Effect of very early treatment in rheumatoid arthritis on bone oedema and synovitis, using magnetic resonance imaging.

OBJECTIVE: To evaluate the magnetic resonance imaging (MRI) findings of hand involvement before and 1 year after treatment in patients with early rheumatoid arthritis (RA). METHOD: MRI of the dominant hand was performed in 22 patients fulfilling the new criteria for early RA. The patients were divided into three groups. Nine had very early RA (VERA; disease duration < 3 months), seven had early RA (ERA; disease duration < 6 months), and six had established RA (ESTRA; disease duration > 12 months). The MRI protocol consisted of fat-suppressed T2, and plain and contrast-enhanced T1-weighted sequences. Assessment of bone marrow oedema, synovitis, and bone erosions was performed by the OMERACT RA MRI scoring system. Patients were treated with methotrexate (MTX) 0.2 mg/kg/body weight/week and prednisone 7.5 mg/day. Clinical assessment was evaluated using the Disease Activity Score for 28 joint indices (DAS28). RESULTS: After treatment, a significant decrease was observed: (a) in DAS28 of VERA (6.2 ± 0.9 vs. 2.4 ± 1.2), ERA (5.3 ± 0.8 vs. 2.8 ± 1.0), and ESTRA patients (5.7 ± 8.0 vs. 2.7 ± 0.7; p < 0.05); (b) in bone oedema (16.77 ± 13.78 vs. 5.88 ± 6.31) and synovitis (12.44 ± 6.44 vs. 2.88 ± 3.25) of VERA patients; and (c) in synovitis (7.57 ± 6.32 vs. 1.42 ± 1.81) of ERA patients (p < 0.05). No significant difference was found in erosions in any group. CONCLUSION: Bone marrow oedema and synovitis decrease significantly when RA is diagnosed and treated early. MRI is useful in the early detection of these changes. MTX treatment resulted in a significant decrease in DAS28 score and significant improvement in bone oedema and synovitis.

Diffuse periventricular leukomalacia in preterm children: assessment of grey matter changes by MRI.

BACKGROUND: Preterm children may have cognitive deficits and behavioural disorders suggestive of grey matter (GM) injury. The prevalence is higher in preterm children with diffuse periventricular leukomalacia (dPVL). OBJECTIVE: Evaluate changes in the volume of 116 GM areas in preterm children with dPVL. METHODS AND MATERIALS: Eleven preterm children with dPVL, gestational age 32.8 ± 2.6 weeks, examined at corrected age 22.0 ± 18.2 months and 33 matched preterm controls with normal brain MRI were studied. Volumes of 116 individual GM areas, and white matter/cerebrospinal fluid (WM/CSF) ratio were calculated on T1-weighted high-resolution images after segmentation. RESULTS: Relative to controls, children with dPVL had decreased GM volume of the hippocampus, amygdala, and frontal lobes and temporal middle gyrus (P < 0.05); increased GM volume of the putamen, thalamus, globus pallidum, superior temporal gyrus and of the parietal and occipital lobes (P < 0.05) and lower WM volume/higher CSF volume (P < 0.05). WM/CSF ratios also differed (P < 0.05). CONCLUSIONS: Preterm children with dPVL have increased regional GM volume in some areas probably related with a process of brain plasticity-regeneration and reduced GM volume in areas associated with cognition and memory.

Heterotopic ossification in systemic sclerosis.

Although myopathy or myositis may occur in systemic sclerosis (SSc) as well as soft tissue calcification, ossification is not a feature of the disease. Here we present an unusual case of extended calcification and, to a lesser degree, ossification of the right gluteal region, lateral thigh, and knee, with associated myopathy and functional impairment. Heterotopic ossification (HO), or myositis ossificans, has not been reported so far in scleroderma patients, making this case, in our opinion, unique and interesting. However, differential diagnosis from other causes of extraskeletal ossification, such as tumours or tumour-like conditions, is required.

A case of Brucella spondylitis in a patient with psoriatic arthritis receiving infliximab.

