Effect of adalimumab on axial manifestations in Japanese patients with psoriatic arthritis: a 24 week prospective, observational study.

OBJECTIVES: PsA is characterized by enthesitis, synovitis and osseous involvement in the peripheral and axial joints. Few studies have examined axial involvement in PsA using imaging techniques. Here we examined axial involvement in PsA patients using MRI. In addition, we determined the efficacy of 24 week adalimumab treatment in improving the MRI findings of spondylitis and sacroiliitis. METHODS: This was a prospective, open-label, single-arm study in patients with PsA. Adalimumab was administered to patients for a total of 24 weeks. MRI examinations were conducted at baseline and at week 24 of adalimumab treatment. RESULTS: Thirty-seven patients with PsA were included in this study. Spondylitis was observed in at least one site of the positive scan in 91% (n = 31) of patients with PsA. The number of arthritic sites in the cervical, thoracic and lumbar regions of the spine was 48, 67 and 53, respectively. All patients had MRI-determined sacroiliitis of grade ≥1 severity while 28 patients (82%) had grade ≥2 sacroiliitis in at least one sacroiliac region. Sacroiliac arthritis was statistically more severe on the right side than on the left side (P < 0.05). In 34 patients with PsA, the thoracic spine was the most common site of spondylitis. In addition, 24 week adalimumab treatment led to an improvement in the mean number of spondylitis sites and the mean grade of sacroiliitis. CONCLUSION: Treatment with adalimumab for 24 weeks resulted in improvement in spondylitis and sacroiliitis.

Axial involvement in patients with early peripheral spondyloarthritis: a prospective MRI study of sacroiliac joints and spine.

OBJECTIVES: To assess axial involvement on MRI in early peripheral spondyloarthritis (pSpA) and to evaluate whether axial inflammation predicts relapse on treatment withdrawal. METHODS: Fifty-six patients with early, active, newly diagnosed pSpA underwent MRI of the sacroiliac joints (SIJs) and spine prior to golimumab initiation. At sustained clinical remission of pSpA, treatment was withdrawn and a second MRI was performed. Bone marrow oedema (BME) was scored by three readers according to the Spondyloarthritis Research Consortium of Canada (SPARCC) method. Scores were compared with an axial spondyloarthritis cohort (Belgian Arthritis and Spondylitis cohort). Structural lesions were assessed using a similar method. Furthermore, fulfilment of the Assessment of Spondyloarthritis International Society (ASAS) definition of a positive MRI for sacroiliitis was assessed. Spinal images were evaluated for BME and structural lesions using the Canada-Denmark MRI spine scoring system by two readers. RESULTS: Thirty-six per cent showed SIJ BME at baseline, all fulfilling the ASAS definition of sacroiliitis. No association with back pain was found. Twenty-one per cent displayed SIJ structural lesions. Spinal BME was limited: the median inflammation scores were low and no patients had ≥5 inflammatory corner lesions. On clinical remission, a significant decrease in SIJ SPARCC scores was detected. On clinical remission, no significant differences in SIJ SPARCC scores were noted between patients relapsing and those maintaining remission after treatment discontinuation. CONCLUSION: In patients with early pSpA, a surprisingly high prevalence of sacroiliitis on MRI was observed; SPARCC scores decreased significantly on tumour necrosis factor inhibition. Residual inflammation on MRI was not predictive of relapse of peripheral manifestations. No relevant inflammatory spinal involvement was detected. Collectively, our findings suggest a higher inflammatory burden in patients with early pSpA than anticipated.

Prevalence of sacroiliitis and acute and structural changes on MRI in patients with psoriatic arthritis.

