Magnetic resonance imaging: a valuable method for the detection of synovial inflammation in rheumatoid arthritis

OBJECTIVE: Clinical assessment of rheumatoid arthritis (RA) based on pain and swelling and physical examination is limited by observer error and interpretation. We compared magnetic resonance imaging (MRI) and clinical examination to detect synovitis in RA. METHODS: Twelve patients with active RA were assessed according to Ritchie index, swollen joint count and score, swollen joint count of hands and wrists [2 wrists, 10 metacarpophalangeal (MCP), 10 proximal interphalangeal (PIP)], morning stiffness, pain intensity, Disease Activity Score (DAS), erythrocyte sedimentation rate, and C-reactive protein. MR images of hands and wrists were obtained with an adapted device, on T1 weighted (T1W) spin echo (SE) coronal images before and after gadolinium DTPA, TIW SE axial images with gadolinium DTPA, T2* gradient echo recall coronal and axial sequences, and assessed by 2 radiologists (O = no synovitis, 1 = synovitis). RESULTS: The swollen joint count on hands and wrists was 59 on clinical examination (mean 5.08 +/- 3.15 per patient; 20/24 wrists, 7/120 MCP, 32/120 PIP) and 162 on MRI (mean 13.50+/- 5.65; 22/24 wrists, 70/120 MCP, 70/120 PIP). Statistically significant correlations were found between MRI synovitis count and swollen joint count (p = 0.015) and score (p = 0.019), Ritchie Index (p = 0.035), DAS (p = 0.02) and morning stiffness (p = 0.07). MRI revealed synovitis significantly more often than clinical examination (162 vs 59; p = 0.00002) [2-fold in PIP (70/32) and 10-fold in MCP (70/7)]. Clinical examination and MRI were concordant for 157/264 joints (59.5%). The association of normal MRI with synovitis on clinical examination was observed in 2 cases, the opposite in 105. CONCLUSION: MRI is more sensitive than clinical examination to detect synovitis of hands and wrists in RA, especially for MCP and PIP joints, and is valuable for assessment of inflammation in hands and wrists in RA.     

Evidence for a different anatomic basis for joint disease localization in polymyalgia rheumatica in comparison with rheumatoid arthritis

OBJECTIVE: The anatomic basis for joint disease localization in polymyalgia rheumatica (PMR) is poorly understood. This study used contrast-enhanced and fat suppression magnetic resonance imaging (MRI) to evaluate the relationship between synovial and extracapsular inflammation in PMR and early rheumatoid arthritis (RA). METHODS: Ten patients with new-onset PMR and 10 patients with early RA underwent dynamic contrast-enhanced MRI and conventional MRI of affected metacarpophalangeal (MCP) joints. Synovitis and tenosynovitis were calculated based on the number of enhancing voxels, initial rate of enhancement, and maximal enhancement of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA). Periarticular bone erosion and bone edema were scored according to the OMERACT (Outcome Measures in Rheumatology Clinical Trials) scoring system in both groups. The degree of extracapsular Gd-DTPA enhancement was assessed in both conditions using semiquantitative scoring. RESULTS: No significant differences were seen in the volume of synovitis (P = 0.294), degree of flexor tenosynovitis (P = 0.532), periarticular erosions (P = 0.579), or degree of bone edema (P = 0.143) between RA and PMR joints. However, despite comparable degrees of synovitis, the proportion of MCP joints showing extracapsular enhancement was higher in the PMR group (100%) than in the RA group (50%) (P = 0.030). One PMR patient, but none of the RA patients, had bone edema at the capsular insertion. CONCLUSION: Despite degrees of synovitis and tenosynovitis comparable with those in RA, PMR-related hand disease is associated with prominent extracapsular changes, suggesting that inflammation in these tissues is more prominent than joint synovitis, which is common in both conditions. This suggests that the anatomic basis for joint disease localization differs between RA and PMR.     

