The articular manifestations of progressive systemic sclerosis (scleroderma).

The articular manifestations of progressive systemic sclerosis (PSS) were studied in 38 patients. Of these, 66% experienced joint pain and 61% had signs of joint inflammation. Limitation of joint movement was seen in 45%. Radiological abnormalities included periarticular osteoporosis (42%), joint space narrowing (34%), and erosions (40%). Erosive disease did not correlate with disease duration, presence of rheumatoid factor, antinuclear antibodies, distal tuft resorption, or the extent of the scleroderma skin changes. Calcinosis was seen more frequently in those patients with articular erosions (67%). Erosive osteoarthritis of the distal interphalangeal joints (7 patients) was associated with impaired finger flexion. Joint involvement in PSS occurs frequently and may resemble rheumatoid arthritis in the early stages but is less destructive. The occurrence of unrelated arthropathy, such as primary osteoarthritis, is not uncommon, and its differentiation from true PSS joint disease can be difficult.     

Distal interphalangeal joint involvement in rheumatoid arthritis

Sixty-two patients with seropositive rheumatoid arthritis (RA) were evaluated radiographically for distal interphalangeal (DIP) joint involvement and were compared with 50 age- and sex-matched control subjects. The frequency of DIP erosions was 37% in the patients versus 14% in the controls; these erosions were mild and were not related to disease duration. Erosions elsewhere in the hand and wrist were of all degrees of severity and were related in part to disease duration. Osteophytes occurred frequently in both the RA group (71%) and the control group (60%). However, joint space narrowing occurred more frequently in RA patients (77%) than in the controls (46%) (P less than 0.009). The findings from this study suggest that in RA patients, DIP erosions occur frequently, do not occur in isolation, and are not simply a marker for severe global erosive disease in the hand and wrist. The high frequency of osteophytosis and joint space narrowing in both groups probably represents the overlap of osteoarthritis and RA that occurs in many patients.     

The arthropathy of advanced progressive systemic sclerosis

The peripheral joint radiographs of 55 carefully selected patients with classic progressive systemic sclerosis (PSS) and 10 patients with CREST syndrome were reviewed in a longitudinal fashion. Thirty-three PSS and 7 CREST patients were available for followup (mean followup period 28.7 and 29.8 months, respectively). The high frequency of conventionally recognized abnormalities such as flexion contractures, digital tuft resorption, sclerodactyly, and subcutaneous calcinosis was reconfirmed. Additional hand findings included joint space narrowing (13%), juxtaarticular demineralization (4%), ankylosis (2%), marginal erosions (9%), and previously undescribed dorsal erosions (15%). All PSS findings showed progression, although isolated reversibility was noted. The CREST group showed a similar frequency and distribution of findings but with less tendency to progression. With the exception of an increased active joint count in PSS patients with erosions, computer-assisted analysis of multiple clinical and laboratory variables showed no correlation with any radiographic abnormality. These results confirm the presence of an erosive arthropathy in PSS not attributable to overlap with either rheumatoid arthritis or systemic lupus erythematosus.     

Magnetic resonance imaging of the knee: a tool for prediction of joint damage in early rheumatoid arthritis?