Sacroiliac joint involvement is one of the earliest manifestations of psoriatic arthritis (PsA). Magnetic resonance imaging (MRI) is a useful tool in the early diagnosis of axial disease due to its sensitivity for detecting acute and chronic changes associated with sacroiliitis. In this study, we evaluated the prevalence of sacroiliitis, acute and structural image changes on MRI in PsA patients and identified predictive clinical, laboratory and disease activity factors. Cross-sectional study on PsA patients submitted to MRI of the sacroiliac joints. The scans were evaluated by two blinded radiologists and the level of agreement was calculated (kappa). Clinical, disease activity and quality-of-life indices (DAS28, BASDAI, PASI, MASES, HAQ, CRP, ESR) were estimated. The sample consisted of 45 PsA patients with a mean age of 50.1 ± 11.5 years. The prevalence of sacroiliitis was 37.8% (n = 17), 47% of which was unilateral. The kappa coefficient was 0.64. Only 5 (29.4%) of the 17 patients with sacroiliitis on MRI had back pain. The most prevalent acute and chronic changes on MRI were, respectively, subchondral bone edema (26.7%) and enthesitis (20%), periarticular erosions (26.7%) and fat metaplasia (13.3%). CRP levels were higher among sacroiliitis patients (p = 0.028), and time of psoriasis was positively associated with chronic lesions (p = 0.006). Sacroiliitis on MRI was highly prevalent in our sample of PsA patients. Raised CRP levels were significantly associated with sacroiliitis, and longer time of psoriasis was predictive of chronic sacroiliitis lesions. Most sacroiliitis patients displayed no clinical symptoms.

Spinal-pelvic orientation: potential effect on the diagnosis of spondyloarthritis.

OBJECTIVE: To assess associations of spinal-pelvic orientation with clinical and imaging-study findings suggesting axial SpA (axSpA) in patients with recent-onset inflammatory back pain. METHODS: Spinal-pelvic orientation was assessed in DESIR cohort patients with recent-onset inflammatory back pain and suspected axSpA, by using lateral lumbar-spine radiographs to categorize sacral horizontal angle (<40° vs ⩾40°), lumbosacral angle (<15° vs ⩾15°) and lumbar lordosis (LL, <50° vs ⩾50°). Associations between these angle groups and variables collected at baseline and 2 years later were assessed using the χ2 test (or Fisher's exact) and the Mann-Whitney test. With Bonferroni's correction, P < 0.001 indicated significant differences. RESULTS: Of 362 patients, 358, 356 and 357 had available sacral horizontal angle, lumbosacral angle and LL values, respectively; means were 39.3°, 14.6° and 53.0°, respectively. The prevalence of sacroiliitis on both radiographs and MRI was higher in the LL < 50° group than in the LL ⩾50° group, but the difference was not statistically significant. Clinical presentation and confidence in a diagnosis of axSpA did not differ across angle groups. No significant differences were identified for degenerative changes according to sacral horizontal angle, lumbosacral angle or LL. CONCLUSION: Spinal-pelvic balance was not statistically associated with the clinical or imaging-study findings suggesting axSpA in patients with recent-onset inflammatory back pain.

Familial mediterranean fever: assessment of clinical manifestations, pregnancy, genetic mutational analyses, and disease severity in a national cohort.

The aims of this study were to investigate the main clinical and laboratory features, including pregnancy and genetic analysis, of Turkish Familial Mediterranean Fever (FMF) patients and to analyze the relationships between genotypic features, age of disease onset, clinical findings, and disease severity. A study was planned within a national network of 22 different centers. Demographics, clinical and laboratory findings, attack characteristics, drugs, pregnancy and birth history, disease severity, and gene mutation analyses were evaluated. Disease severity, assessed using a scoring system developed by Pras et al., was evaluated in relation to gene mutations and age of disease onset. A total of 979 patients (643 females and 336 males; mean age: 35.92 ± 11.97 years) with FMF were included in the study. Of a total of 585 pregnancies, 7% of them resulted in preterm birth and 18.1% resulted in abortions. During pregnancy, there was no FMF attack in 61.4% of patients. Of the MEditerranean FeVer (MEFV) mutations, 150 (24.3%) cases were homozygous, 292 (47.3%) cases were heterozygous, and 175 (28.4%) were compound heterozygous. Patients with homozygous gene mutations had more severe disease activity, earlier age of disease onset, higher rates of joint and skin involvement, sacroiliitis, and amyloidosis. Patients with compound heterozygous genotype displayed severe disease activity in close resemblance to patients with homozygous mutation. In addition, patients with compound heterozygous mutations had higher rates of protracted febrile myalgia and elevated fibrinogen levels. In 63.9% of compound heterozygous patients, age of onset was < 20 years, with greater disease severity, and high rates of attack frequency and colchicine resistance. Our results suggest that indicators for disease severity include early onset of disease and homozygous gene mutations. Furthermore, patients with compound heterozygous mutations displayed significant presentations of severe disease activity.

