Positive Power Doppler Research Articles

Subclinical synovitis measured by ultrasound in rheumatoid arthritis patients with clinical remission induced by synthetic and biological modifying disease drugs

BackgroundRheumatoid arthritis (RA) patients with disease in clinical remission might show subclinical synovitis, which can be related to the progress of structural joint damage. ObjectiveTo determine and compare the degree of synovial inflammation by ultrasound (US) in patients with RA in clinical remission, treated with DMARD or combination therapy with DMARD and anti-TNF. MethodsHospital-based cross-sectional study of 58 patients with RA in sustained remission for at least 6 months by DAS28 <2.6, who attended the Rheumatology Service at the Hospital Universitario de Caracas. Patients underwent clinical, functional, and laboratory assessments. Ultrasound was performed in hands measuring synovial effusion, synovial hypertrophy and power Doppler signal; using a semiquantitative 4-point scale of 0=none to 3=severe. Chi-square and t-test were used to compare the clinical, functional, laboratory and US assessments between the DMARD (N=37) and combination therapy with DMARD and anti-TNF (N=21) groups. A p-value <0.05 was considered statistically significant. ResultsOut of 58 patients, 25.9% had remission by US and 74.1% had synovial effusion or hypertrophy or positive power Doppler signal. Non-significant differences in US synovitis between the two groups were found. ConclusionsPersistent US activity was evident in a high percentage of rheumatoid arthritis patients in clinical remission by DAS28. No differences in subclinical synovitis measured by US were found between patients with DMARD and anti-TNF-induced clinical remission.

High prevalence of hip involvement and decrease in inflammatory ultrasound lesions during tumour necrosis factor-α blocking therapy in ankylosing spondylitis.

To assess the prevalence of clinical, US and radiographic hip involvement in AS patients with active disease and to explore the associations between these assessments. Furthermore, to evaluate the effect of 6 months of TNF-α blocking therapy on tender and inflammatory power Doppler US lesions of hip joints. Consecutive AS patients starting TNF-α blocking therapy were evaluated for hip joint involvement. At baseline, patient-reported history of hip involvement was assessed and radiographic evaluation (BASRI-hip) was performed. Clinical examination (tender hip joints) and US examination took place before and after 6 months of treatment. Of the 111 included patients, 20% reported a history of hip involvement. At baseline, tender hip joints were present in 23% of patients. US examination showed inflammatory lesions in 17% of patients, of which 74% had positive power Doppler. Structural lesions were present in 20% of patients, of which 55% had osteophytes. Structural radiographic damage was seen in 10% of patients. Highest concordance was found between history of hip involvement and radiographic hip involvement (phi coefficient 0.333). After 6 months of TNF-α blocking therapy, significant decrease was found in tender hip joints (from 29 to 11), total number of inflammatory US lesions (from 29 to 9) and positive power Doppler (from 22 to 6). The prevalence rate of hip involvement in AS patients varies from 10 to 23%, depending on the type of hip assessment. TNF-α blocking therapy significantly improved tender hip joints, and inflammatory US lesions including positive power Doppler.

The value of joint ultrasonography in predicting arthritis in seropositive patients with arthralgia: a prospective cohort study

BackgroundThe value of joint ultrasonography (US) in the prediction of clinical arthritis in individuals at risk of developing rheumatoid arthritis (RA) is still a point of debate, due to varying scanning protocols and different populations. We investigated whether US abnormalities assessed with a standard joint protocol can predict development of arthritis in seropositive patients with arthralgia.MethodsAnti-citrullinated protein antibodies and/or rheumatoid factor positive patients with arthralgia, but without clinical arthritis were included. US was performed at baseline in 16 joints: bilateral metacarpophalangeal 2–3, proximal interphalangeal 2–3, wrist and metatarsophalangeal (MTP) joints 2–3 and 5. Images were scored semi-quantitatively for synovial thickening and for positive signs on power Doppler (PD). Association between US abnormalities and arthritis development at the joint and at the patient level was evaluated. Also, we investigated the added value of US over clinical parameters.ResultsOut of 163 patients who underwent US examination, 51 (31%) developed clinical arthritis after a median follow-up time of 12 (interquartile range 5–24) months, of which 44 (86%) satisfied the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA. US revealed synovial thickening and PD in at least one joint in 49 patients (30%) and 7 patients (4%), respectively. Synovial thickening was associated with both development and timing of clinical arthritis in any joint (patient level) when MTP joints were excluded from the US assessment (odds ratio 6.6, confidence interval (CI) 1.9–22), and hazard ratio 3.4, CI 1.6–6.8, respectively, with a mean time to arthritis of 23 versus 45 months when synovial thickening was present versus not present). There was no association between US and arthritis development at the joint level. Predictive capacity was highest in the groups with an intermediate and high risk of developing arthritis based on a prediction rule with clinical parameters.ConclusionsSynovial thickening on US predicted clinical arthritis development at the patient level in seropositive patients with arthralgia when MTPs were excluded from the US assessment. Positive PD signs were infrequently seen in these at-risk individuals and was not predictive. In patients at intermediate risk of RA, US may help to identify those at higher risk of developing arthritis.