OBJECTIVE: To evaluate the usefulness of magnetic resonance imaging (MRI) in predicting destructive rheumatoid arthritis (RA) in the knee joint, and to compare this method with clinical examination and conventional radiography (CR). METHODS: Clinical evaluations of the knee joint, followed by MRI and CR examinations were performed in 30 patients with early RA. The MRI examination included evaluation of inflammation using a synovitis score and evaluation of destruction with an erosion score. The first examinations were performed within 14 months from disease onset. Twenty-eight patients were re-examined after 1 year, and 23 patients after 3 years. 'Disease activity score' (DAS), using a 28 joints score (DAS28); health assessment questionnaire (HAQ); rheumatoid factor (RF); and C-reactive protein (CRP) were also analysed. RESULTS: At baseline, MRI found synovitis in 29 patients, of whom 18 also had clinical synovitis. At baseline five patients had 17 MRI erosions, whereas on CR two patients had one erosion each. After 1 year 17 of 35 and after 3 years 28 of 55 MRI erosions were detected also on CR. In only one case CR showed an erosion that was not visible on MRI. The MRI synovitis score (reflecting the extent of the synovitis) at baseline correlated significantly with the number of erosions on MRI both at year 1 and 3, and with the number of erosions on CR at 3 years. In logistic multiple regression analyses the MRI-synovitis score proved to be the best independent predictor of erosiveness. CONCLUSION: MRI was superior to clinical examination and CR in detecting erosions. MRI synovitis score was the best independent predictor of erosiveness in the knee joint in patients with early RA.     

Role of metacarpophalangeal joint anatomic factors in the distribution of synovitis and bone erosion in early rheumatoid arthritis

OBJECTIVE: To investigate the role of metacarpophalangeal (MCP) joint anatomic and biomechanical factors in the distribution of synovitis and bone erosion in early rheumatoid arthritis (RA). METHODS: Thirty-three patients with early RA with clinically diagnosed MCP joint disease and 28 healthy controls were examined by magnetic resonance imaging of the second to fifth MCP joints of the dominant hand. T1 and T2 fat-suppressed coronal sequences were obtained to assess erosion, and dynamic contrast-enhanced images were acquired to assess synovitis in all of the RA patients and in 8 of the controls. Erosions were defined as bone defects with sharp margins observed using T1-weighted imaging in 2 planes, with a cortical break seen in at least 1 plane. The location of erosions was recorded. The volume of synovitis surrounding each MCP joint (divided into 8 regions) was calculated by summation of voxels derived from the maximal enhancement parameters. The synovial volumes adjacent to MCP joint collateral ligaments were determined by correcting synovial volumes for the positions of asymmetrically placed flexor tendons. RESULTS: In patients with early RA in whom bone erosions were present, there was a propensity for involvement of the radial side of the second (P < 0.0001), third (P = 0.002), and fourth (P = 0.056) MCP joints, but not the fifth. Fifty-two of the 110 erosions (47.3%) occurred adjacent to the radial collateral ligaments of the second, third, and fourth MCP joints. The volume of synovitis was also greater on the radial side of the second (P < 0.0001) and third (P < 0.001) MCP joints. A predilection for synovitis in all of the MCP joints adjacent to the radial collateral ligaments was evident when the positional effects of the flexor tendon were considered. The position of radial collateral ligaments had an effect on erosion formation that was independent of synovitis. A predilection for radial bone damage was also evident in the controls, although lesions were 5-fold less frequent, were generally smaller, and had well-defined margins. CONCLUSION: This study shows that there is a predilection for both synovitis and bone erosion formation on the radial side of the MCP joints in early RA, and that joint inflammation appears to drive the inherent tendency for bone damage on the radial side of joints. These findings have implications regarding the pathogenesis of joint damage in RA.     

Clinical features of the arthritis of mixed connective tissue disease

Seventeen of 19 patients with mixed connective tissue disease (MCTD) had arthritis as a significant initial feature of their disease; 8 were given an initial diagnosis of rheumatoid arthritis (RA) and 4 received chrysotherapy. RA-like hand deformities were present in 35% and contractures and/or persistent loss of joint motion in 47%. Joint radiographs showed abnormalities in 41% and included erosions and/or cysts in 30%. The arthritis of MCTD may be both erosive and deforming and this disease should be considered in patients presenting as RA with unusual features.     

