasma PTX-3 levels were measured. Subgroup analyses were performed according to clinical manifestations of patients with BD. RESULTS: Both PTX-3 and CRP levels were significantly higher in patients with BD than controls (1.33±0.29 vs 0.85±0.12, p<0.05 for PTX-3 and 0.71±0.13 vs 0.27±0.03, p<0.001 for CRP, respectively). Area under the curve was 0.633±0.062 vs 0.729±0.05, respectively. Mean PTX-3 and CRP levels were 1.1 vs 1.5, p=0.5; 0.5 vs 0.9, p=0.5; respectively, in patients with mucocutaneous involvement alone and with other involvements, whereas they were 0.9 vs 1.6, p=0.1; 0.5 vs 0.8, p=0.3; respectively, in patients with and without peripheral arthritis, and were 1.7 vs 0.9, p=0.06; 1.0 vs 0.5, p=0.07; respectively, in patients with and without uveitis. CONCLUSION: Although PTX-3 levels were higher in patients with BD than healthy controls, sensitivity and specificity of PTX-3 was not different than CRP in patients with BD.

Ultrasonographic Assessment of Fifth Metatarsophalangeal Joint Erosion in Rheumatoid Arthritis: Which Aspect Is Better?

In this study, the best ultrasound (US) aspect for detection of fifth metatarsophalangeal (MTP) joint erosions, the most frequently eroded joint, in rheumatoid arthritis (RA) patients is investigated. Forty-eight RA patients (F/M = 35/13, mean age and disease durations 50.3 ± 11.8 and 7.9 ± 6.9 y, respectively) were evaluated by B-mode US for erosion. Images were obtained from the dorsal, lateral and plantar aspect of the fifth MTP joint, in longitudinal and transverse scans. The fifth MTP erosions were detected in 36 of 48 patients (75%) and 67 of 96 feet (69.8%). Of the erosions, 15 (22.4%), 53 (79.1%) and 59 (88.0%) were observed at dorsal, lateral and plantar aspects, respectively. Despite not being statistically different, the detection rate of fifth MTP erosions was numerically higher in the plantar aspect than both the lateral and dorsal aspects. In conclusion, the fifth MTP erosions in RA patients are more commonly detected in the plantar aspect US than in dorsal and lateral assessments.

Rosai-Dorfman disease with factor XII deficiency.

A 17-year-old female patient presented with chronic symmetrical oligoarthritis of both knees and ankles, xerostomia, xerophthalmia, multiple bilateral lymphadenopathies in the cervical region, and bilateral parotid enlargement with the histological finding of chronic sialoadenitis. She had been already given methotrexate, chloroquine, and corticosteroids with the diagnosis of rheumatoid arthritis (RA) before referral to our outpatient clinic. Because her complaints and the lumps did not remit and she could be classified as neither RA nor primary Sjögren's syndrome (SS) according to 1987 ACR RA criteria or European preliminary criteria for SS, lymph node biopsy was repeated and revealed the diagnosis of Rosai-Dorfman disease (RDD) with the histological findings of histiocytes, phagocyting lymphocytes in enlarged sinuses, and mature plasma cells infiltrating the pulpa. All the medications were stopped after the pathological diagnosis of RDD and consulting with the Division of Hematology. She was reevaluated with magnetic resonance imaging, which showed dense infiltrative areas around knee and ankle joints, and computed tomography that showed a soft tissue mass surrounding the descending aorta and upper part of the abdominal aorta. Activated partial thromboplastin time was found to be prolonged in prebiopsy examinations, and factor XII deficiency was detected after detailed hematological evaluation. The symptoms of joint involvement were relieved with nonsteroidal antiinflammatory drugs. She has been followed-up without medication without obvious clinical or laboratory change. We herein report a patient with RDD mimicking RA and SS. We consider that RDD should be kept in mind especially in patients with resistant symptoms to conventional therapies, younger disease onset, and predominant parotid and lymph node enlargement.