Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis

Objective: Despite recent advances, early diagnosis of psoriatic arthritis (PsA) remains a challenge in clinical practice. Ultrasound (US) could be a useful tool for the diagnosis and management of PsA. The objective of this review was to determine the role of US in early diagnosis of PsA.Methods: We have performed a literature review aiming to evaluate studies on US findings in psoriasis and their predictive value of progression to PsA, as well as studies on US features specific for PsA in comparison with other conditions.Results: A total of 40 studies were included. Sixteen studies assessed US findings in psoriasis, of which only 3 prospectively evaluated the role of US in predicting progression to PsA. Patients with PsA had a greater frequency of US abnormalities, in particular enthesitis and Power Doppler(PD) signal compared to patients with psoriasis only. In the longitudinal studies, psoriatic patients with higher enthesopathy scores at baseline were more likely to progress to PsA. Twenty-four studies evaluated US abnormalities in PsA and compared them to other conditions. Most specific US features that distinguish PsA from psoriasis were PD signal and erosions in joints and entheses. Extra-synovial changes, including peri-tendinous dermal soft tissue oedema with associated PD signal and flexor tendon enthesopathy, as well as thickening of the pulleys in the flexor tendons were highly characteristic for PsA, as they were frequently found in PsA patients, but in none of the RA patients. US-detected entheseal abnormalities in particular erosions and PD signal were more frequent in patients with PsA compared to fibromyalgia.Conclusion: Despite the wide use of US in PsA, more research is needed to identify predictive factors of progression to PsA in patients with psoriasis, as well as to determine most specific US features that differentiate PsA from other conditions.

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Accuracy of Physical Examination to Detect Synovial and Extra-Synovial Pathologies in Psoriatic Arthritis in Comparison to Ultrasonography

Journal of Clinical Medicine ◽

10.3390/jcm9092929 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2929

Author(s):

Ummugulsum Gazel ◽

Dilek Solmaz ◽

Gizem Ayan ◽

Catherine Ivory ◽

Jacob Karsh ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Physical Examination ◽

Flexor Tendon ◽

Power Doppler ◽

Fair Agreement ◽

Poor Agreement ◽

Flexor Tendons ◽

Hand Pain ◽

Grey Scale ◽

Us Findings

We aimed to explore the accuracy of physical examination (PE) to detect the synovial and extra-synovial pathologies in psoriatic arthritis (PsA) in comparison to ultrasonography (US). Twenty-nine PsA patients with hand pain were included in the study. A detailed PE of the hands was performed and US scans were performed for the joints, extensor and flexor tendons, and entheses of the second to fifth fingers of both hands. The agreement between PE and US findings was calculated. The strongest agreement for the joints was between “swollen joints” and power Doppler (PD) signals in the metacarpophalangeal (MCP) joints and grey scale synovitis in the proximal interphalangeal (PIP) joints. The agreement of tender entheses on PE and inflammation on US (hypoechogenicity, thickening, and/or PD signals) was poor for both extensor (Kappa = −0.027, Prevalence Adjusted and Bias Adjusted Kappa (PABAK) = 0.344) and flexor compartments (Kappa = 0.039, PABAK = 0.569). Similar to enthesitis, comparison of any PE and US findings showed a poor agreement at the extensor and flexor tendon regions (extensor: Kappa = 0.123, PABAK = 0.448, and flexor: Kappa = 0.171, PABAK = 0.431). Our study showed that there was a poor to fair agreement of PE and US findings of hands. US can add value when determining the source of pain in PsA in the small joints.