Efficacy of wIRA in the treatment of sacroiliitis in male patients with ankylosing spondylitis and its effect on serum VEGF levels.

BACKGROUND: This study aimed to assess the efficacy of water-filtered infrared A (wIRA) in sacroiliitis in male patients with ankylosing spondylitis (AS) and the effect of wIRA therapy on serum vascular endothelial growth factor (VEGF). METHODS: One hundred twenty male AS patients with active sacroiliitis were randomly divided into wIRA group and control group. wIRA treatment was performed twice daily for 5 consecutive days with 24-h interval before switching the treatment (crossover design). Bath ankylosing spondylitis disease activity index (BASDAI) scores, pain visual analogue scale (VAS), and morning stiffness VAS were recorded prior to and after each treatment period. Additionally, C-reactive protein (CRP), serum VEGF, and resistance index (RI) of sacroiliac joints detected by ultrasonography were recorded at baseline and after the first and second treatment period, respectively. The efficacy was examined by using repeated measures analysis of variance (ANOVA). RESULTS: BASDAI, pain VAS, and morning stiffness VAS scores decreased significantly (P < 0.001) after wIRA treatment and no-wIRA treatment (control group), and the difference between the two groups was significant (P < 0.001). CRP declined and RI increased during the wIRA treatment as compared with the no-wIRA treatment (P < 0.001). The increase in RI was associated with improvement of pain VAS scores (P = 0.018), while serum VEGF was unaffected by the treatment. CONCLUSIONS: wIRA treatment achieved symptom and pain relief for AS patients with active sacroiliitis. wIRA treatment also improved RI revealed by ultrasonography, and this effect was associated with improved pain VAS scores.

When brucellosis met the Assessment of SpondyloArthritis international Society classification criteria for spondyloarthritis: a comparative study.

OBJECTIVES: To distinguish brucellosis patients fulfilling the Assessment of SpondyloArthritis international Society (ASAS) classification criteria for spondyloarthritis (SpA) from SpA patients. METHODS: Brucellosis patients diagnosed from September 2012 to December 2017 who met the ASAS classification criteria for SpA were analyzed with clinical characteristics and laboratory and imaging examinations. Axial or peripheral SpA patients were respectively included into the comparative analysis with a 4:1 ratio. RESULTS: Twenty-two brucellosis (10 axial and 12 peripheral) patients (male, 16 cases; 72.72%; mean (S.D.) age, 40.23 (16.49) years) and 88 SpA patients were included. All brucellosis patients had been misdiagnosed or considered as SpA before admission to our center. The brucellosis patients had shorter disease duration (axial, P = 0.001; peripheral, P = 0.108). More than half (59.09%) of the patients had contact history with livestock. The low back pain (LBP) of brucellosis patients was generally less improved with exercise (axial, P = 0.001; peripheral, P = 0.008). More brucellosis patients had myalgia (axial, P < 0.001; peripheral, P = 0.071) or fever (axial, P < 0.001; peripheral, P = 0.107). None of them had positive HLA-B27. Blood culture tests were performed in all brucellosis patients and only 4 (18.18%) were positive. Twenty (90.91%) brucellosis patients were gold-immunochromatographic assay (GICA) positive. Bone marrow edema and bone erosion in sacroiliac joints were respectively detected in 100% (10/10) and 90% (9/10) axial brucellosis patients by MRI. Adjacent muscle involvement was found in 80% (8/10) of the patients. CONCLUSIONS: Indicators including disease duration, contact history of livestock, features of LBP, myalgia, fever, and HLA-B27 can help the differential diagnosis of brucellosis and SpA. GICA test and sacroiliac joints MRI can furtherly confirm the diagnosis of brucellosis.