Magnetic resonance imaging appearance of the hands and feet in patients with early rheumatoid arthritis

OBJECTIVE: To describe the magnetic resonance (MRI) imaging findings of the feet in patients with early rheumatoid arthritis (RA), and to compare MRI appearance of the feet with that of the hands. METHODS: Thirty consecutive patients (18 women, 12 men; age range 19-64 yrs) with early RA underwent MRI of hands and feet. Axial fat suppressed gadolinium enhanced T1 weighted spin-echo and gadolinium enhanced 3-dimensional gradient-echo (FLASH) images were obtained. RESULTS: In the hands, MRI findings suggested active synovitis of the wrist and metacarpophalangeal (MCP) joints in 28 (93%) and 27 (90%) patients, respectively. In the feet, active synovitis was observed in 29 (97%) patients. Bone erosions were seen in the wrist joints in 24 (80%) patients. Observers found as many bony changes in the MCP as in the metatarsophalangeal joints [23 (77%) patients]. MRI detected tenosynovitis in 16 (53%) patients in the hands, and in 18 (60%) patients in the feet. Bursitis located between or beneath the metatarsal heads was a common MRI finding [19 (63%) patients]. CONCLUSION: Additional MRI of the feet may be useful when evaluation of the hands does not help identify early RA.     

Magnetic resonance imaging of the hand for the diagnosis of rheumatoid arthritis in the absence of anti-cyclic citrullinated peptide antibodies: a prospective study

OBJECTIVE: To assess the practical usefulness of magnetic resonance imaging (MRI) in establishing a positive diagnosis of rheumatoid arthritis (RA) in a cohort of patients with early inflammatory polyarthralgia, in the absence of anti-cyclic citrullinated peptide (anti-CCP) antibodies. METHODS: We prospectively followed 30 outpatients with inflammatory polyarthralgia and/or synovitis of at least one joint. Patients were disease modifying antirheumatic drug-naive and received no corticosteroids. At the initial visit a clinical examination, radiographs of hands, wrists and feet, and MRI of hands were performed. Rheumatoid factor and anti-CCP antibodies were assessed. The MRI procedure was T1 fat saturation with gadolinium injection [scores were established on the basis of the axial view of the carpal and metacarpal joints, using the RA MRI scoring system (RAMRIS) defined in the OMERACT study]. In all patients, radiographs at baseline were normal and anti-CCP antibodies were negative. RESULTS: At one-year followup, the final diagnosis was: 16 RA; the non-RA group was composed of 4 cases of spondyloarthropathy, 2 cases of fibromyalgia, 4 cases of undifferentiated arthritis (3 of which were self-limiting), 1 sicca syndrome, 1 hemochromatosis, 1 polymyositis, and 1 paraneoplastic syndrome. No statistical difference was found between patients with and without RA for carpal erosion, synovitis, and tenosynovitis. However, a statistical difference was observed between the RA and non-RA group where metacarpophalangeal (MCP) erosion scores were concerned (p = 0.024). This difference persisted when we compared erosions of the second and third MCP in the 2 groups (p = 0.044). ROC curve analysis revealed a positive MCP score at 15, with a specificity of 70% and a sensitivity of 64%. CONCLUSION: In our population of 30 anti-CPP negative patients with normal radiographs, MRI of hands, showing MCP erosions, can be helpful for the diagnosis of RA.     

Cervical spine involvement early in the course of rheumatoid arthritis

ObjectivesCervical spine involvement in rheumatoid arthritis (RA) is considered a feature of long-standing disease. We describe two patients who presented with cervical symptoms as early features of RA.MethodsWe report two RA cases with cervical spine involvement as early features and use MEDLINE to review the literature concerning the frequency and disease duration of this manifestation and its imaging with plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).ResultsAn 80-year-old man with cervical myelopathy from a C1–C2 rheumatoid pannus underwent decompression surgery before development of peripheral synovitis from RA. A 63-year-old woman presented with neck pain and polyarthritis at RA diagnosis, with imaging that confirmed a C1–C2 rheumatoid pannus. Onset of cervical spine involvement in RA is generally after 10 years of disease duration, ranging from 3 months to 45 years after peripheral synovitis among patients with seropositive erosive RA. Occurring in 9–88% of RA patients, cervical spine involvement may result in cervical instability due to either mechanical compression or vascular impairment of the spinal cord. Bone erosions and atlanto-axial subluxation on standard radiographs are two major signs of cervical spine involvement in RA. MRI identifies earlier signs of RA and has a higher sensitivity in detecting bone erosions compared to conventional radiography.ConclusionsCervical spine involvement in RA is not an uncommon condition but is rare at early disease onset. Symptoms of cervical pain and myelopathy should prompt a thorough neurological examination accompanied by imaging.     