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Ultrasound and Doppler US in Evaluation of Superficial Soft-tissue Lesions

Journal of Clinical Imaging Science ◽

10.4103/2156-7514.127965 ◽

2014 ◽

Vol 4 ◽

pp. 12 ◽

Cited By ~ 22

Author(s):

Huseyin Toprak ◽

Erkan Kiliç ◽

Asli Serter ◽

Ercan Kocakoç ◽

Salih Ozgocmen

Keyword(s):

Soft Tissue ◽

Imaging Modality ◽

Power Doppler ◽

Soft Tissue Lesions ◽

Doppler Us ◽

Size Number ◽

Ultrasound Technology ◽

Superficial Tissue ◽

Superficial Soft Tissue

Improved developments in digital ultrasound technology and the use of high-frequency broadband transducers make ultrasound (US) imaging the first screening tool in investigating superficial tissue lesions. US is a safe (no ionizing radiation), portable, easily repeatable, and cheap form of imaging compared to other imaging modalities. US is an excellent imaging modality to determine the nature of a mass lesion (cystic or solid) and its anatomic relation to adjoining structures. Masses can be characterized in terms of their size, number, component, and vascularity with US and Doppler US especially with power Doppler US. US, however, is operator dependent and has a number of artifacts that can result in misinterpretation. In this review, we emphasize the role of ultrasound, particularly power Doppler, in superficial soft-tissue lesions.

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Ultrasonographic detection, definition and quantification of soft tissue oedema in psoriatic dactylitis

Medical Ultrasonography ◽

10.11152/mu-2258 ◽

2019 ◽

Vol 21 (4) ◽

pp. 414 ◽

Cited By ~ 4

Author(s):

Ilaria Tinazzi ◽

Luca Idolazzi ◽

Alen Zabotti ◽

Luisa Arancio ◽

Alberto Batticiotto ◽

...

Keyword(s):

Soft Tissue ◽

Subcutaneous Tissue ◽

Power Doppler ◽

Tendon Sheath ◽

Contralateral Side ◽

Scanning Technique ◽

Delphi Round ◽

Volar Aspect ◽

Definition Of ◽

Tissue Oedema

Aim: To define and score finger soft tissue oedema in psoriatic dactylitis by ultrasound.Material and methods: A systematic literature review (SLR) on ultrasound-detected finger soft tissue oedema was performed. Subsequently, based on the SLR, a Delphi survey was developed and circulated among a group of 13 expert sonographers, in order to obtain agreement on detection, definition and scoring of finger oedema by B-mode and power Doppler ultrasound. Agreement was considered achieved when each statement was approved by >75% of participants.Results: At the first Delphi round, 91 % agreement was obtained for the scanning technique to adopt, including the most appropriate area to evaluate. At the second round, 76% agreement was achieved on the definition of soft tissue finger oedema. At the third round, 76% agreement was obtained for B-mode and power Doppler scores. The volar aspect of the finger and comparisons with the contralateral side were agreed to be the most appropriate in terms of scanning technique. Agreed ultrasound definition of finger soft tissue oedema was “abnormal hypoechoic/anechoic areas, diffused or localized within the subcutaneous tissue between the epidermidis and the tendon-related anatomic structures (i.e. flexor tendon sheath, peritenonium, tendon pulleys), with local thickening, with or without local abnormal Doppler signal, visualised in two perpendicular planes and not evident on the contralateral side”. Semiquantitative (0-3) scores for both B-mode and power Doppler were agreed to be the most appropriate to be used.Conclusion: Our work produced, for the first time, technical indications, definition and scoring for the ultrasound assessment of soft tissue oedema in psoriatic dactylitis

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Role of joint damage, malalignment and inflammation in articular tenderness in rheumatoid arthritis, psoriatic arthritis and osteoarthritis

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-218744 ◽

2021 ◽

pp. annrheumdis-2020-218744

Author(s):

Irina Gessl ◽

Mihaela Popescu ◽

Victoria Schimpl ◽

Gabriela Supp ◽

Thomas Deimel ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Psoriatic Arthritis ◽