The role of ultrasonography in the diagnosis of painful shoulder syndrome in rheumatoid arthritis

Aim of the work To identify the role of ultrasonography in diagnosis of painful shoulder syndrome in rheumatoid arthritis (RA). Patients and methods A total of 45 patients with RA who fulfilled the ACR/EULAR 2010 criteria for RA were included, involving 65 shoulders. There were seven male and 38 female patients, and their mean age was 48.02±15.41 years. Their mean disease duration was 15.5±11.25 years. They were subjected to full history taking, thorough clinical examination, laboratory investigations, plain radiography, and shoulder ultrasonography. Results The 65 RA shoulders were divided according to the disease activity score 28 (DAS28) into group A (with high DAS28), which included 15 (23%) shoulder joints, and group B (with moderate DAS28), which included 50 (77%) shoulder joints. Ultrasound findings of groups A and B revealed bicipital tenosynovitis in 47 and 22%, rotator cuff (RC) tendinopathy in 66.7 and 24%, humeral head erosions in 80 and 48%, effusion in 66.7 and 18%, subacromial/subdeltoid (SA/SD) bursitis in 66.7 and 28%, and positive power Doppler signals (PDS) in 60 and 14%, respectively. There was a highly significant difference in effusion and a significant difference in RC tendinopathy and SA/SD bursitis between both groups. There was a significant to highly significant difference in SA/SD bursitis, RC tendinopathy, and bicipital tenosynovitis between patients with positive and negative PDS. Conclusion Ultrasonography is a useful tool in the diagnosis of shoulder pain in RA that can distinguish between various causes, helping in proper decision making regarding the treatment strategy. Bicipital tenosynovitis, SA/SD bursitis, glenohumeral joint effusion, humeral head erosions, and positive PDS were significant predictors of inflammatory nature of the painful shoulder syndrome.

Patients with juvenile idiopathic arthritis in clinical remission with positive power Doppler signal in joint ultrasonography have an increased rate of clinical flare: a prospective study

BackgroundUltrasonography (US) studies carried out on joints of juvenile idiopathic arthritis (JIA) patients in clinical remission demonstrate the presence of subclinical synovitis. The significance of subclinical synovitis and the positive power Doppler (PD) signal on US in JIA in clinical remission is not well understood. The objectives of this study were to assess whether the changes detected by US in patients with JIA in clinical remission can predict disease flare and to evaluate factors associated with flare and joint damage over 30 months of follow-up.MethodsA prospective study was performed with clinical and ultrasound evaluation in 34 joints of JIA patients in clinical remission. Clinical evaluation including physical exam, functional capacity and inflammatory markers was performed at baseline and every six months thereafter, for a total period of 30 months. US evaluation included presence of synovitis, PD signal and erosion at baseline and every 12 months thereafter. Subclinical synovitis was defined when there was synovitis with or without positive PD signal in US joints of patients in clinical remission. Flare was defined as any joint presenting clinical arthritis requiring therapy modification.ResultsWe evaluated a total of 35 patients, 28 (80%) girls, 14 (40%) persistent oligoarticular subtype, 12 (34.3%) oligoarticular extended and 9 (25.7%) polyarticular and 26 (74.3%) in remission on medication. Twenty (57.1%) patients flared. The risk of flare was five times higher in patients with positive PD signal and 14 times higher in patients in remission on medication. Regarding the assessment of joints after 6 months and 12 months of US evaluation, 70/3162 (2.2%) joints and 80/2108 (3.8%) joints flared, respectively. Joints with subclinical synovitis with positive PD signal flared more after 6 and 12 months. Twenty five of 2108 (1.2%) joints showed erosion over time. Joints with subclinical synovitis with or without positive PD signal showed more erosion.ConclusionsPatients in remission on medication with subclinical synovitis with positive PD signal on US have a higher risk of flare, therefore they should be monitored closely during treatment. In the same way, joints with subclinical synovitis with or without positive PD signal should be monitored due to the risk of flare and joint damage.