Pyogenic sacroiliitis in children: don't forget the very young.

Pyogenic sacroiliitis (PS) is rare with less than 100 pediatric cases reported in the medical literature. To better characterize PS in the pediatric population, we investigated a series of children presenting with PS. Retrospective data analysis was done at an academic tertiary center between the years of 2000 and 2017. All hospitalized children ≤ 16 years of age with PS were evaluated. Of the 894 children hospitalized with osteoarticular infections, 18 were diagnosed with PS (2%) and are included in the review. Two clinically distinct groups were identified. PS in infants (n = 13, 72.2%, mean age 1.1 years) had an indolent course and a faster recovery without any bacterial source identified. In contrast, the group of older children (n = 5, 27.8%, mean age 11.6 years) had a more complicated course and a higher rate of identified bacterial infections.Conclusion: We describe an under-recognized entity of PS in infants with a mild clinical course and fast recovery that differ from the "classical" septic sacroiliitis. Infants with PS did not suffer from invasive complications, and pathogen characteristics of older children were not identified. Infants with fever, irritability, decreased range of motion in the pelvic area, and pain during diapering should alert the clinician to this diagnosis. What is Known: • Pediatric pyogenic sacroiliitis is an extremely rare condition usually caused by Staphylococcus aureus with highest incidence in adolescents. • The diagnosis of PS is challenging due to its rarity and difficulty in assessing the sacroiliac joint. What is New: • We describe an under-recognized entity of PS in infants with a mild clinical course, without invasive complications and with fast recovery that differ from "classical" septic sacroiliitis. • Infants with fever, irritability, decreased range of motion in the pelvic area and pain during diapering should raise clinical suspicion of this diagnosis.

Association between inflammatory back pain features, acute and structural sacroiliitis on MRI, and the diagnosis of spondyloarthritis.

OBJECTIVES: To evaluate the association between inflammatory back pain (IBP) features, acute and structural MRI findings suggestive of sacroiliitis, and diagnosis of spondyloarthritis (SpA). METHODS: Data from 224 patients who underwent MRI for suspected sacroiliitis (2005-2015) was retrospectively reviewed by an expert rheumatologist for the presence of IBP features and for clinical standard of reference diagnosis. A telephone questionnaire was performed in cases of missing data. Acute and structural MRI parameters were scored by an experienced radiologist for the presence of sacroiliitis using the Assessment of Spondyloarthritis International Society (ASAS) criteria, Berlin score, and observer's global impression (GI) scores. Association between IBP features and MRI scores, and odds ratio for SpA diagnosis, were calculated. RESULTS: One hundred ninety-three subjects were included (119 F:74 M, mean age 39.7 ± 15.6, mean follow-up 49 ± 18 months). Fifty-two (26.9%) subjects were diagnosed with SpA. IBP scores were significantly higher in SpA patients (p < 0.001). IBP, ASAS, and GI MRI scores were significantly associated with the SpA diagnosis (p < 0.001 for all). The presence of night pain and morning stiffness was significantly associated with sacroiliac-joints' bone marrow edema (BME, p < 0.05). Sensitivity for diagnosis of SpA was high for IBP (96%) and low for the MRI parameters (26.9-57.4%), and specificity was low for IBP (32%) and high for the MRI parameters (88.3-94.3%). CONCLUSIONS: The presence of IBP features is highly associated with diagnosis of SpA and correlates with MRI BME, all probably reflect inflammation. The combination of IBP and MRI should be the cornerstone in the clinician's final diagnosis of SpA.

Association Between Inflammatory Back Pain Characteristics and Magnetic Resonance Imaging Findings in the Spine and Sacroiliac Joints.

