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.

The use of ultrasonography in the diagnosis of nail disease among patients with psoriasis and psoriatic arthritis: a systematic review

Abstract Background: Nail involvement has been described as a key clinical feature for both psoriasis (PsO) and psoriatic arthritis (PsA) and is an important risk factor in PsA. Thus, early diagnosis of nail involvement may be essential for better management of PsO and PsA. Ultrasonography is considered a highly promising method to visualize nail disease. The main aim of this review was to evaluate the use of ultrasonography for the diagnosis of nail disease in patients with PsO and PsA by reviewing ultrasound parameters with the best diagnostic accuracy. Main body of the abstract: A systematic search was performed in MEDLINE via the PubMed and LILACS databases. Conference proceedings of relevant rheumatology scientific meetings were also screened. Results: After applying eligibility criteria, only 13 articles and 5 abstracts were included in this review. The selected studies showed a huge variability in evaluation methods (and therefore in the results) and were mainly focused on the assessment of nails ultrasound parameters that may differ among patients and healthy controls, especially the morphological aspects in B-mode ultrasonography and vascularization of the nail bed by Doppler ultrasonography. Our research indicated that the evaluation of nail disease in PsO and PsA is still underrepresented in the literature, probably reflecting a restricted use in clinical practice, despite the widespread use of ultrasonography in the management of chronic arthritis. Short conclusions: Despite the potential relevance of ultrasonography for the diagnosis of nail disease, additional studies are needed to determine which features are more reliable and clinically pertinent to ensure accuracy in the evaluation of nail involvement in PsO and PsA.

As diferenças do Doppler espectral, na artrite psoriática e onicomicose / Differences of spectral Doppler in psoriatic arthritis and onychomycosis

Objetivo Utilizar o Doppler espectral (DE) para quantificar atividade inflamatória e detectar diferenças ecotexturais ungueais em pacientes com artrite psoriásica e onicomicose. Métodos Foram incluídos dois pacientes, um com artrite psoriásica, mas sem dores nas articulações e sem alterações clínicas ungueais; e outro paciente com onicomicose e artrite reumatoide. O exame de ultrassom, pela escala cinza, demonstrou alterações na presença regular da ecotextura na inserção da unha, aumento da espessura do leito ungueal e perda do padrão trilaminar da unha. O Doppler espectral, através do índice de resistência (IR), detecta o processo inflamatório nas enteses ungueais. Resultados Sete articulações interfalângicas distais (IFD) nos dois pacientes foram avaliadas em dois planos, obtendo nove IR. O autor encontrou no paciente com artrite psoriásica: perda normal do padrão trilaminar da unha; leitos ungueais e cápsulas articulares das IFDs preservados. O Doppler espectral evidenciou IR<1, com média±DP igual a 0,50±0,75 em microcirculação nas enteses ungueais e caracterizou erosão óssea ativa em 3a IFD esquerda, com IR igual a 0,38 e 0,63 em planos transversal e longitudinal, respectivamente. O paciente com onicomicose mostrou as seguintes alterações: hipoecogenicidade na inserção ungueal; perda do formato da unha e o Doppler espectral nas enteses ungueais com IR>1, com média±DP igual a 1,71±0,98. Conclusão O uso do ultrassom pode detectar alterações nos leitos ungueais nessas doenças. Futuros estudos poderão melhor caracterizar essas mudanças. .