High-Frame-Rate Power Doppler Ultrasound Is More Sensitive than Conventional Power Doppler in Detecting Rheumatic Vascularisation

Early recognition of joint inflammation will increase treatment efficacy in rheumatoid arthritis (RA). Yet, conventional power Doppler (PD) ultrasound might not be sufficiently sensitive to detect minor inflammation. We investigated the sensitivity of high-frame rate Doppler, combined with singular value decomposition technique, to suppress tissue signals, for microvascular flow in a flow phantom setup and in a proof-of-principle study in healthy controls and in RA patients with different disease activities. In the flow phantom, minimal detectable flow velocity was a factor 3 lower with high-frame-rate PD than with conventional PD ultrasound. In the proof-of-principle study we detected a positive PD signal in all volunteers, diseased or healthy, with high-frame-rate PD ultrasound. We saw a gradual increase in PD signal in RA patients depending on disease activity. In conclusion, high-frame rate Doppler is more sensitive in detecting vascularisation than conventional PD ultrasound.

Ultrasound Evaluation of the Entheses in Daily Clinical Practice during Tumor Necrosis Factor-α Blocking Therapy in Patients with Ankylosing Spondylitis.

To assess structural and inflammatory ultrasound (US) lesions of entheses in ankylosing spondylitis (AS) patients with active disease and to evaluate inflammatory lesions after 6 months of tumor necrosis factor (TNF-α) blocking therapy, in daily clinical practice. Consecutive patients with AS were clinically evaluated and underwent US examination of 9 bilateral entheses before and after 6 months of TNF-α blocking therapy. US examination included the following as inflammatory lesions: bone erosions/cortical irregularities, enthesophytes, calcifications as structural lesions; adjacent bursitis, effusion, increased tendon hypoechogenicity or thickness; and positive power Doppler (PD) signal. At baseline, 105 (95%) of 111 included patients showed US abnormalities. Structural lesions were seen in 74 patients (67%) and inflammatory lesions in 88 (79%). Enthesophytes and positive PD signal were the most prevalent structural and inflammatory lesions, respectively. Most lesions were found at the lower extremities. Additionally, inflammatory lesions occurred at the lateral epicondyle of the elbow. Patients with structural lesions at baseline were significantly older, had longer disease duration, higher modified Stoke AS Spine score, and higher C-reactive protein. Individually, there was a great diversity in changes of inflammatory entheseal lesions during treatment, but on the group level no significant decrease was found. This prospective observational cohort study in daily clinical practice shows a high prevalence of structural and inflammatory US lesions in AS patients with longstanding and active disease. Positive PD signal was the most common inflammatory feature. No significant change in inflammatory US lesions was found after 6 months of TNF-α blocking therapy.

Musculoskeletal Ultrasound in the Treat-to-Target Treatment Strategies in Rheumatoid Arthritis

Treat-to-target (T2T) strategy, aiming at clinical remission or low disease activity, has greatly improved the prognosis of rheumatoid arthritis (RA) since its institution in clinical practice in 2010. However, with the widespread application of ultrasound, the subclinical synovitis has been observed to be commonly present in RA patients in clinical remission. A systematic literature search and meta-analysis elated revealed an association between Power Doppler positivity and the risk of flare (OR 4.52, 95% CI 2.61-7.84, P<0.00001, I2=21%), the risk of progressive bone erosion on patient level (OR 12.80, 95% CI 1.29-126.81, P=0.03, I2=52%) and risk of progressive bone erosion on joint level (OR 11.85, 95% CI 5.01-28.03, P<0.00001, I2=0%). Furthermore, the treatment strategies targeting ultrasound remission in addition to clinical remission better controlled disease activity of RA patients and reduced flare during follow-up comparted to the treatment with clinical remission as the only target. Deeper clinical remission reflects the better control of subclinical synovitis under the ultrasound and could be an optimized treatment target in RA management.