Articular manifestations of mixed connective tissue disease

All but one of 28 patients with mixed connective tissue disease (MCTD) who were studied prospectively had arthralgia, and 15 of them had noticed joint swelling. Arthralgia was the first symptom in 14 patients and one of the first two symptoms in 24. Arthralgia was pauciarticular in 4 and polyarticular in 23. Presence of morning stiffness in 15 patients, symmetrical joint swelling in 16, joint deformity in 6, marginal erosions in roentgenograms of the hands of 12, rheumatoid factor in 25, and subcutaneous nodules in 5 caused 24 of the 28 patients with MCTD to fulfill criteria for definite or classic rheumatoid arthritis. All patients, however, also had prominent signs or symptoms of scleroderma, systemic lupus erythematosus, or polymyositis.     

Small joint involvement: a systematic roentgenographic study in rheumatoid arthritis.

Standard hand and foot roentgenograms from 200 consecutively hospitalised patients with definite or classical rheumatoid arthritis (RA) were read for marginal erosions by three independent observers. For each joint or group of joints analysed the degree of symmetry (S = absolute symmetry, U = unilateral, PS = partial symmetry) was determined. The total number of joints affected significantly correlated only with disease duration; symmetry of erosions and number of affected patients were not influenced by seropositivity. Metatarsophalangeal erosions (in 70%) were the most common and were classified as S in 16%, U in 21%, and PS in 63%. Metacarpophalangeal erosions (in 68%) were also common, with a symmetry pattern of S in 19%, U in 21%, and PS in 60%. Proximal finger interphalangeal erosions (in 42%) were unilateral in 42% (S in 8% and PS in 50%). The only site where symmetry was usual (90%) was the wrist, but radiocarpal and intercarpal joints were considered together. Erosions also occurred in about 16% of the finger distal interphalangeal and 28% of the great toe interphalangeal joints. In RA roentgenographic asymmetry is usual and unilateral involvement common.     

Incidence of acromioclavicular joint involvement in rheumatoid arthritis: a 15 year endpoint study.

OBJECTIVE: To evaluate the incidence of involvement and nature of destruction of acromioclavicular joints (AC) in a prospectively followed cohort of 74 patients with rheumatoid factor positive and erosive rheumatoid arthritis (RA). METHODS: At the 15 year followup, radiographs of 148 AC joints were evaluated, and the grade of destruction was assessed by the Larsen method. RESULTS: No surgical procedures had been performed on the AC joints. Rheumatoid involvement (Larsen Grade > or = 2) was observed in 87/148 (59%) of the AC joints in 50/74 (68%) patients: 37 bilaterally and 13 unilaterally. Incidence of mild erosions (Larsen Grade 2) was 39%, and of severe (Larsen 3-5) 20%. Erosions were most often observed on the inferior edge of the clavicular joint margin. Degenerative features without rheumatoid changes were present in 11 joints. Larsen score (0-100) of peripheral joints correlated well with the AC joint Larsen Grade in both sides: right, r = 0.56 (95% CI 0.38 to 0.70), left, r = 0.49 (95% CI 0.30 to 0.65). CONCLUSION: After 15 years two-thirds of the patients with RA showed involvement of the AC joints. Erosions were located most often on the inferior margin of the joint.     

Associations of erosive arthritis with anti-cyclic citrullinated peptide antibodies and MHC Class II alleles in systemic lupus erythematosus