OBJECTIVE: To investigate the association between magnetic resonance imaging (MRI) findings at the sacroiliac (SI) joints and vertebral endplates and pain characteristics assumed to be indicative of axial inflammation. METHODS: Patients ages 18-40 years with persistent low back pain referred to an outpatient spine clinic participated, including an unknown proportion of axial spondyloarthritis patients. Data included MRI of the spine and SI joints and self-reported responses to questions covering the Calin, Berlin, Assessment of Spondyloarthritis International Society, and Bailly inflammatory back pain (IBP) definitions. RESULTS: In the 1,020 included patients, 53% were women, and the median age was 33 years. Positive associations were found between the SI joint MRI findings and pain characteristics, odds ratios ranging from 1.4 to 2.7. SI joint bone marrow edema (BME) was associated with morning stiffness >60 minutes, and SI joint erosions with the Calin, Berlin, and Bailly IBP definitions, alternating buttock pain, and good response to nonsteroidal antiinflammatory drugs. SI joint fatty marrow deposition (FMD) was associated with insidious onset, and SI joint sclerosis with pain at night. In addition, the spinal MRI changes were associated with IBP, odds ratios ranging from 1.4 to 2.0; vertebral endplate BME was associated with morning stiffness, and vertebral endplate FMD with the Calin and Bailly IBP definitions, improvement with exercise, morning stiffness >30 minutes, and pain worst in the morning. CONCLUSION: The identified associations between inflammatory MRI findings and pain characteristics indicate that axial inflammation to some degree induces a specific pain pattern. Thus, the results add to knowledge of axial inflammatory processes. However, all identified associations were weak, which compromises the use of IBP as a marker of axial inflammation.

MRI Findings of the Sacroiliac Joints in Patients with Low Back Pain: Alternative Diagnosis to Inflammatory Sacroiliitis.

BACKGROUND: Magnetic resonance imaging (MRI) is the most sensitive imaging modality for the detection of sacroiliitis. Diagnosing sacroiliitis on MRI is not always straightforward and can be challenging in some cases. OBJECTIVES: To evaluate the prevalence of alternative diagnoses suggested by MRI and characterize the MR appearance of the most common ones. METHODS: Consecutive MRI examinations of the sacroiliac joints (SIJ) performed between 2005 and 2012 were retrospectively evaluated for the presence of structural and active sacroiliitis findings according to the Assessment of SpondyloArthritis International Society guidelines. Alternative diagnoses, including degenerative changes, diffuse idiopathic skeletal hyperostosis (DISH), Osteitis condensans ilii (OCI), septic sacroiliitis/discitis, stress reaction as well as anatomic variants, were registered. RESULTS: We evaluated 281 MRI examinations, 116 males, 165 females, average age 44 ± 15 years. Sacroiliitis was found in 71 examinations (25%) and alternative diagnoses were suggested in 87 (31%) (OCI 8.9%, anatomic variants 5.3%, septic sacroiliitis 5.3%, degenerative findings 4.3%, diffuse idiopathic skeletal hyperostosis [DISH] 1.5%, stress reaction 0.7%, tumor 0.3%). A normal examination was found in the remaining 123 examinations. Patients with alternative diagnoses were older than those with sacroiliitis (62 vs. 47 years of age, respectively, P > 0.05). Alternative pathologies in the SIJ were significantly more common in females (66) than males (21), P < 0.05. CONCLUSIONS: A substantial proportion of patients with suspected sacroiliitis had normal SIJ while the rest were more commonly diagnosed with other pathologies. A referral by an experienced rheumatologist may improve the sensitivity and specificity of this important examination.

A young female presenting with unilateral sacroiliitis following dengue virus infection: a case report.