Ultrasound resistive index, power Doppler, and clinical parameters in established rheumatoid arthritis.

Ultrasonography (US) is a useful tool for the evaluation of sinovial vascularization and proliferation in rheumatoid arthritis (RA). Accordingly, resistive index (RI) on spectral Doppler (sD) US provides a quantitative analysis of vascular inflammation, but its utility in the evaluation of RA activity has not been established. Our objective was to determine the association of RI with other US parameters of synovitis and with clinical disease activity in established RA. Patients with positive power Doppler (pD) were included in a prospective cross-sectional study. Disease activity and disability were evaluated using the Disease Activity Score in 28-joints (DAS28) and Health Assessment Questionnaire (HAQ), respectively. Gray scale (GS) synovitis, pD, and sD analyses were performed by one of two examiners in wrists and the second and third metacarpophalangeal and proximal interphalangeal joints. The 10-joint GS and 10-joint pD scores and mean RI were then calculated. Weighted kappa (WK) values were employed to assess interobserver reability, and correlations were tested using the Spearman coefficient. Ninety-five RA patients (median duration of disease of 7years and mean DAS28 of 4.32±1.66) were included. WK values in real-time US were 0.77 for synovitis, 0.87 for pD, and 0.68 for RI. There were no significant correlations of RI with 10-joint GS, 10-joint pD, DAS28, joint counts, or HAQ (P>0.10 for all tests). Patients in remission had a mean RI similar to those with high disease activity (0.62±0.10, n=15 versus 0.63±0.13, n=34, respectively). The addition of the RI score did not seem to improve US performance in patients with established RA.

Utility of ultrasonography in guiding modification of disease modifying anti-rheumatic drugs and steroid therapy for inflammatory arthritis in routine clinical practice.

To determine the utility of ultrasonography in guiding modification of disease-modifying anti-rheumatic drug (DMARD) and steroid therapy for inflammatory arthritis (IA) in routine clinical practice. In this retrospective study, we analyzed DMARD and steroid use in IA patients referred to a rheumatologist-led ultrasound clinic. Power Doppler (PD) vascularity and greyscale (GS) synovial hypertrophy joint findings were categorized as positive/negative for each patient. The erythrocyte sedimentation rate (ESR) was used as a measure of disease activity. We assessed single visit data for 46 adult IA patients: 67.4% (n = 31) rheumatoid arthritis (RA), 15.2% (n = 7) psoriatic arthritis, 10.9% (n = 5) spondyloarthritis, and 6.5% (n = 3) undifferentiated IA. The mean ESR was 28.8 mm/h. Thirty-seven patients with both GS and PD ultrasound results were subsequently analyzed. All patients (n = 10) escalated and/or initiated on DMARD and 9/10 patients escalated or initiated on steroids were PD and GS positive. Six of seven patients with dose reduction and/or cessation of DMARDs and five of seven patients with dose reduction or cessation of steroids were PD negative. Of six patients who were GS positive and PD negative, three had dose reduction and/or cessation of DMARDs, while four had dose reduction of steroids; none of the six patients had DMARD/steroid escalation. By clarifying joint inflammation in an IA cohort with overall low ESR, ultrasonography of physician-selected joints can improve clinical assessment, resulting in treatment modification. Positive PD findings were particularly influential, while the clinical significance of GS positivity alone requires further investigation.