A 69-year-old woman with psoriatic arthritis treated with infliximab presented with low back pain of recent onset and fever. Serological, microbiological and imaging studies revealed Brucella spondylitis at the L5-S1 level. Immunosuppressive therapy was suspended and antibiotic therapy including doxycycline and rifampicin was administered for six months. The patient responded adequately with clinical and laboratory improvement and a considerable remission of spondylitis on repeat magnetic resonance imaging scan. The pathophysiology of tumor necrosis factor (TNF) alpha in Brucellosis and the role of anti-TNFalpha therapy are discussed.

Magnetic resonance imaging findings of the cervical spine in patients with rheumatoid arthritis. A cross-sectional study.

OBJECTIVES: To investigate by magnetic resonance (MR) imaging the occurrence of cervical spine (CS) involvement in rheumatoid arthritis (RA) patients. METHODS: Fifty-one consecutive unselected patients, who fulfilled the revised American College of Rheumatology criteria for RA, were investigated. All patients had a complete physical and laboratory evaluation. Radiological evaluation included hand and wrist x-rays, as well as CS radiographs in anteroposterior, lateral and lateral in full flexion views. In addition, MR (Spin Echo T2-weighted sagittal scans [neutral and flexion position], plain and contrast enhanced T1-weighted sagittal and axial scans) was performed in all patients. Hand x-rays were evaluated according to the Larsen's criteria, while CS radiographs were evaluated according to Winfield classification. Disease activity was assessed by disease activity score for 28 joint indices (DAS-28). RESULTS: There were 42 females and 9 males with a mean age of 56.5 +/- 10.4 years and mean disease duration 12.4 +/- 8.5 years. Thirty-three patients (64.7%) had positive IgM rheumatoid factor (RF). Thirty patients presented clinical findings, mainly cervical pain and stiffness of CS (25 with positive and 5 with negative MR), while, radiological findings of CS involvement were found in 40 patients. Forty-four patients (86.2%) presented MR findings of CS involvement (peridental pannus 88%; dens erosion 23.5%; atlantoaxial subluxation 13.7%; subaxial subluxations 10%; brainstem compression 5.9%). Peridental pannus correlated with high DAS-28, positive IgM RF and advanced erosive changes of the wrist and hand (p < 0.05) in the univariate analysis. However, multivariate logistic regression analysis did not confirm such correlation. CONCLUSIONS: We conclude that the frequency of CS involvement in Greek RA patients is high but the destructive changes are mild. However, in patients with active erosive peripheral disease it is very probable to also have some changes in CS. These may be clinically important and in such cases, MR may offer valuable information.

Cyclosporine A in the treatment of early rheumatoid arthritis. A prospective, randomized 24-month study.

OBJECTIVE: To investigate the efficacy, tolerability and safety of cyclosporine A (CSA) in early rheumatoid arthritis (RA) patients. METHODS: Patients with an early diagnosis of RA, a disease duration of less than 3 years, and without prior disease modifying antirheumatic drug (DMARD) treatment were studied. They randomly received oral CSA (3 mg/kg/day) or oral methotrexate (MTX) (0.15 mg/kg/week). In addition, all patients in both groups received oral prednisone (7.5 mg/day). RESULTS: Fifty-two patients were assigned to the CSA group and 51 to the MTX group. After 24 months of treatment, 48 patients from the CSA group and 48 from the MTX group showed significant clinical improvement. This was evaluated by the duration of morning stiffness, grip strength, the total joint count, joint swelling, and joint tenderness and pain, compared to pre-treatment values. The clinical improvement was also associated with a significant decrease in ESR and CRP values in both groups. No significant radiological deterioration was observed in the CSA patients compared to those treated with MTX after 24 months. Four patients from the CSA group dropped out of the study, two because of a synovitis flare, one because of severe hypertrichosis and one because of severe gingival hyperplasia. Three patients from the MTX group withdrew, one because of disease flare-up and two because of gastrointestinal disturbances. CONCLUSION: Early immunointervention in RA patients appears to be crucial to limit the development of joint damage. Cyclosporine A appears to be effective, well tolerated and safe in the long-term treatment of RA and can therefore be used as a first immunomodulatory drug in the armamentarium for the treatment of RA.