A 1-year follow-up study of dynamic magnetic resonance imaging in early rheumatoid arthritis reveals synovitis to be increased in shared epitope-positive patients and predictive of erosions at 1 year

OBJECTIVES: Dynamic magnetic resonance imaging (MRI) allows visualization of the synovial membrane and measurement of synovitis within the joint. A cohort of patients with early rheumatoid arthritis (RA) were studied using MRI of the dominant wrist and clinical assessments. Associations between synovitis and the shared epitope genotype (SE) were looked for and synovitis as a predictor of joint erosion was examined. METHODS: Gadolinium-enhanced MRI scans of the dominant wrist were performed in 42 early RA patients at baseline (median disease duration = 4 months) and after 1 yr. Images were obtained at 42-s intervals over the first 6 min after gadolinium-diethylenetriamine pentaacetic acid injection using six cuts in the coronal plane, 2 mm apart. The site of maximal synovial enhancement was selected as the region of interest (ROI). The rate of enhancement (E-rate) was calculated and compared with synovitis scores from static MRI scans, clinical disease activity scores and HLA-DRB1*04/01 genotyping [sequence-specific primer polymerase chain reaction (SSP-PCR) and DNA sequencing]. RESULTS: Reproducibility of the E-rate measurement was assessed by re-evaluating 10 randomly selected scans in a blinded fashion. Intra-observer reliability was high with an intraclass correlation coefficient of 0.91, 95% confidence interval (CI) 0.65-0.97. The E-rate correlated strongly at baseline with the maximum level of synovial enhancement (E-max) (r = 0.88, P < 0.0001) and the static MRI synovitis score (r = 0.52, P = 0.0004). There was also a weaker but significant correlation between E-rate and the pain score (r = 0.29, P = 0.04). The E-rate fell from baseline to 1 yr (P = 0.02) concordant with clinical improvement after treatment with standard therapies. E-rate scores were higher in SE+ than SE - patients (F(1,25) = 5.19, P = 0.03) and were predictive of MRI erosions at 1 yr [chi-square = 5.0 (1 d.f.), P = 0.03]. The baseline C-reactive protein (CRP) was also predictive of MRI erosions at 1 yr to a similar degree [chi-square = 4.7 (1 d.f. ), P = 0.03] but the mean static synovitis score at baseline was the strongest predictor [chi-square = 9.2 (1 d.f.), P = 0.003]. CONCLUSIONS: These results show that dynamic MRI can be used to score synovitis objectively in early RA patients. Synovitis was greater in SE+ patients, suggesting an early genetic influence on joint inflammation, and was predictive for the development of erosions at 1 yr.     

Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis.

OBJECTIVE: To evaluate and characterize magnetic resonance imaging (MRI) findings in the metacarpophalangeal (MCP) joints of rheumatoid arthritis (RA) patients macroscopically, using miniarthroscopy (MA; needle arthroscopy). METHODS: The second MCP joint of the dominant hand of 22 RA patients (13 with various RA activities/stages; 9 with early RA [< or = 1.5 years' duration]) was examined by MRI followed by MA. Findings were evaluated by standardized semiquantitative measures of synovial and bony pathologic changes of the MCP joint, and were compared with the clinical and conventional radiologic findings. RESULTS: Erosions and pre-erosions were detected in 17 of 22 patients by MRI; 2 of the other 5 patients (all early RA) displayed bony changes on MA. All 10 joints with pre-erosions on MRI (grade I bony alterations on MRI) exhibited significant cartilaginous and bony pathology on MA. Synovial membrane pathology was detected in all but 1 patient by MRI and in all patients by MA, although findings of plain radiography were normal in 6 of the 22 patients and another 9 patients had a Larsen score of 1. Semiquantitative analysis of synovial findings of MRI revealed gadolinium diethylenetriaminepentaacetic acid enhancement as a significant marker of macroscopically varied synovial vascularity and hyperemia, both of which strongly correlated with clinical activity (as measured by the Disease Activity Score). The extent of synovitis/synovial proliferation shown by MA and MRI were significantly correlated with each other, but not with any other activity or damage parameter analyzed. CONCLUSION: In RA, both MRI and MA findings support early detection and staging of synovial changes. Ongoing longitudinal studies are aimed at evaluating the value of synovial proliferation as visualized by both methods.     