Foot neuropathy in rheumatoid arthritis patients: clinical, electrophysiological, and ultrasound studies

This study aimed to evaluate neuropathic foot pain in patients with rheumatoid arthritis (RA) using electrophysiological studies and musculoskeletal ultrasound (MSUS) to address the association between these findings and disease activity. Evaluation of the usefulness of this combination was undertaken. The present study was designed as a cross-sectional study. A total of 50 RA patients underwent a complete history-taking and rheumatologic examination. According to the cut-off point of Disease Activity Score in 28 joints, patients were divided into two equal groups (25 patients each): active and inactive. In total, 25 healthy individuals were included as controls. Routine tibial and peroneal nerve conduction studies, as well as electromyography of tibialis anterior and abductor hallucis muscles, were carried out. MSUS assessment of the ankle joint and extra-articular portion of the foot complex was also performed. Electrophysiological findings of foot neuropathy were observed in 78% of the patients, irrespective of the disease activity level. In total, 48% of the patients had mononeuropathies of a demyelinating pattern (entrapment neuropathies), whereas the other 30% had symmetrical polyneuropathy with axonal degeneration. Combined distal tibial and peroneal nerve entrapments were reported in 16% of the patients. A positive power Doppler signal and joint erosions showed a highly statistical significant prevalence among the active group in comparison with patients in remission (P ≤ 0.001). Peripheral nerve affection is common in the rheumatoid foot, irrespective of the disease activity status. The most common neuropathies were posterior tarsal tunnel syndrome, peroneal nerve entrapment at the fibular neck, and pure sensory axonal neuropathy. A positive power Doppler signal and bone erosions of the ankle joint, detected by MSUS, were associated with RA disease activity. Electrophysiology was superior to MSUS for the diagnosis of posterior tarsal tunnel syndrome.

Vascular Remodeling Underlies Re-Bleeding in Hemophilic Arthropathy

Hemophilic arthropathy is a debilitating condition that can develop as a consequence of frequent joint bleeding despite adequate clotting factor replacement. The mechanisms leading to repeated spontaneous bleeding are unknown. To better understand these mechanisms, we investigated the time course of synovial, vascular, stromal and cartilage changes in response to a single induced hemarthrosis in FVIII-deficient mice, compared the observed changes in vascular architecture to the changes in mouse models of rheumatoid arthritis (RA) and osteoarthritis (OA), and explored the extent to which these findings correlated with the development of hemophilic arthropathy in patients. Following a single induced hemarthrosis in the FVIII-deficient mouse, we found soft tissue hyperproliferation with marked induction of neoangiogenesis and evolving abnormal vascular architecture in the injured joint. While soft tissue changes were rapidly reversible, and cartilage changes were mild and mostly reversible, ongoing structural changes of abnormal vascularity persisted for months. These vascular changes involved pronounced remodeling with expression of α-Smooth Muscle Actin (SMA), Endoglin (CD105) and vascular endothelial growth factor (VEGF), as well as altered joint perfusion as determined by in vivo imaging. Surprisingly, these vascular changes were also seen in uninjured joints, suggesting systemic mediation of the observed effects. Changes in vascular architecture and pronounced expression of α-SMA were unique to hemophilia, and were not found in joint tissue obtained from RA or OA mice or from tissue from patients with OA or RA. Since FVIII-deficient mice do not suffer from spontaneous joint bleeding, human studies needed to be designed to reveal if such vascular changes were associated with joint bleeding and joint deterioration. Therefore, to determine if vascular perfusion changes were also present in hemophilia patients and to what extent they were related with joint bleeding and the degree of arthropathy, a cohort of 26 adult patients with hemophilia was studied prospectively. Radiographic Pettersson Scores and clinical Hemophilia Joint Health Scores (HJHS) were assessed and joint bleed status and vascularity changes were investigated by dynamic in vivo imaging using power Doppler (PD) during high resolution musculoskeletal ultrasound examinations of 156 joints (both elbows, knees and ankles of each patient) at baseline and, subsequently of 10 joints during painful episodes. Subclinical joint bleeding was present in 41% of joints at baseline. Positive PD signals were more frequently present in joints with subclinical bleeding than in joints without (83% vs. 55%; p< 0.01), while the mean PD signal score was significantly higher in bleeding joints (3.1 vs. 1.5; p < 0.01). Importantly, joint bleed status was independently associated with PD signal score (odds ratio [OR] = 1.45 [95% CI: 1.13, 1.86, p = 0.0035]) and with Pettersson score (OR = 1.21 [95%CI: 1.03, 1.43, p = 0.0185]) after adjusting for HJHS. Acute bleeding episodes, irrespective of occurring in previously non-bleeding or in previously subclinically bleeding joints only happened in joints where vascularity changes were present at baseline. Moreover, during these episodes, mean PD signal increased significantly from 3.5 at baseline to 6.0 (maximum 9 per joint; p≤0.05). Therefore, in vivo imaging demonstrated that those vascular changes, first observed in the FVIII-deficient mouse, were significantly associated with bleeding and joint deterioration in hemophilia patients.In aggregate, our observations in hemophilic mice and patients provide strong evidence that abnormal blood vessel formation and dynamic vascular remodeling facilitate and perpetuate joint bleeding in response to local and/or systemic stimuli. While changes in vascularity appear to be an important link to repeated bleeding and progression of arthropathy, the interrelations of bleeding and vascular changes are complicated and will require further study. These findings not only provide new insights into the pathobiology of progression of hemophilic arthroapthy, but also open new avenues to study molecular targets for angiogenesis inhibition to prevent aberrant vessel formation, potentially increasing the effectiveness of clotting factor replacement therapy. DisclosuresVon Drygalski:CSL Behring: Honoraria, Speakers Bureau; Novo Nordisk: Honoraria, Research Funding; Biogen: Honoraria, Research Funding; Hematherix Inc: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Bayer: Honoraria, Research Funding; Pfizer: Honoraria; Baxalta: Honoraria, Research Funding. Mosnier:Hematherix Inc: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