Objective To evaluate the use of the spectral Doppler (SDoppler) to quantify inflammatory activity and to detect nail echotextural differences in patients with psoriatic arthritis and onychomycosis. Methods Two patients, one with psoriatic arthritis but with no joint pain nor nail clinical change and the other with onychomycosis and rheumatoid arthritis were included. The gray scale ultrasound study, showed changes in the regular presence of echotexture at the nail insertion, thickening of the nail bed and loss of trilaminar nail pattern. The spectral Dopplerresistance index (RI), detects the inflammatory process in nail entheses. Results Seven distal interphalangeal (DIP) joints in both patients were evaluated in two planes, getting nine RI. In the patient with psoriatic arthritis the author found: loss of normal trilaminar nail plate aspect, and nail beds and DIP joint capsules preserved. The spectral Doppler showed RI<1, with mean±SD=0.50±0.75 in the microcirculation at nail entheses, with characterization of a bone erosion in the third left DIP joint, with RI=0.38 and 0.63 in transverse and longitudinal planes, respectively. The patient with onychomycosis showed the following changes: hypoechogenicity at nail insertion; loss of nail shape, and spectral Doppler in nail entheses with RI>1, with mean±SD=1.71±0.98. Conclusion The use of ultrasound can detect changes in the nail beds in these diseases. Future studies will further characterize these changes. .

Comparison of clinical and sonographical findings of Achilles tendon involvement in newly diagnosed and established cases of psoriasis

To compare the clinical and sonographical findings of Achilles tendon involvement in newly diagnosed [disease duration <6 months] and established psoriatic patients [disease duration >5years]. This cross-sectional, comparative study was carried out in Departments of Dermatology and Radiology, Military Hospital, Rawalpindi, over a period of six months. 70 patients of psoriasis were divided into two groups comprising 35 patients in each. Group I patients were newly diagnosed cases while group II included the established psoriatic patients. All patients with clinical and histological evidence of psoriasis were included. Patients with history of osteoarthritis, rheumatoid arthritis or foot trauma were excluded. Detailed history and complete clinical examination was carried out as per pro forma. The condition was considered symptomatic when there was tendon swelling, pain, tenderness or functional impairment. Ultrasound of Achilles tendon was done, keeping patient in prone position by using Pro Sound SSD 5500 Toshiba ultrasonographic machine with high frequency probe [7.5MHz] to assess findings of Achilles tendon in psoriatic patients. Fibrillar tendon structures, tendon thickness, peritenon, and bursae were evaluated. On clinical assessment 1 [2.8%] patient in group I and 5 [14.3%] patients in group II had Achilles tendon involvement. On ultrasonographic assessment, 3 [8.5%] patients in group I and 15 [42.8%] patients in group II showed involvement of Achilles tendon [p <0.05]. Achilles tendon involvement occurs in significant number of patients with long standing psoriasis as compared to newly diagnosed cases. It also revealed that enthesitis progresses with the duration of disease

Ultrasonography in clinical assessment of inflammatory and destructive changes in patients with psoriatic arthritis

To investigate the presence of asymptomatic entheseal abnormalities in psoriatic patients in an attempt for preclinical detection of psoriatic arthritis before joint affection becomes established. study included 50 patients who were divided into 2 groups; group I included 20 psoriatic patients with established psoriatic arthritis [as a control group] and group II included 30 psoriatic patients who didn't have any rheumatologic manifestations. Clinical assessment, routine laboratory studies, rheumatoid factor assessment, routine X-ray, musculoskeletal ultrasound [US], and power Doppler sonography were performed to all patients. US detected changes in 53.3% of psoriatic patients. The most common was inactive synovitis [53.3%], followed by tenosynovitis of flexor and extensor tendons of the hand [33.3%], then achillis tendinitis in 20%, and active synovitis along with achillis bursitis to be 6.7% for each. It was found that the PASI score and CRP were statistically higher in psoriatic patients with US findings than those with no US findings [p<0.05]. Higher tilers of CRP were associated with more synovitis, effusion, achillis tendinitis and bursitis in psoriatic patients; yet CRP tilers did not have in effect on US findings in patients with arthritis. It was found that active joint disease was significantly associated with joint spurs. US could detect subclinical musculoskeletal changes in asymptomatic psoriatic patients, and these changes are related to active skin disease and high levels of inflammatory markers. That is why proper control of skin disease and regular US follow up may lead to early, subclinical diagnosis of psoriatic arthritis and hence, early intervention to prevent joint destruction