Abstract
Background: Undifferentiated arthritis (UA) is defined as an inflammatory arthritis that does not fulfill criteria for a definite diagnosis. Delay in reaching a specific diagnostic and therapy may lead to impaired functional outcomes. Our aim was to identify synovial biomarkers associated with definitive diagnostic classification in patients with UA.Methods: DMARD-naïve UA patients with available initial synovial tissue (ST) and a final diagnosis of rheumatoid arthritis (RA) or psoriatic arthritis (PsA) during follow-up were included and compared with patients with well-defined disease (RA or PsA). Clinical, arthroscopic, and pathological data were compared between groups. Pathology included quantitative immunohistochemical (IHC) analysis of cell types and human interferon-regulated MxA. Principal component analysis (PCA) was performed to extract disease patterns.Results: One hundred and five patients were included: 31 patients with DMARD-naïve UA (19 evolving to RA and 12 to PsA during a median follow up of 7 years), 39 with established RA, and 35 with established PsA. ST from the UA group showed higher macrophage density compared with the established RA and PsA groups. Patients with UA evolving to RA (UA-RA) showed higher MxA expression and CD3+ T-cell density compared with established RA. UA patients evolving to PsA (UA-PsA) showed increased vascularity and lining synovial fibroblast density compared with established PsA. Synovitis of UA-PsA patients showed more mast cells and lining fibroblasts compared with UA-RA. No between-group differences in local or systemic inflammation markers were found.Conclusions: Our results show differences in the cellular composition of UA synovium compared with RA and PsA, with higher density of the cellular infiltrate in the UA groups. Initial expression of the interferon inducible gene MxA could be a biomarker of progression to RA, while higher mast cell and fibroblastic density may be associated with PsA progression.
Highlights
Undifferentiated arthritis (UA) is defined as an inflammatory arthritis not satisfying classification criteria for rheumatoid arthritis (RA) [1,2,3] or peripheral spondyloarthritis [4], including psoriatic arthritis (PsA) [5]
Regarding the pharmacological treatment used during the long follow-up in UA patients, UA patients evolving to RA received more csDMARDs (89% were treated with a mean of 1.5 cDMARDs and currently 71% of them were taken methotrexate and 29% leflunomide) and bDMARDs [4 (21%) patients had been treated with a mean of 1.5 biologics, and currently 6 have biologics treatment−2 etanercept, 2 tocilizumab, and 2 abatacept-] than UA patients evolving to PsA (33% of patients had been treated with methotrexate, and currently 2 were taken methotrexate and 2 others patients adalimumab)
UA evolving to PsA showed more CD117+ mast cells and Hsp47+ lining synovial fibroblasts than UA evolving to RA, whereas UA evolving to RA showed significantly higher MxA (IGS) expression, and more CD68+ macrophages and CD3+ lymphocytes
Summary
Undifferentiated arthritis (UA) is defined as an inflammatory arthritis not satisfying classification criteria for rheumatoid arthritis (RA) [1,2,3] or peripheral spondyloarthritis (pSpA) [4], including psoriatic arthritis (PsA) [5]. In our early arthritis cohort (n = 381), we found that 30% of patients met criteria for RA, 10% for SpA and 16% did not fulfill criteria for any specific disease after 1 year of follow up [6]. Delay in reaching a definitive diagnosis and appropriate therapy may lead to persistent joint inflammation and damage and poor functional outcomes. Undifferentiated arthritis (UA) is defined as an inflammatory arthritis that does not fulfill criteria for a definite diagnosis. Delay in reaching a specific diagnostic and therapy may lead to impaired functional outcomes. Our aim was to identify synovial biomarkers associated with definitive diagnostic classification in patients with UA
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