Ultrasound imaging-guided percutaneous treatment of rotator cuff calcific tendinitis: success in short-term outcome.

Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month. A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month. In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12-17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to success. Numeric rating scale score for pain showed similar results. Pain at admission was also related to age, calcification size, ultrasound and Gärtner score, power Doppler positivity, bursal wall thickening and biceps tenosynovitis. The success of the procedure with quick improvement in function and symptoms is warranted in soft and middle-sized calcifications, in young adults. Ultrasound-guided percutaneous procedures for RCCT must be safe, effective and with prompt pain relief and function restoration. This study shows which clinical picture is more favourable to this purpose and actual prognostic factors for DNL (soft and middle-sized calcifications, in young adults, are more favourable).

Polyarteritis nodosa confined to the breasts associated with polyenthesitis

Polyarteritis nodosa (PAN) was first described as an inflammatory arterial disorder by Kussmaul and Maier in 1866 [1]. PAN was characterized as a necrotizing vasculitis of small- to-medium-sized arteries. It was subclassified into systemic, cutaneous/subcutaneous, and microscopic types. Cutaneous/subcutaneous PAN is generally recognized to have a good prognosis [1]. PAN-associated vasculitis localized to the breast is very rare, with few reported cases [2–9]. Most of the cases were diagnosed as giant cell arteritis (GCA) [2–5], as PAN was considered uncommon [6–8]. We herein report a case of PAN of the breast associated with polyenthesitis. A 71-year-old Japanese woman presented with bilateral breast pain, myalgia, enthesitis of both patellar ligaments, fever, weight loss, and general fatigue. She was admitted to our hospital. Physical examination was significant for five tender breast nodules, approximately 1–2 cm in diameter, with associated erythema (Figure 1A). There were no other skin lesions. Laboratory tests demonstrated elevated levels of C-reactive protein (CRP) of 19.8 mg/dl, erythrocyte sedimentation rate (ESR) of 124 mm/1 h, and white blood cell count of 18.4 × 109/L. Anti-proteinase 3, myeloperoxidase neutrophil cytoplasmic antibodies, and anti-nuclear antibodies were all negative. Hepatic and renal functions were normal. Human leukocyte antigen (HLA) typing demonstrated positive A2, A31, B46, and B61 antigens. Physical examination, mammography, and ultrasonography did not show any architectural distortions and calcifications which are considered as the sign of breast cancer. A biopsy of a nodule in the left breast revealed leukocytoclastic medium-sized arteritis without giant cell invasion (Figure 1B and C), indicating PAN. Breast nodule did not reveal typical septal and lobular panniculitis. Flurodeoxyglucose (FDG)-positron emission tomography/computed tomography showed high FDG uptake in multiple entheses, including spinous processes (Figure 1D), both ischial tuberosities, and patellar ligaments (Figure 1E), indicating polyenthesitis. Ultrasonography of the left patellar ligament demonstrated a positive power Doppler signal in the tibial insertion, indicating tibial tuberosity enthesitis (Figure 1F). The patient was diagnosed with PAN limited to the breasts associated with polyenthesitis. Treatment with daily oral prednisolone (40 mg) was initiated, resulting in immediate improvement in the patient's symptoms and normalization of the serum CRP and ESR values. She was discharged and had experienced no subsequent complications or flare-ups for 3 years.