Atlantoepistrophic magnetic resonance imaging involvement in early rheumatoid arthritis: an aggressive tight control therapy not fully arresting the disease

Objective

Rheumatoid arthritis (RA) is the most common inflammatory disorder affecting the cervical spine. The purpose of this study was to characterize the atloaxial involvement with magnetic resonance imaging (MRI) in patients with early RA at the moment of diagnosis and after 18 months of a tight control therapy.

Methods

Twenty consecutive patients with early RA without cervical symptoms and 20 healthy controls were enrolled. The patients underwent unenhanced and enhanced gadolinium MRI study of the upper cervical spine at diagnosis and after 18 months of therapy. The presence of pannus tissue at MRI was considered active synovitis.

Results

Five (25%) of the 20 patients presented craniocervical involvement with active synovitis at MRI. At onset, patients with cervical involvement presented higher levels of erythrocyte sedimentation rate, a higher swollen joint count, and a higher Disease Activity Score in 44 joints level. All 5 patients (100%) with cervical involvement presented already peripheral erosions. After 18 months, 1 of 5 patients with atloepistrophic synovial involvement at baseline presented complete regression of the enhancement of synovial periodontoid process, and 1 presented a decrease of this enhancement. None of the patients developed erosive process at the odontoid. The only patient with complete regression of the enhancement presented a very early disease (<3 months).

Conclusion

Our study demonstrates involvement of the atloaxial junction in 25% of early RA patients, in particular in patients with active and erosive arthritis. An early diagnosis and aggressive treatment with a combination therapy, aiming for remission, does not always reduce atlantoaxial synovitis.     

Elucidation of the relationship between synovitis and bone damage: a randomized magnetic resonance imaging study of individual joints in patients with early rheumatoid arthritis

OBJECTIVE: To simultaneously image bone and synovium in the individual joints characteristically involved in early rheumatoid arthritis (RA). METHODS: Forty patients with early, untreated RA underwent gadolinium-enhanced magnetic resonance imaging (MRI) of the second through fifth metacarpophalangeal joints of the dominant hand at presentation, 3 months, and 12 months. In the first phase (0-3 months), patients were randomized to receive either methotrexate alone (MTX) or MTX and intraarticular corticosteroids (MTX + IAST) into all joints with clinically active RA. The MTX-alone group received no further corticosteroids until the second phase (3-12 months), when both groups received standard therapy. RESULTS: In the first phase, MTX + IAST reduced synovitis scores more than MTX alone. There were significantly fewer joints with new erosions on MRI in the former group compared with the latter. During the second phase, the synovitis scores were equivalent and a similar number of joints in each group showed new erosions on MRI. In both phases, there was a close correlation between the degree of synovitis and the number of new erosions, with the area under the curve for MRI synovitis the only significant predictor of bone damage progression. In individual joints, there was a threshold effect on new bone damage related to the level of synovitis; no erosions occurred in joints without synovitis. CONCLUSION: In early RA, synovitis appears to be the primary abnormality, and bone damage occurs in proportion to the level of synovitis but not in its absence. In the treatment of patients with RA, outcome measures and therapies should focus on synovitis.     

Regional variation and differential response to therapy for knee synovitis adjacent to the cartilage-pannus junction and suprapatellar pouch in inflammatory arthritis: implications for pathogenesis and treatment