OBJECTIVE: To determine the associations of erosive arthritis (EA) with anti-cyclic citrullinated peptide (anti-CCP) antibodies and major histocompatibility class (MHC) II alleles in systemic lupus erythematosus (SLE). METHODS: One hundred four patients with SLE were evaluated for arthritis and classified as EA, nonerosive arthritis, or no arthritis. EA was further classified as major or minor erosions. Sera from patients and 130 serum controls were tested for anti-CCP2 and rheumatoid factor (RF). Patients and 117 genetic controls were genotyped for HLA-DRB1 and HLA-DQB1. Statistical associations were tested using chi-square tests and odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Eight patients (8%) were anti-CCP+ and they accounted for 11% (8/71) of patients with synovitis. Twelve patients (11%) had EA. Among patients with synovitis, EA was associated with anti-CCP (OR 28.5, 95% CI 4.7-173.8, p = 0.001), with a weaker association for RF (p = 0.3). Six patients with EA had major erosions and also met criteria for rheumatoid arthritis (RA). Four of these patients (67%) were anti-CCP+. HLA-DQB1*0302 was associated with EA (p = 0.01), with similar trends for HLA-DRB1*0401 and 2 copies of the shared epitope (SE). There were trends for associations of HLA-DQB1*0302 and 2 SE copies with anti-CCP production. CONCLUSION: The frequency of EA in SLE is likely to be higher than previously reported. Anti-CCP+ patients with SLE are more likely to have EA. Anti-CCP may be a useful serological marker for EA for patients presenting with synovitis. Anti-citrulline antibodies may have a pathogenic role in the development of major erosions, resulting in clinical features that overlap SLE with RA (rhupus).     

Low-cost, low-field dedicated extremity magnetic resonance imaging in early rheumatoid arthritis: a 1-year follow-up study

OBJECTIVE: To study the ability of low-cost low-field dedicated extremity magnetic resonance imaging (E-MRI) to assess and predict erosive joint damage in the wrist and metacarpophalangeal (MCP) joints of patients with early rheumatoid arthritis. METHODS: 24 previously untreated patients with rheumatoid arthritis with joint symptoms for <1 year were evaluated at the time of diagnosis and after 6 and 12 months of methotrexate treatment with conventional clinical or biochemical examinations, x rays of both hands and wrists, and E-MRI of the dominant wrist and MCP joints. RESULTS: At baseline, all patients showed magnetic resonance imaging (MRI) synovitis, and MRI erosions were detected in 21 bones (10 patients). 6 (29%) of these, distributed among two patients, were seen on x ray. One x ray erosion was not detected by MRI. At 1 year, MRI and x ray detected 15 and 8 new erosions, respectively, and 19% of MRI erosions at baseline had progressed to x ray erosions. In bones with MRI erosions at baseline, the relative risk of having x ray erosions at the 1-year follow-up was 12.1, compared with bones without baseline MRI erosions (lesion-centred analysis). If bones with baseline x ray erosions were excluded, the relative risk was 5.2. In patients with baseline MRI bone erosion or oedema, the relative risk of having x ray erosions at 1 year was 4.0, compared with patients without these signs at baseline (patient-centred analysis). CONCLUSION: In this group of patients with early rheumatoid arthritis who were treated uniformly, baseline E-MRI erosions in MCP or wrist bones markedly increased the risk of x ray erosions at the 1-year follow-up. Low-cost, low-field dedicated extremity MRI is promising for assessment and prognostication of early rheumatoid arthritis.     

C4 and C5 body vertebral erosions in early rheumatoid disease

Summary Erosions at the antero-superior angles of C4 and C5 developed in 11 patients (22%) with rheumatoid arthritis of less than one year's duration were followedup over a 10-year period. These erosions do not appear to have been described before.     

Power Doppler e mezzi di contrasto nello studio della membrana sinoviale reumatoide

Pannus formation is a fundamental event in the pathogenesis of rheumatoid arthritis and its hypervascularisation seems to be crucial to the development of joint damage. High-resolution greyscale ultrasonography is a safe, quick, and inexpensive imaging tool that allows an accurate detection of even minimal morphostructural changes in patients with rheumatoid arthritis, including joint effusion, thickening of synovial membrane and bone erosions. More recently, power Doppler sonography has proved to be a reliable tool for semiquantitative assessment of the vascularity of the synovial tissue. The contrast-enhanced power Doppler sonography seems to be a helpful adjunct in assessing synovitis and the therapeutic response to the different therapies in patients with rheumatoid arthritis. The aim of this radiological vignette was to show a representative example of use of power Doppler sonography with contrast agent in assessing rheumatoid synovitis.     

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.     