El papel de la ultrasonografía para la evaluación subclínica de la artritis reumatoide en remisión. Revisión sistemática de la literatura

There is an interest in the role of ultrasound (US), particularly the presence of power Doppler (PD) signal and synovial hypertrophy in the evaluation of subclinical activity in rheumatoid arthritis patients (RA) on remission. ObjectiveExamine the evidence to determine the usefulness of US and PD in the evaluation of patients with RA in remission using clinimetric properties. Materials and methodsA systematic literature search was performed using electronic databases PubMed, EMBASE, BioMed Central, Cochrane registry of clinical trials and secondary reference sources of articles published up to 2 March 2014, with the key terms “arthritis, rheumatoid” or “arthritis” and “ultrasonography” or “ultrasonography, Doppler, pulsed” and “remission induction” were used until March 2, of the 2014, without language restriction. Observational cohort studies that assessed the prevalence of subclinical activity by US and PD in adult patients with RA in clinical remission were included. Methodological quality of the articles was verified and relevant information extracted from each one. ResultsA total of 13 studies were identified for analysis. RA activity using these imaging techniques was observed in 14.6 to 95% for US synovial hypertrophy and 1.2 to 64.5% for PD in remission patients using clinimetry. ConclusionsIn RA patients with clinical remission, variable subclinical activity was observed with ultrasound detected by synovial hypertrophy and a positive intra-articular PD signal. The latter enables residual from inflammatory pannus to be differentiated, and to also predict relapse and correlate with disease progression, allowing therapeutic changes. More studies evaluating treatment and prognostic outcomes are required.

A comparative study between ultrasonographic hand features in systemic sclerosis and rheumatoid arthritis patients: Relation to disease activity, clinical and radiological findings

Aim of the workTo compare ultrasonographic (US) hand features in systemic sclerosis (SSc) and rheumatoid arthritis (RA) patients and to investigate their relationship with disease activity, clinical and radiographic data. Patients and methodsForty SSc and 30 RA patients were consecutively included. All patients underwent clinical examination, X-ray and US on the hand and wrist joints to detect synovitis, tenosynovitis, and calcinosis. Disease activity score-28 (DAS28) and European Scleroderma Activity index were used for RA and SSc patients respectively. Health Assessment Questionnaire-Disability Index (HAQ-DI) was used in all patients. ResultsThe frequency of synovitis and tenosynovitis detected by US was found to be higher than that found by clinical examination in both RA and SSc patients (p=0.01, p=0.02, respectively). US synovitis was detected in 10 SSc (25%) and in 17 RA patients (56%). US tenosynovitis was found in 18 SSc (45%) versus 11 RA patients (36.6%). US synovitis and tenosynovitis in RA patients showed a statistically significant correlation with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor, HAQ-DI and DAS28. Positive intrasynovial power Doppler signal was significantly frequent in RA than SSc patients (p<0.001). Sclerosing tenosynovitis appeared to be specific to SSc patients. Calcifications were observed in both SSc and RA patients, but with no statistically significant difference (p=0.69). ConclusionUS provided valuable disease activity information in both RA and SSc patients more than clinical examination. US articular involvement in SSc is less frequent compared to that in RA, with specific appearance of sclerosing tenosynovitis in SSc patients.

Effectiveness of Certolizumab Pegol in Treating Rheumatoid Arthritis Patients with Persistent Inflamed Residual Mono- or Oligosynovitis Resistant to Prior TNF-α Inhibitors.