OBJECTIVE: To use magnetic resonance imaging (MRI) to investigate the importance of knee joint synovitis at the cartilage-pannus junction (CPJ) in rheumatoid arthritis (RA) as compared with synovitis at a distant site in the suprapatellar pouch (SPP) and as compared with CPJ synovitis in the spondylarthropathies (SpA), and to assess the relative response of knee joint synovitis to therapy at the CPJ and SPP sites. METHODS: Dynamic contrast-enhanced MRI (DEMRI) of actively involved knee joints in 24 patients (13 with RA and 11 with SpA) was undertaken. The area of synovitis was calculated at the CPJ and SPP regions of interest in patients with RA and in patients with SpA. Differences in CPJ and SPP synovitis were determined using calculated DEMRI parameters which included the initial rate of contrast enhancement (IRE) and the maximal enhancement (ME). Changes in the synovial area at the CPJ and SPP were also measured in 10 patients with early RA, following treatment with disease-modifying antirheumatic drugs (DMARDs) (either methotrexate or leflunomide). RESULTS: In patients with RA or SpA, the area of synovitis was significantly larger immediately adjacent to the CPJ compared with a distant site at the SPP (in RA, mean synovitis area 162 mm2 at the CPJ versus 114 mm2 at the SPP [P = 0.010]; in SpA, mean synovitis area 214 mm2 at the CPJ versus 143 mm2 at the SPP [P = 0.002]), but the differences in the areas of synovitis at these sites were not significant between the RA and SpA patients. The IRE and ME values were also higher at the CPJ compared with the SPP, both in the RA patients (IRE P = 0.054, ME P = 0.018) and in the SpA patients (IRE P = 0.002, ME P = 0.001). A larger reduction in the area of synovitis was seen at the SPP compared with the CPJ following DMARD therapy in the RA patients (mean reduction 35% at the SPP [P = 0.023] and 12% at the CPJ [P not significant]). CONCLUSION: The non-disease-specific variations in synovitis and the differential responses to therapy in RA patients have implications for improving our understanding of CPJ synovitis. The results suggest that the pathophysiologic events at the CPJ reflect common anatomic, immune system, or biomechanical factors that play a role in modulating the severity of arthritis, and these events are not specific to RA since the same process was observed in other arthritides.     

Low field dedicated magnetic resonance imaging in untreated rheumatoid arthritis of recent onset

OBJECTIVE: To compare a low field dedicated extremity magnetic resonance imaging system (E-MRI) with x ray and clinical examination, in the detection of inflammation and erosive lesions in wrist and metacarpophalangeal (MCP) joints in newly diagnosed, untreated rheumatoid arthritis (RA). PATIENTS AND METHODS: Twenty five patients (disease duration < or =1 year) and three healthy controls entered the study. An x ray examination and MRI (before and after intravenous injection of a contrast agent) of the 2nd-5th MCP joints and the wrist was performed. The number of erosions on x ray examination and MRI was calculated, and synovitis in the MCP joints and wrists was graded semiquantitatively. RESULTS: E-MRI detected 57 bone erosions, whereas only six erosions were disclosed by x ray examination (ratio 9.5:1). Synovial hypertrophy grades were significantly higher in RA joints with clinical signs of joint inflammation-that is, swelling and/or tenderness (median 3, 5th-95th centile 1-4) than without these clinical signs (median 2, 5th-95th centile 1-3), p < 0.001. 51% of the joints without clinical signs of synovitis showed synovial hypertrophy on E-MRI. There was a positive correlation between MRI scores of synovitis and the number of erosions detected by MRI in the MCP joints (Spearman r(s) = 0.31, p < 0.01). No healthy controls had erosions or synovitis on MRI. CONCLUSION: Joint destruction starts very early in RA and E-MRI allows detailed evaluation of inflammatory and destructive changes in wrists and MCP joints in patients with incipient RA.     

Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement

OBJECTIVES: To investigate the progression of joint damage in early rheumatoid arthritis (RA) using magnetic resonance imaging (MRI) of the wrist and determine whether this technique can be used to predict prognosis. METHODS: An inception cohort of 42 early patients has been followed up prospectively for one year. Gadolinium enhanced MRI scans of the dominant wrist were obtained at baseline and one year and scored for synovitis, tendonitis, bone marrow oedema, and erosions. Plain radiographs were performed concurrently and scored for erosions. Patients were assessed clinically for disease activity and HLA-DRB1 genotyping was performed. RESULTS: At one year, MRI erosions were found in 74% of patients (31 of 42) compared with 45% at baseline. Twelve patients (28.6%) had radiographic erosions at one year. The total MRI score and MRI erosion score increased significantly from baseline to one year despite falls in clinical measures of inflammation including erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and swollen joint count (p < 0.01 for all). Baseline findings that predicted carpal MRI erosions at one year included a total MRI score of 6 or greater (sensitivity: 93.3%, specificity 81.8%, positive predictive value 93.3%, p = 0.000007), MRI bone oedema (OR = 6.47, p < 0.001), MRI synovitis (OR = 2.14, p = 0.003), and pain score (p = 0.01). Radiological erosions at one year were predicted by a total MRI score at baseline of greater than 13 (OR = 12.4, p = 0.002), the presence of MRI erosions (OR = 11.6, p = 0.005), and the ESR (p = 0.02). If MRI erosions were absent at baseline and the total MRI score was low, radiological erosions were highly unlikely to develop by one year (negative predictive value 0.91 and 0.92 respectively). No association was found between the shared epitope and erosions on MRI (p = 0.4) or radiography (p = 1.0) at one year. CONCLUSIONS: MRI scans of the dominant wrist are useful in predicting MRI and radiological erosions in early RA and may indicate the patients that should be managed aggressively. Discordance has been demonstrated between clinical improvement and progression of MRI erosion scores.     