BACKGROUND: Dengue is a common arthropod-borne viral infection in Sri Lanka which is spread by the mosquitos of the genus Aedes. The clinical features of dengue include high-grade fever associated with arthralgia and myalgia. However, dengue virus is not considered an arthritogenic virus. We report a case of a previously healthy young female who presented with imaging-confirmed right-sided sacroiliitis 10 days after developing dengue fever. This is the first reported case that shows a possible link between dengue infection and development of arthritis. CASE PRESENTATION: A 14-year-old Sri Lankan female presented to our medical unit with right buttock and hip pain of 3 weeks' duration. She had serologically confirmed dengue infection 10 days prior to the onset of buttock pain. A clinical examination revealed features of right sacroiliitis. An X-ray of her sacroiliac joint showed joint space widening and reactive bone changes. Magnetic resonance imaging of her pelvis and sacroiliac joint confirmed the diagnosis of acute sacroiliitis. She had an erythrocyte sedimentation rate of 110 mm first hour with a normal C-reactive protein. Her human leukocyte antigen-B27, rheumatoid factor, antinuclear antibody, chikungunya antibody, hepatitis serology, Brucella serology, and tuberculin skin test were negative. She was treated with nonsteroidal anti-inflammatory drugs and showed gradual improvement. CONCLUSIONS: After excluding possible causes for sacroiliitis, we postulated that sacroiliitis in the index case could have been caused or triggered by dengue virus infection. However there is a possibility that the sacroiliitis merely coincided with the dengue virus infection. This case illustrates the possibility that dengue virus could have a link with the development of arthritis in the same manner as other arthritogenic viruses; possible mechanisms for this include direct invasion of the synovium and the joint tissue by the virus, immune complex formation and deposition in the joint tissue, and immune dysregulation. Further studies are needed in this field to gain more knowledge, as dengue infection is highly prevalent in Sri Lanka.

Contraction of the transverse abdominal muscle in pelvic girdle pain is enhanced by pain provocation during the task.

BACKGROUND: Understanding of the pathogenesis of pain in the lumbopelvic region remains a challenge. It is suggested that lumbopelvic pain is related to decreased contraction of the transverse abdominal muscles (TrA). OBJECTIVE: To investigate how pain provoked by a task influences TrA contraction during that task. DESIGN: A case-control cross-sectional study. METHOD: We recruited 40 non-pregnant women with persistent pregnancy-related posterior pelvic girdle pain (PGP) and 33 parous women (healthy controls) without PGP. TrA thickness was measured by ultrasound at various levels of bilateral hip adduction, with increments of 20 N from 0 to 140 N. Pain during the tests was registered. RESULTS: After correction for the level of adduction force, TrA thickness increase during pain-provoking tests of participants with PGP was 6.3 percentage points higher than in their pain-free tests (p = 0.01) and 0.91 percentage points higher than in the pain-free tests of healthy controls (p < 0.01). CONCLUSION: TrA contraction in PGP is enhanced when a task provokes pain. These results may have consequences for the treatment of persistent pregnancy-related posterior pelvic girdle pain.

Clinical predictors of magnetic resonance imaging-detected sacroiliitis in children with enthesitis related arthritis.

OBJECTIVES: To determine the predictors of sacroiliitis detected by magnetic resonance imaging (MRI) in children with enthesitis-related arthritis. METHODS: In this retrospective, longitudinal study, we retrieved clinical and laboratory data from the charts of patients with confirmed enthesitis related arthritis and evaluated their association with magnetic sacroiliitis detected at first MRI after disease onset. The MRI images of sacroiliac joints were read by 2 independent radiologists and validated against those from 25 age- and sex-matched subjects with known non-rheumatologic conditions. RESULTS: We reviewed the clinical records of 20 patients with enthesitis-related arthritis for whom MRI images of sacroiliac joints were available. Five had bilateral MRI sacroiliitis, 3 unilateral sacroiliitis while 12 had no sacroiliitis. All MRI images of sacroiliiitis showed bone-marrow oedema but no erosions, sclerosis or sacroiliac enthesitis. Personal history of buttock pain or abnormal physical examination of sacroiliac joints predicted MRI sacroiliitis with a positive predictive value of 0.75 (95% confidence interval 0.35-0.95). In the absence of these clinical elements, MRI sacroiliitis was unlikely to be found (negative predictive value 0.83; 95% confidence interval 0.50-0.97). CONCLUSION: In children with enthesitis-related arthritis the presence of buttock pain or of abnormal sacroiliac joint examination is a strong predictor of magnetic sacroiliitis.