White matter water diffusion changes in primary Sjögren syndrome.

BACKGROUND AND PURPOSE: Histopathologic studies have demonstrated WM damage in primary Sjögren syndrome. The purpose of this study was to evaluate WM microstructural changes by use of DTI-derived parameters in patients with primary Sjögren syndrome. MATERIALS AND METHODS: DTI was performed in 19 patients with primary Sjögren syndrome (age, 64.73 ± 9.1 years; disease duration, 11.5 ± 7.56 years) and 16 age-matched control subjects. Exclusion criteria were a history of major metabolic, neurologic, or psychiatric disorder and high risk for cardiovascular disease. Data were analyzed by use of tract-based spatial statistics, for which the WM skeleton was created, and a permutation-based inference with 5000 permutations was used with a threshold of P < .01, corrected for multiple comparisons to enable identification of abnormalities in fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity. RESULTS: Tract-based spatial statistics showed decreased fractional anisotropy in multiple areas in patients with primary Sjögren syndrome compared with control subjects, located mainly in the corticospinal tract, superior longitudinal fasciculus, anterior thalamic radiation, inferior fronto-occipital fasciculus, uncinate fasciculus, and inferior longitudinal fasciculus. Increased mean diffusivity and radial diffusivity and decreased axial diffusivity were observed in most of the fiber tracts of the brain in patients with primary Sjögren syndrome, compared with control subjects. CONCLUSIONS: Patients with primary Sjögren syndrome show loss of WM microstructural integrity, probably related to both Wallerian degeneration and demyelination.

Voxel-based morphometry and diffusion tensor imaging of the optic pathway in primary open-angle glaucoma: a preliminary study.

BACKGROUND AND PURPOSE: Neuropathologic studies in experimental and human glaucoma have demonstrated degenerative changes in the optic pathway. The purpose of this study was to assess the optic pathway in POAG by using VBM and DTI. MATERIALS AND METHODS: Eighteen patients 57.05 ± 11.38 years of age with POAG of 8.30 ± 5.14 years' duration and 18 control subjects underwent a complete ophthalmologic examination, including quantification of the RNFLT by using Stratus OCT 3, and brain imaging. The imaging protocol consisted of a T1-weighted high-resolution 3D spoiled gradient-echo sequence and a multisection spin-echo- planar diffusion-weighted sequence. Data preprocessing and analysis were performed by using Matlab 7.0 and SPM 5. RESULTS: Left temporal and right nasal RNFLTs were significantly thinner than right temporal and left nasal RNFLTs. In patients, VBM revealed a significant reduction in the left visual cortex volume, the left lateral geniculate nucleus, and the intracranial part of the ONs and the chiasma. In addition, a significant decrease of FA was observed in the inferior fronto-occipital fasciculus, the longitudinal and inferior frontal fasciculi, the putamen, the caudate nucleus, the anterior and posterior thalamic radiations, and the anterior and posterior limbs of the internal capsule of the left hemisphere (P < .05). CONCLUSIONS: Neurodegenerative changes of the optic pathway and several brain areas associated with the visual system can be observed by using VBM and DTI in patients with POAG, suggesting that glaucoma is a complex neurologic disease.

Conventional MRI and magnetisation transfer imaging of the brain and optic pathway in primary open-angle glaucoma.

