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Role of Musculoskeletal Ultrasound in Juvenile Idiopathic Arthritis

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Role of Musculoskeletal Ultrasound in Juvenile Idiopathic Arthritis REVIEW Role of musculoskeletal ultrasound in juvenile idiopathic arthritis Juvenile idiopathic arthritis is a serious autoimmune childhood disease that encompasses several types of chronic arthritis. Diagnosis is largely based on history and physical examination, although imaging modalities may play a role in diagnosis and also guiding management. In the past few years, technological advances in musculoskeletal ultrasound have led to a dramatic increase in the application of ultrasound in diagnosing and monitoring juvenile arthritis and other rheumatologic diseases. This article will review recent publications regarding the use of ultrasound in the diagnosis and treatment of juvenile idiopathic arthritis. 1,2 KEYWORDS: enthesitis n juvenile idiopathic arthritis n steroid injection n synovitis Johanna Chang n tenosynovitis n ultrasound & Alessandra Bruns*2 1Department of Pediatrics, Division of Allergy/Immunology/Rheumatology, Over the past decade, musculoskeletal CT, MRI and also MSK-US may play a role University of San Diego, CA, USA ultrasound (MSK-US) has been described by in diagnosing and managing JIA. Advances 2Ultrasound Clinic, Department of Rheumatology, University of many rheumatologists as the ‘stethoscope’ of in MSK-US have led to more widespread Sherbrooke, Sherbrooke, Canada the joint. Unlike conventional radiography, an interest among pediatric rheumatologists in the *Author for correspondence: established imaging technique for identifying application of US to diagnose JIA and to monitor [email protected] progressive joint damage, US is sensitive to soft the effects of localized and systemic therapy. tissue lesions and can detect early erosive bone This article will review recent publications lesions [1,2] . The development of higher frequency regarding the use of US in the diagnosis and probes (12–18 MHz) and portable US machines treatment of JIA. Although the International has led to better resolution of small joints League of Arthritis and Rheumatism (ILAR) and the increased use of MSK-US in patients classification is the most commonly used with rheumatologic disease. Improvements in classification system for juvenile arthritis today, color Doppler (CD) and power Doppler (PD) many of the research and published reports in imaging, where the amount of color is related to childhood arthritis use terminology established degree of blood flow, allow for better assessment by older classification criteria, such as juvenile of soft tissue inflammation [1,3,4] . Several studies chronic arthritis (JCA) and juvenile rheumatoid have emerged supporting the clinical utility of arthritis (JRA). All three classifications refer to MSK-US in evaluating rheumatologic diseases chronic arthritis in children in which all other in children, especially in juvenile idiopathic diseases are excluded [7]. This review article refers arthritis (JIA), which will be described in this to the original classifications used in each study. review. MSK-US is particularly well suited to the pediatric population in that it has no ionizing Overview of JIA radiation, does not require sedation and can be The incidence of JIA ranges from one to 22 easily performed in a clinical outpatient setting. per 100,000, while the prevalence ranges from Additionally, MSK-US allows for the dynamic eight to 150 per 100,000 [8]. JIA is characterized assessment of clinically challenging joints and is by objective arthritis in one or more joints for relatively inexpensive compared with computed a minimum of 6 weeks in a patient less than tomography (CT) or MRI [5,6]. or equal to 16 years of age after other types of JIA is the most common rheumatic disease in childhood arthritis have been excluded. There children and encompasses several types of chronic are no specific laboratory tests for the diagnosis arthritis. JIA is a serious autoimmune disease that of JIA, and diagnosis is largely dependent on can cause significant short-term and long-term patient history and physical examination. disability, including permanent joint damage Arthritis is clinically defined as the presence [7]. Diagnosis of JIA is largely based on history of joint swelling not due to bony enlargement and physical examination; however, imaging or inactive synovitis or, in the absence of joint modalities including plain