Radiologic outcome and its relationship to functional disability in juvenile rheumatoid arthritis

OBJECTIVE: To determine the radiologic outcome in juvenile rheumatoid arthritis (JRA) and the relationship of radiologically detected joint damage to functional disability using multivariate analyses. METHODS: Selection criteria included a diagnosis of JRA made by 1977 American College of Rheumatology criteria, onset of arthritis > or = 5 years prior to study, current age > or = 8 years, a minimum grade 3 reading ability, and the availability of radiographs. Disability was measured by the Childhood Health Assessment Questionnaire (CHAQ) and Steinbrocker classifications. Radiographs taken within 2 years after onset (early) and the most recent radiographs (late) were examined by a single pediatric radiologist blinded to patients' identities, diagnoses, and outcomes. Multiple regression analyses were performed. RESULTS: On late radiographs the frequencies of joint space narrowing were 38, 14, 43, and 79%, respectively, among patients with systemic, pauciarticular, rheumatoid factor (RF) negative polyarticular, and RF positive polyarticular onset; erosions occurred in 63, 25, 39, and 75%, respectively. Early erosions were most frequent in patients with RF+ polyarticular onset, while both joint space narrowing and erosions occurred early in systemic onset. Radiologic signs of joint damage were most frequent at hips and wrists, while knees and ankles were relatively spared. Based on patients who had radiographs performed within one year of clinical study, 17.7% of the variation in CHAQ score was explained by joint space narrowing, 32.4% by pain, and 5% by a severe rating on physician's global estimate of disease activity. The odds of a Steinbrocker class > I were increased by joint space narrowing, pain, systemic onset, and active joint count. CONCLUSION: Differences in the frequencies and patterns of joint damage occur both among JRA onset subtypes and among individual joints. Radiographic damage, especially joint space narrowing, correlates with functional disability. However, pain is the major contributor to variation in CHAQ scores.     

Deforming arthropathy of the hands in systemic lupus erythematosus

Forty-one of 858 patients with systemic lupus erythematosus (SLE) developed clinical deformity of their hands. This deformity was clinically and radiologically different from that found in 40 patients with classical or definite rheumatoid arthritis (RA), and tended to appear early in the course of disease. Characteristics of this arthropathy included nonerosive carpal collapse; exceptional erosion of the styloid processes; Z deformity of the thumb; nonerosive ulnar deviation and subluxation of MCP joints; parametacarpophalangeal joint hook formation; scant and asymmetric joint erosions; and swan neck deformity of the fingers. Most of these changes seemed to be due to involvement of the ligaments rather than to the destructive effect of synovitis. Patients with SLE with deforming arthropathy had a higher frequency of rheumatoid factor positivity, sicca symptoms and antibodies to native DNA, whereas they had lower incidence of facial rash and photosensitivity than did those without. Other manifestations did not differ. We propose that most patients with SLE with deforming arthropathy belong to a subset of SLE rather than representing the coexistence of SLE and RA.     

Esophageal dysfunction in patients with progressive systemic sclerosis and mixed connective tissue diseases

Esophageal motility was studied in 37 patients with progressive systemic sclerosis (PSS), 12 patients with mixed connective tissue disease (MCTD) and 40 controls by the manometry method, using an open tube and continuous perfusion, and by radiological examination. Radiology was normal in 17 patients with PSS and five patients with MCTD, and abnormal in 15 patients with PSS and three with MCTD. The most frequent abnormality was slow transit time of barium. Manometry of the esophageal body was normal in 20 patients with PSS and six patients with MCTD, and abnormal in 17 patients with PSS and six with MCTD. Lack of contraction in the middle lower segments of the esophagus was the abnormality most frequently observed. Lower esophageal sphincter pressure was significantly lower among patients with PSS and MCTD than among the controls. Dysphagia was reported by ten patients with PSS and by six patients with MCTD. Radiology and manometry showed similar changes in PSS and MCTD, but dysphagia was more frequent among patients with MCTD.     