Power Doppler ◽

Joint Damage ◽

Joint Space ◽

Early Arthritis ◽

Damage Score ◽

Established Disease ◽

Active Inflammation

ObjectivesTo determine whether clinical tenderness can be considered a sign of inflammatory joint activity in patients with rheumatoid arthritis (RA), osteoarthritis (OA) or psoriatic arthritis (PsA) and to assess other possible factors associated with tenderness.MethodsPatients diagnosed with RA, PsA and OA underwent clinical and ultrasound examination of wrists and finger joints. Radiographs of the hands were scored for erosions, joint space narrowing (JSN), osteophytes and malalignment. A binary damage score (positive if ≥1 erosion, JSN and/or presence of malalignment) was calculated. Differences in grey scale signs of synovitis and power Doppler (PD) between tender non-swollen (TNS) versus non-tender non-swollen (NTNS) joints were calculated. Disease duration was assessed,<2 years was regarded as early and >5 years as long-standing arthritis.ResultsIn total, 34 patients (9 early and 14 long-standing) from patients with RA, 31 patients (7 early and 15 long-standing) with PsA and 30 with OA were included. We found equal frequencies of PD signal between TNS and NTNS joints in RA (p=0.18), PsA (p=0.59) or OA (p=0.96). However, PD had a significant association with tenderness in early arthritis both in RA (p=0.02) and in PsA (p=0.02). The radiographic damage score showed significant association with tenderness in RA (p<0.01), PsA (p<0.01) and OA (p=0.04).ConclusionTenderness might not always be a sign of active inflammation in RA, PsA and OA. While tenderness in early arthritis may be more related to inflammation, established disease is better explained by joint damage and malalignment.

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Differential diagnosis between rheumatoid arthritis and psoriatic arthritis: the value of ultrasound findings at metacarpophalangeal joints level

Annals of the Rheumatic Diseases ◽

10.1136/ard.2010.147272 ◽

2011 ◽

Vol 70 (6) ◽

pp. 1111-1114 ◽

Cited By ~ 90

Author(s):

Marwin Gutierrez ◽

Emilio Filippucci ◽

Fausto Salaffi ◽

Luca Di Geso ◽

Walter Grassi

Keyword(s):

Rheumatoid Arthritis ◽

Differential Diagnosis ◽

Psoriatic Arthritis ◽

Synovial Fluid ◽

Potential Role ◽

Power Doppler ◽

Extensor Tendon ◽

Synovial Hypertrophy ◽

Ultrasound Findings

ObjectiveTo investigate the potential of ultrasound (US) in the differential diagnosis between rheumatoid arthritis (RA) and psoriatic arthritis (PsA) at metacarpophalangeal (MCP) joints level.Methods18 RA patients and 20 PsA patients with clinical involvement of MCP joints were included. All US examinations were performed by two rheumatologists investigating: presence of joint cavity widening (JCW), synovial fluid and/or synovial hypertrophy, peritenon extensor tendon inflammation (PTI) and intra-articular or peri-tendinous power Doppler (PD) signal.ResultsA total of 83 MCP joints in 18 RA patients were assessed. In all of these the authors found different degrees of JCW. 15 of 83 (18%) MCP joints showed synovial fluid, whereas 68 of 83 (82%) MCP joints showed synovial hypertrophy. In 72 of 83 (86.7%) MCP joints intra-articular PD was detected. No PTI pattern was found in these patients.In PsA patients, a total of 82 MCP joints in 20 patients were assessed. 54 of 82 (65.8%) MCP joints showed PTI pattern (p = 0.001). In 50 of these 54 (92.5%) MCP joints extra-articular PD signal was detected (p = 0.001). 28 of 82 (34.1%) MCP joints showed different degrees of JCW. 6 of 28 (21.4%) MCP joints presented synovial fluid, whereas 22 of 28 (78.5%) MCP joints showed synovial hypertrophy. In 8 of 82 (9.7%) MCP joints the JCW and PTI patterns were found contemporaneously.ConclusionsPreliminary results demonstrate that PTI pattern is a higher characteristic of PsA, which suggests a potential role of US in the differential diagnosis between RA and PsA at MCP joints level.

