Swelling Of Metacarpophalangeal Joints Research Articles

Ultrasonography of enthesis in psoriatic arthritis: a descriptive and reliability analysis of elemental lesions and power Doppler subtypes

Objective: To evaluate the reliability and prevalence of enthesis ultrasound (US) elemental lesions in patients with psoriatic arthritis (PsA), using the Madrid Sonographic Enthesis Index (MASEI) and Outcome Measures in Rheumatology (OMERACT) definitions.Methods: The study included 27 PsA patients with metacarpophalangeal joint swelling. An US rheumatologist performed the MASEI examination. Prevalence and reliability of the included elemental lesions [structure, thickness, erosion, enthesophytes, power Doppler (PD), and bursae] were evaluated. In addition, three other PD definitions were checked: PD OMERACT (≤ 2 mm to the bone profile), PD enthesis–tendon (> 2 mm from the bone profile), and PD bursa. Short (3–5 s) videos of US examinations were recorded for reliability assessment.Results: MASEI and all PD definitions showed good to excellent reliability. The best reliability values were found in erosions, bursae, and PD. When present, the PD signal always appeared in more than one location of the evaluated areas. Enthesis Doppler was present in 81.5% of patients. Abnormal tendon structure and enthesophytes were the most prevalent lesions.Conclusion: MASEI demonstrates to be a reliable tool in PsA. All enthesis US Doppler definitions demonstrate to be reliable for its use in PsA with minimal differences, being PD MASEI the most sensitive in active patients.

Peritenon Extensor Tendon Inflammation in Psoriatic Arthritis Is an Enthesitis-related Lesion.

To analyze the association between enthesitis, synovitis, and peritenon extensor tendon inflammation (PTI) in psoriatic arthritis (PsA). PsA patients with swelling of metacarpophalangeal joints were included. Greyscale and power Doppler (PD) were used for synovitis and PTI ultrasound identification. Madrid Sonographic Enthesis Index (MASEI) was used for enthesitis assessment. PD activity was evaluated using PD item of MASEI and PD Outcome Measures in Rheumatology (OMERACT) definition. Synovitis had no association with enthesitis. PTI was associated with PD MASEI and PD OMERACT. Only PD OMERACT showed a positive correlation with PTI. In PsA, PTI is associated to enthesitis, as opposed to synovitis.

A Pain in the Colon: Rheumatoid Arthritis as an Unusual Cause of Colonic Ischemia

Colonic ischemia is the most common form of intestinal ischemia and is defined by the reduction of blood flow to a level insufficient to maintain cellular metabolic function. Rheumatoid vasculitis (RV) can occur in up to 5% of rheumatoid arthritis (RA) patients with intestinal involvement in 10-38% of patients. We report a rare case of RA as the cause of isolated right sided colonic ischemia. A 61-year-old African American woman with a history of RA, pulmonary sarcoidosis, and hypertension presented with abdominal pain and non-bloody diarrhea for two weeks. She reported four to five loose watery bowel movements a day. The abdominal pain was intermittent, cramping, and not associated with food. She also endorsed joint stiffness in her hands. Her medication list included daily aspirin 81mg, hydroxychloroquine 400mg, prednisone 5mg, hydrochlorothiazide 25mg, and twice daily leflunomide 20mg. She was previously on etanercept and stopped 6 months prior.Significant physical exam findings revealed a normotensive patient with mild diffuse abdominal tenderness, metacarpophalangeal joint swelling, and swan neck deformity of her fingers. Other than high titers of rheumatoid factor (RF), anti-cyclic citrullinated peptide antibody, and elevated c-reactive protein (1.7mg/dL), laboratory workup was unremarkable with a negative infectious workup. Colonoscopy revealed multiple superficial linear ulcerations with erythematous borders from the cecum to the hepatic flexure. Pathology from the biopsies showed no granulomas but noted areas of hemorrhage, ischemia, and nuclear dust suggestive of neutrophilic vasculitis surrounding thrombosed small vessels consistent with RV. A CT angiography showed diffuse mucosal enhancement of the ascending colon with associated fat stranding and patent abdominal arterial vasculature. Her symptoms resolved after supportive treatment, titration of prednisone, and restarting etanercept. Clinicians should be aware of RA as a rare cause of colonic ischemia. Although there are no formal diagnostic criteria, the diagnosis should be suspected in patients with colonic ischemia who have RA, high titers of RF with characteristic histopathology showing neutrophilic vasculitis on colonoscopy biopsies after more common causes are ruled out. The pathogenesis is thought to arise from immune complex formation from RF in small vessels. Treatment involves supportive care and immunosuppression of the RA.1556_A Figure 1. Colonoscopy showing superficial ulcerations in the right colon.1556_B Figure 2. Abdominal CT showing mucosal enhancement of the ascending colon.1556_C Figure 3. Histopathology showing nuclear dust suggestive of neutorphilic vasculitis surrounding a thrombotic small vessel.

Determining early referral criteria for patients with suspected inflammatory arthritis presenting to primary care physicians: a cross-sectional study.

ObjectiveEarly diagnosis and initiation of treatment for inflammatory arthritis can greatly improve patient outcome. We aimed to provide standardized and validated criteria for use by primary care physicians (PCPs) in the identification of individuals requiring referral to a rheumatologist.Patients and methodsWe analyzed the predictive value of a wide variety of demographic variables, patient-reported complaints, physical examination results, and biomarkers in order to identify the most useful factors for indicating a requirement for referral. Patients for this cross-sectional study were enrolled from various centers of the city of Jeddah, Saudi Arabia, if they were ≥18 years of age and presented to a PCP with small joint pain that had been present for more than 6 weeks. A total of 203 patients were enrolled, as indicated by the sample size calculation. Each patient underwent a standardized physical examination, which was subsequently compared to ultrasound findings. Biomarker analysis and a patient interview were also carried out. Results were then correlated with the final diagnosis made by a rheumatologist.ResultsA total of 9 variables were identified as having high specificity and good predictive value: loss of appetite, swelling of metacarpophalangeal joint 2 or 5, swelling of proximal inter-phalangeal joint 2 or 3, wrist swelling, wrist tenderness, a positive test for rheumatoid factor, and a positive test for anti-citrullinated protein antibodies.ConclusionNine variables should be the basis of early referral criteria. It should aid PCPs in making appropriate early referrals of patients with suspected inflammatory arthritis, accelerating diagnosis and initiation of treatment.