Prospective 7 year follow up imaging study comparing radiography, ultrasonography, and magnetic resonance imaging in rheumatoid arthritis finger joints

OBJECTIVE: To perform a prospective long term follow up study comparing conventional radiography (CR), ultrasonography (US), and magnetic resonance imaging (MRI) in the detection of bone erosions and synovitis in rheumatoid arthritis (RA) finger joints. METHODS: The metacarpophalangeal and proximal interphalangeal joints II-V (128 joints) of the clinically dominant hand of 16 patients with RA were included. Follow up joint by joint comparisons for erosions and synovitis were made. RESULTS: At baseline, CR detected erosions in 5/128 (4%) of all joints, US in 12/128 (9%), and MRI in 34/128 (27%). Seven years later, an increase of joints with erosions was found with CR (26%), US (49%) (p<0.001 each), and MRI (32%, NS). In contrast, joint swelling and tenderness assessed by clinical examination were decreased at follow up (p = 0.2, p<0.001). A significant reduction in synovitis with US and MRI (p<0.001 each) was seen. In CR, 12 patients did not have any erosions at baseline, while in 10/12 patients erosions were detected in 25/96 (26%) joints after 7 years. US initially detected erosions in 9 joints, of which two of these joints with erosions were seen by CR at follow up. MRI initially found 34 erosions, of which 14 (41%) were then detected by CR. CONCLUSION: After 7 years, an increase of bone erosions was detected by all imaging modalities. In contrast, clinical improvement and regression of synovitis were seen only with US and MRI. More than one third of erosions previously detected by MRI were seen by CR 7 years later.     

An appraisal of magnetic resonance imaging of the wrist in rheumatoid arthritis

OBJECTIVES: To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis, staging, and follow-up of the rheumatoid wrist. METHODS: A Medline search was performed to identify all publications from the years 1985 to 1999 concerning MRI of the wrist in patients with rheumatoid arthritis (RA). Additional papers were retrieved by scanning the references to the Medline-listed articles. Details of the MRI technique, as well as clinical data, were analyzed and compared. RESULTS: A total of 55 papers were identified. There were considerable variations in imaging sequence, section type, and slice thickness. Erosions and synovitis were the conditions that mostly profited from the adoption of MRI. Although the visualization of erosions was better detailed with MRI than with conventional radiography, erosions were only rarely related to clinical and laboratory parameters. Another advantage was that synovitis imaging, which can be enhanced by contrast agents, was amenable to quantitation. The extent of the synovial surface and the rate of contrast enhancement in a series of consecutive, rapidly acquired images were the most common measures. CONCLUSIONS: MRI of the rheumatoid wrist is a useful technique to ascertain the criteria for diagnosis and progression of RA, and to monitor the effects of treatment. Implementation of a standardized protocol could further increase its value.     

Established rheumatoid arthritis - new imaging modalities

New imaging modalities are assuming an increasingly important role in the investigation and management of rheumatoid arthritis. It is now possible to obtain information about all tissues within the joint in three dimensions using tomographic techniques such as magnetic resonance imaging (MRI) and high-resolution computerized tomography. Erosions are very clearly depicted using these modalities and MRI also allows imaging of soft tissues with assessment of joint inflammation. High-resolution ultrasound is a convenient clinical technique for the assessment of erosions, synovitis and tenosynovitis in real-time and facilitates diagnostic and therapeutic interventions such as joint aspiration and injection. Exciting experimental modalities are also being developed with the potential to provide not just morphological but functional imaging. Techniques such as positron emission tomography (PET) and single photon emission tomography (SPECT) can reveal actively metabolizing bone and the proliferation of synovial cells via radioactive labeling. Bioluminescence and fluorescence reflectance imaging are other approaches that allow imaging, and potentially the delivery of therapeutic agents, at a molecular level.