Importance of timing of post-contrast MRI in rheumatoid arthritis: what happens during the first 60 minutes after IV gadolinium-DTPA?

BACKGROUND: Volumes of inflamed synovial membrane determined by magnetic resonance imaging (MRI) are closely related to histopathological synovitis and may predict erosive progression in rheumatoid arthritis (RA). However, after IV injection, leakage of MRI contrast from the synovium gradually compromises the differentiation of synovium from joint fluid. OBJECTIVE: To determine the time period after IV MRI contrast (gadolinium-DTPA (Gd)) injection in which synovial membrane volume determination is reliable. METHODS: MRI of five RA knees with clinical synovitis was carried out, with axial, T(1) weighted, spin echo images before IV Gd injection and every 1.75 minutes for 60 minutes post-Gd. By a semiautomated "signal enhancement threshold" method, including voxels with >35% or >45% relative post-Gd enhancement, synovial membrane volumes were estimated at each time point. At 4.25 minutes post-Gd, volumes were also determined by a more accurate but time consuming "manual method". RESULTS: The initially observed synovium-effusion borderline remained clearly visible, and on the same location, within at least the initial 11 minutes post-Gd (that is, within the normal time frame of post-Gd imaging in RA) but started blurring and moving centripetally thereafter. Compared with volumes at all other time points, synovial membrane volumes at 0.75 and 2.50 minutes post-Gd were significantly lower (Wilcoxon-Pratt), suggesting that some synovial membrane areas had not yet exceeded the enhancement threshold. Thereafter, the measured volumes remained practically unchanged. CONCLUSION: This study suggests that MR image acquisition in arthritic knee joints should be performed within the initial approximately 10 minutes after gadolinium contrast injection to achieve the most accurate distinction between synovium and joint fluid but that small time variations are not of major importance to the measured synovial membrane volumes.     

The diagnostic dilemma of undifferentiated inflammatory synovitis of the knee joint/joints: a comprehensive approach

Objective: The objective of this pilot study was to describe clinical features, laboratory investigations and enhanced MRI features in patients presenting with undifferentiated inflammatory synovitis of the knee. Patient and methods: Fifteen patients with undifferentiated inflammatory synovitis of the knee joint were recruited for this study. All patients underwent full history‐taking, detailed rheumatological examination, synovial fluid analysis including polarized microscopy, rheumatoid factor (RF), anti‐nuclear antibody (ANA), anti‐cyclic citrullinated peptide (CCP), C‐reactive protein, and erythrocyte sedimentation rate. MRI/gadolinium‐enhanced MRI was done for all patients with unilateral presentation and for the most symptomatic knee in cases of bilateral knee involvement. Results: Enhanced MRI showed the following findings: synovial enhancement and effusion 15/15, pannus formation 13/15, bone marrow edema 3/15, bone erosions 2/15, cartilaginous erosions 1/15, synovial cysts 2/15, Baker's cyst 2/15, periarticular soft tissue edema 3/15, and lipoma arborescencs 2/15. Conclusions: Undifferentiated synovitis of the knee is not necessarily a benign condition. It represents a diagnostic dilemma in rheumatological practice that deserves early identification and early treatment in order to prevent inevitable and irreversible articular damage if left untreated. The ability of MRI to detect early changes like bone marrow edema and bony and cartilaginous erosions (usually not obvious on plain X‐rays) makes this a highly sensitive tool for evaluation of patients presenting with undifferentiated synovitis affecting the knee joint. When combined with gadolinium, it allows accurate assessment of the degree of synovial thickening (pannus) and picks up local intra‐articular lesions especially in patients with unilateral disease.     