We report four cases of successful treatment with certolizumab pegol (CZP) of rheumatoid arthritis (RA) patients with persistent inflamed residual mono- or oligosynovitis resistant to prior TNF-α inhibitors. Although the patients were in a moderate disease activity, a low activity, or a remission of RA, they sustained inflammatory mono-/oligoarthritis even after treatment with prior TNF inhibitors. They were then all treated with CZP and observed in a serial ultrasonography. In all cases, the positive power Doppler signals in the joint have disappeared promptly and all of the patients were able to retain remission in the long term. The treatment of CZP to the refractory mono-/oligoarthritis of inflammatory synovitis in RA patients has not been previously described. The cases suggest that it may be associated with the feature of CZP, possible effective penetration into the site of inflammation.

Poster 212 Atypical Presentation of Gout Masquerading as Severe Osteoarthritis in a Woman with Longstanding Metatarsalgia: a Case Report

Disclosures: J. Luz, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: Patient with prior 1st TMT arthrodesis and 5 months S/P 4th metatarsal osteotomy reports persistent severe pain, intermittent swelling and redness on the base of 5th metatarsal and generalized metatarsalgia. Orthotics, iontophoresis, and months of narcotic analgesics failed to improve pain. Examination demonstrated no abnormalities. X-ray showed a well-healed osteotomy, intact TMT arthrodesis, and DJD. MRI showed mild edema in subcutaneous tissue of dorsal 5th metatarsal base with no bone marrow edema or fracture. Program Description: 50-year-old obese woman with severe left foot osteoarthritis (OA) and chronic metatarsalgia. Setting: Tertiary center outpatient clinic. Results or Clinical Course: MUS examination at the 5th TMT joint revealed synovial thickening, hyperechoic stippling within thickened joint capsule, and positive color power Doppler signal consistent with the MUS appearance of gouty arthropathy. The 1st MTP joint also showed chronic synovitis and crystal deposition. Uric acid level was 6.1; CRP was elevated at 8.6. She received an ultrasound-guided corticosteroid injection into the inflamed joint followed by gout treatment with allopurinol, Colcrys for flare prophylaxis, and hydroxychloroquine. Pain gradually improved; narcotics, and later Colcrys, were weaned off. One year after initiating treatment, patient remained pain-free. Follow-up MUS examination showed prior erosive joint changes but no active synovitis. Discussion: Gout has been considered a preferential male disease, often presenting as podagra. Women with risk factors (e.g. obesity, HTN) can also develop gout and are more likely to present atypically, particularly in the setting of underlying OA. Ultrasound assists in the diagnosis of gout via detection of tophi, the double contour sign, and synovial pathology. Chronic gouty inflammation can cause bony erosions, as also seen in severe OA. Conclusions: MUS can greatly aid clinicians in the differential diagnosis of arthritis and crystalline disease. Presence of severe OA in the foot should raise clinical suspicion for underlying inflammatory arthritis, including gout.

Power Doppler sonography to predict the risk of surgical recurrence of Crohn's disease.

The aim of this work is to investigate the role of power Doppler sonography as an additional predictor of surgical recurrence in Crohn's disease. A sample of 33 patients, with ileal or ileocolonic Crohn's disease, that had underwent intestinal resection, were retrospectively enrolled. All patients had bowel ultrasonography 7-16months after resection. Power Doppler sonography of the preanastomotic ileum was evaluated as a possible prognostication tool to assess the risk of long-term need for reoperation. The absolute incidence of surgical recurrence in those who had a positive power Doppler was 42%, while that of those who had a negative power Doppler was 28.6%. Combining the power Doppler with bowel wall thickness, the surgical recurrence risk grew from 41.2% of those with a positive power Doppler and thickness >3mm to 55.6% of those with a positive power Doppler and thickness >6mm. Power Doppler look to be another useful prediction tool for the personalization of patient's care. It could be useful to perform power Doppler in all patients with a wall thickness >5mm: for those who have a positive power Doppler it may be indicated as a more aggressive prophylactic therapy.

AB0662 Inflammatory Power Doppler Ultrasound Lesions of the Entheses and Hip Joints in Patients with Ankylosing Spondylitis before and after 6 Months of Tnf-α Blocking Therapy in Daily Clinical Practice

BackgroundInflammatory entheseal and hip involvement are characteristic extra-spinal manifestations of ankylosing spondylitis (AS). In clinical studies these manifestations are commonly evaluated by enthesitis indexes such as the Maastricht AS Enthesitis...