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Is there subclinical enthesitis in early psoriatic arthritis? A clinical comparison with power doppler ultrasound

Arthritis Care & Research ◽

10.1002/acr.21733 ◽

2012 ◽

Vol 64 (10) ◽

pp. 1617-1621 ◽

Cited By ~ 43

Author(s):

J. E. Freeston ◽

L. C. Coates ◽

P. S. Helliwell ◽

E. M. A. Hensor ◽

R. J. Wakefield ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Doppler Ultrasound ◽

Power Doppler ◽

Power Doppler Ultrasound ◽

Clinical Comparison ◽

Early Psoriatic Arthritis

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Dactylitis in psoriatic arthritis – prevalence and reliability of ultrasound lesions in a clinical setting

10.21203/rs.3.rs-42887/v1 ◽

2020 ◽

Author(s):

Sara Helena Kamp Felbo ◽

Mikkel Østergaard ◽

Inge J. Sørensen ◽

Lene Terslev

Keyword(s):

Psoriatic Arthritis ◽

Soft Tissue ◽

Clinical Setting ◽

Flexor Tendon ◽

Color Doppler ◽

Extensor Tendon ◽

Subcutaneous Edema ◽

Sum Score ◽

Reader Reliability ◽

Flexor Tenosynovitis

Abstract Objectives. To investigate the prevalence of ultrasound elementary lesions in dactylitis in psoriatic arthritis (PsA), and the reliability of scoring these lesions in a clinical setting.Methods. In 31 patients with PsA and clinical dactylitis, ultrasound assessment of the affected digit was performed using grey-scale and color Doppler mode. One examiner scanned all patients and a 2nd examiner scanned 10 patients for inter-reader reliability. The following lesions were evaluated: subcutaneous edema; soft tissue thickening; synovitis of the digital joints; tenosynovitis of the flexor tendon; enthesitis at the deep flexor tendon and the extensor tendon entheses; and paratenonitis of the extensor tendon. A dactylitis sum-score was calculated. Findings in clinically tender and non-tender digits were compared.Results. The most frequent lesions were soft tissue thickening (81%) and subcutaneous edema (74%) followed by synovitis (56–68%) and flexor tenosynovitis (52%). Color Doppler was most frequently found subcutaneously (55%) and around the flexor tendons (45%). All lesions were typically found in combinations, most commonly subcutaneous edema and synovitis (71%), subcutaneous edema and flexor tenosynovitis (52%), and all three in combination (52%). Tender digits had a higher dactylitis sum-score and numerically higher prevalence of most lesions than non-tender digits. Intra- and inter-reader agreements were moderate to excellent, though lower for few components of digital enthesitis, especially hypoechogenicity.Conclusion. Dactylitis in PsA appears to encompass several pathologies, most often subcutaneous changes combined with synovitis and/or flexor tenosynovitis. Reliability of scoring established ultrasound lesions of dactylitis in a clinical setting is moderate-excellent.

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Ultrasound in rheumatoid arthritis

Oxford Textbook of Rheumatoid Arthritis ◽

10.1093/med/9780198831433.003.0018 ◽

2020 ◽

pp. 195-206

Author(s):

Andrew Filer ◽

Maria Antonietta D’Agostino ◽

Ilfita Sahbudin

Keyword(s):

Rheumatoid Arthritis ◽

Psoriatic Arthritis ◽

Early Diagnosis ◽

Structural Damage ◽

Structural Changes ◽

Imaging Modality ◽

Ultrasound Guided ◽

Crystal Arthritis ◽

Rheumatology Practice

Ultrasound in increasingly used in rheumatology practice in the assessment of inflammatory patient, including facilitating early diagnosis of rheumatoid arthritis (RA), predicting its outcome, measuring structural damage, and monitoring its progression. This imaging modality can visualize both inflammatory and structural changes in patients with unclassified arthritis and RA, as well as other inflammatory arthritides such as psoriatic arthritis (PsA), spondyloarthropathy (SpA), and crystal arthritis. This chapter aims to provide an overview of the recent advances of this technique for in the assessment of RA. Firstly, the principles which underpin the physics of ultrasound are summarized, followed by the musculoskeletal pathologies which are amenable to ultrasound examination. In addition, it also highlights the role of ultrasound in procedures (e.g. ultrasound-guided biopsy and ultrasound-guided injection).

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