Cervical spine involvement early in the course of rheumatoid arthritis

Objectives

Cervical spine involvement in rheumatoid arthritis (RA) is considered a feature of long-standing disease. We describe two patients who presented with cervical symptoms as early features of RA.

Methods

We report two RA cases with cervical spine involvement as early features and use MEDLINE to review the literature concerning the frequency and disease duration of this manifestation and its imaging with plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).

Results

An 80-year-old man with cervical myelopathy from a C1–C2 rheumatoid pannus underwent decompression surgery before development of peripheral synovitis from RA. A 63-year-old woman presented with neck pain and polyarthritis at RA diagnosis, with imaging that confirmed a C1–C2 rheumatoid pannus. Onset of cervical spine involvement in RA is generally after 10 years of disease duration, ranging from 3 months to 45 years after peripheral synovitis among patients with seropositive erosive RA. Occurring in 9–88% of RA patients, cervical spine involvement may result in cervical instability due to either mechanical compression or vascular impairment of the spinal cord. Bone erosions and atlanto-axial subluxation on standard radiographs are two major signs of cervical spine involvement in RA. MRI identifies earlier signs of RA and has a higher sensitivity in detecting bone erosions compared to conventional radiography.

Conclusions

Cervical spine involvement in RA is not an uncommon condition but is rare at early disease onset. Symptoms of cervical pain and myelopathy should prompt a thorough neurological examination accompanied by imaging.     

Synovitis occurs in some clinically normal and asymptomatic joints in patients with early arthritis

OBJECTIVE: To determine if clinically asymptomatic knee joints in patients with recent onset arthritis reveal histological evidence of synovitis. METHODS: As part of a prospective study of patients with synovitis of less than one year duration, we performed blind needle biopsies on the knees of 20 patients who had synovitis elsewhere but no symptoms or detectable swelling or tenderness of the biopsied joint. RESULTS: Histologic evidence of synovitis was observed in 11 knees (55%). All patients with synovitis had evidence of synovial lining cell hyperplasia, increased vascularity, and lymphocytic infiltrates. Five of 6 patients with rheumatoid arthritis (RA) and 5 of 8 with undifferentiated arthritis had histological evidence of synovitis, but none of the 5 with reactive arthritis (ReA) had synovitis in the asymptomatic joints. Histologic evidence of synovitis persisted in some after clinical resolution of previous pain and swelling, while it occurred in others with no history of previous involvement of that knee. CONCLUSION: Even asymptomatic joints in patients with RA and undifferentiated arthritis of recent onset reveal histologic signs of synovitis. The earliest changes may occur before symptoms. Histologic changes also persist after resolution of previous early symptoms. Evidence of inflammation was not present in asymptomatic joints in our 5 patients diagnosed with ReA.     

Histological patterns of synovitis and serum chemokines in patients with rheumatoid arthritis

OBJECTIVE: Studies indicate the genetic, biological, and clinical heterogeneity of rheumatoid arthritis (RA). Recently the histological diversity of RA has been postulated. We investigated whether serum concentrations of interleukin 8 (IL-8), RANTES (regulated upon activation normal T cell expressed and secreted), and monocyte chemoattractant protein-1 (MCP-1) are correlated with histological appearance of the rheumatoid synovitis. METHODS: Using ELISA we assessed IL-8, RANTES, and MCP-1 concentrations in serum of 47 patients with RA and 30 patients with osteoarthritis (OA). RESULTS: Morphological analysis of synovial specimens distinguished 2 types of rheumatoid synovitis. Twenty-eight RA samples presented diffuse infiltrates of mononuclear cells with no specific microanatomical organization and were categorized as diffuse synovitis. In the remaining 19 specimens, classified as follicular synovitis, formation of lymphocytic follicles with germinal center-like structures was observed. Serum levels of studied chemokines were increased in patients with RA compared to the OA control group (p < 0.001 for all comparisons). Concentrations of IL-8, RANTES, and MCP-1 were highest in serum of RA patients with follicular synovitis in comparison with patients with diffuse synovitis (p < 0.01, p < 0.01, and p < 0.05, respectively) and could distinguish RA patients with these 2 histological disease patterns. Serum levels of chemokines correlated with markers of disease activity such as erythrocyte sedimentation rate, C-reactive protein concentrations, and Disease Activity Score. CONCLUSION: Distinct histological variants of rheumatoid synovitis associated with different serum levels of IL-8, RANTES, and MCP-1 reflect clinical activity of the disease and confirm the concept of RA heterogeneity.     