Neuropathological studies in experimental and human glaucoma have shown degenerative changes in the optic pathway. The purpose of the study was to evaluate, with conventional MRI and magnetisation transfer imaging, the brain and the optic pathway of patients with primary open-angle glaucoma (POAG). 26 patients, aged 67.4+/-8.6 years, and 26 control subjects were studied. The presence of white matter hyperintensities (WMH) was evaluated on fluid-attenuated inversion recovery images of the brain. The area of the optic nerves was assessed on coronal short tau inversion recovery images. Magnetisation transfer ratio (MTR) was measured in the chiasm and in the grey and white matter (CGM and CWM) of the calcarine fissure. More WMH were observed in patients (total 261, mean 10.8, standard deviation 12.7) than in control subjects (total 127, mean 4.7, standard deviation 5.7; p<0.001). The area (mm(2)) of optic nerves (10.7+/-5.7) and the MTR (%) of the chiasm (53.7+/-8.4), the CWM (60.9+/-4.2) and the CGM (53.6+/-5.6) were all lower in patients than in control subjects (13.6+/-4.3, 62.1+/-6.2, 67.6+/-8.6 and 57.0+/-4.6, respectively; p<0.05). The area of optic nerves showed significant correlation with the MTR of the chiasm (R = 0.41), the MTR of the CGM (R = 0.33), the MTR of the CWM (R = 0.34) and the cup to disc ratio (R = -0.46). POAG leads to optic nerve atrophy and degeneration of the optic pathway. The finding of an increase in the number of WMH suggests that cerebrovascular disease may play a role in the pathogenesis of POAG.

Pulmonary involvement in patients with early rheumatoid arthritis.

OBJECTIVES: To assess the pleuropulmonary changes in patients with early rheumatoid arthritis (RA), using high-resolution computed tomography (HRCT). METHODS: Forty-three non-smoking patients with early RA were included. The disease duration was<1 year, without previous treatment. Disease activity was assessed using the 28-joint indices score (DAS28). Hand and wrist X-rays were evaluated using Larsen's criteria. Pulmonary functional tests (PFTs) were performed in 32 patients. The patients and 18 non-smokers healthy individuals were assessed by plain chest X-ray (CXR) and HRCT of the lungs. RESULTS: HRCT revealed air trapping in 69% (25/36), bronchiectasis in 58% (25/43), bronchial wall thickening in 52% (22/43) and ground glass opacities (GGOs) in 35% (15/43) of the patients. Pleural thickening and effusion were observed in 11% (5/43). CXR was abnormal in one patient revealing a single pulmonary nodule. GGOs were the only HRCT sign observed exclusively in RA patients. All the other abnormalities were depicted in the control group at the same frequency as in the patients. However, the extent (as expressed by the HRCT score) of air trapping, bronchiectasis and bronchial wall thickening was significantly greater in the patients than in the control group (p<0.05). The PFTs were within normal values. DAS28, PFTs, and the Larsen score did not show any significant correlation with either each HRCT sign score separately or the total score. CONCLUSIONS: Lung abnormalities are frequently observed in patients with early RA on HRCT, even when CXR and PFTs are normal. Limited areas of GGOs were the abnormalities depicted exclusively in patients.

Influence of cyclosporin A on radiological progression in early rheumatoid arthritis patients: a 42-month prospective study.

The aim of this study was to evaluate whether cyclosporin A (CsA) influences the radiological disease progression in early rheumatoid arthritis (RA) patients in comparison with other disease-modifying drugs (DMARDs). A total of 103 early RA patients, without prior use of DMARDs, were randomized to receive CsA (3 mg/kg per day) or methotrexate (MTX) (0.15 mg/kg per week). In addition, all patients received prednisone (7.5 mg/day). After 42 months of treatment, pairs of hand and wrist radiographs of 41 patients treated with CsA and 42 treated with MTX were evaluated blindly and separately by two investigators, using reference radiographs for scoring. A scale scoring similar to Larsen's standard radiographs with minor modifications was used. The studied radiographs were obtained at the beginning and 42 months after therapy in both groups. Patients in both groups responded beneficially to the above treatment regimens. In the CsA group, 37 patients (71 %) remained radiographically stable and 4 worsened, while in the MTX group 39 patients (76%) remained stable and 3 deteriorated. No significant radiological worsening was found in the CsA-treated patients as compared to those treated with MTX. Early immuno-intervention in RA patients appears to be crucial for the future development of joint damage: CsA can delay radiological disease progression and may inhibit joint damage deterioration in early RA patients.