Bone edema determined by magnetic resonance imaging reflects severe disease status in patients with early-stage rheumatoid arthritis

OBJECTIVE: To determine the significance of bone edema, detected by magnetic resonance imaging (MRI), in early-stage rheumatoid arthritis (RA). METHODS: We simultaneously examined serologic variables, MRI of wrist sites and finger joints of both hands, clinical disease activity score (DAS), and HLA-DR typing at entry in 80 patients with early-stage RA. RESULTS: The number of bones scored as positive for bone edema correlated with the number of sites scored as positive for MRI synovitis and MRI bone erosion, rate of enhancement (E-rate), and serum C-reactive protein (CRP), matrix metalloproteinase 3 (MMP-3), and interleukin 6 (IL-6). Findings for MRI synovitis and MRI bone erosion, E-rate, CRP, MMP-3, IL-6, seropositivity, and titer of anti-cyclic citrullinated peptide antibody (anti-CCP antibody), DAS28-CRP and HLA-DRB1*0405 allele carriership, were significantly higher in the positive versus the negative bone edema group. CONCLUSION: Bone edema based on our scoring system may reflect severe disease status in patients with early-stage RA. However, its clinical value at entry in prognostication of RA should be examined through prospective clinical followup studies.     

Power Doppler ultrasound assessment of rheumatoid hand synovitis

OBJECTIVE: To evaluate power Doppler ultrasound (PD) as a technique in assessing response to treatment with steroids in rheumatoid hand synovitis. METHODS: Twelve patients with rheumatoid hand synovitis were assessed before and after treatment with steroids. Variables used to assess synovitis activity in each patient included patient visual analog scale (VAS) score for pain, physician assessment score (PAS), erythrocyte sedimentation rate (ESR), and PD of the metacarpophalangeal joints. RESULTS: Nine female and 3 male patients were studied; mean age was 53.3+/-6.5 yrs and mean disease duration 6.5+/-4.5 yrs. All patients had a good clinical response to steroid treatment and there was a significant improvement in the synovitis activity assessments. Wilcoxon signed-rank test using the exact method was applied to the change in disease activity variables. For PD signal, p < 0.002; VAS, p < 0.0016; ESR, p < 0.031; PAS, p < 0.008. CONCLUSION: PD quantifies synovitis and may be a useful adjunct to disease assessment and the response to treatment in RA.     

Sensitivity and significance of nuclear magnetic tomography findings of finger joints in rheumatoid arthritis

Evaluation of the sensitivity and value of magnetic resonance imaging (MRI) findings and miniarthroscopic investigations (mini-/needle-arthroscopy = MA) of metacarpophalangeal (MCP) joints in patients with rheumatoid arthritis (RA). 30 patients with RA (21 female, 9 male), disease duration 2 months to 22 years and mean disease activity score (DAS) of 3.90 (range: 2.00-7.67) were examined by MRI of the hand (MCP region) and following MA of the MCP-II joints. MRI parameters for arthritis (synovial enhancement, synovial extension, cortical alterations, joint gap width) and corresponding macroscopic items (synovial extension, synovial hyperemia and vascularity, cortical alterations) by MA, scored semiquantitatively for synovitis (graduated from 0-III degree), were correlated. Additionally, normal radiographs of the hands were performed and compared with MRI findings concerning the detection of bony lesions. Evaluation of the 30 MRI and MA examination revealed highly significant correlations (p < 0.0001) for the parameters of synovial extension (MRI/MA), cortical alterations (MRI/MA) and synovial enhancement (MRI) compared to synovial hyperemia and vascularity (MA). We found significant correlations for parameters of activity and chronicity of RA pathology as assessed by MRI and MA. The detection rate of cortical lesions by MRI was two and a half times higher than by X-ray. MRI findings of MCP-II joints compared to those of MCP III-V showed that the MCP-II joint was more strongly involved.