film radiography, swelling, limitation of motion accompanied part of 10.2217/IJR.12.71 © 2013 Future Medicine Ltd Int. J. Clin. Rheumatol. (2013) 8(1), 97–107 ISSN 1758-4272 97 REVIEW Chang & Bruns Role of musculoskeletal ultrasound in juvenile idiopathic arthritis REVIEW by heat and tenderness [9,10]. Most institutions sacro-iliac joints and lower back, as well as classify childhood arthritis using the 1997 criteria enthesitis, or inflammation at the region of proposed by the ILAR that further differentiates tendon insertions. ERA includes patients with JIA into different subtypes: polyarticular, arthritis secondary to inflammatory bowel oligoarticular, systemic, enthesitis-related disease (IBD), reactive arthritis or ankylosing (ERA), psoriatic or undifferentiated [7]. spondylitis. Patients with ERA account for Oligoarticular JIA is the most common form 3–11% of patients with JIA and 13% of all of JIA, involving 50–60% of patients with JIA. patients with a rheumatologic condition [12] . Peak age of onset is between 1 and 5 years, with ERA mainly affects male patients over the age a female-to-male ratio of 4:1. Children with of 6 years, although it typically involves older oligoarticular JIA have arthritis in less than five patients who are in their preteen or adolescent joints for at least 6 weeks [8]. Children with a years. ERA is strongly associated with uveitis. diagnosis of psoriasis, a family history of psoriasis, Most patients have a positive HLA-B27; 82–95% a positive HLA-B27 or a positive rheumatoid of patients with ankylosing spondylitis are HLA- factor (RF) are excluded from the diagnosis of B27 positive [7,11,12]. oligoarticular JIA. Children with anti-nuclear Psoriatic arthritis is characterized by antibody (ANA)-positive oligoarticular JIA are swelling of the digits (‘dactylitis’) and is usually at high risk for the development of uveitis, which accompanied by a diagnosis of psoriasis in the is often asymptomatic and requires frequent patient or in a first-degree family member. ophthalmologic examinations for early detection Diagnosis is obtained in patients with chronic to prevent eye damage [7,11,12]. arthritis and definite psoriasis or chronic Children with polyarticular JIA have arthritis and two of the following criteria: arthritis in five or more joints for at least dactylitis, nail pitting or onycholysis, or a 6 weeks. Polyarticular JIA affects 30–55% of family history of psoriasis. Psoriatic arthritis patients with JIA. Patients with a positive RF or can occur before, during or after dermatologic anticyclic citrullinated protein (CCP) antibody manifestations. Psoriatic arthritis affects 2–11% tend to have more erosive disease and a chronic of patients with JIA. Age of onset is typically course progressing into adulthood. Peak age of during the preschool years as well as middle- onset is biphasic with a female-to-male ratio of to-late childhood. Psoriatic arthritis is slightly 5:1. Children with polyarticular JIA typically more common in girls with a female-to-male present with symmetric arthritis involving the ratio of 2.5:1. In total, 15–20% of patients with small joints of the hands, although arthritis of psoriatic arthritis have an asymptomatic chronic larger joints such as the knee or ankle can also uveitis, while a very low percentage can develop a accompany small joint disease. Children with painful symptomatic uveitis similar to that seen polyarticular JIA can rarely develop rheumatoid in patients with ERA [7,11,12]. nodules. Uveitis affects approximately 5% of Patients who do not satisfy inclusion criteria patients with polyarticular disease [7,11,12]. for any of the six ILAR classifications or meet Systemic JIA involves 4–17% of patients with criteria for more than one of the six ILAR JIA [12] . Systemic JIA does not have a peak onset classifications can be included in the category and affects males and females equally. Patients of undifferentiated arthritis. Patients with with systemic JIA usually present with fever undifferentiated arthritis must have objective and rash accompanied by high inflammatory arthritis for a minimum of 6 weeks [7,11]. markers. Although many present with symmetric, polyarticular arthritis, some children with Technical aspects of MSK-US systemic JIA develop arthritis later during the Modern US devices utilize multifrequency disease course. Diagnosis requires the presence probes. The frequency of the sound wave of arthritis with a minimum of 2 weeks of daily determines how deeply the tissue will be quotidian fevers accompanied by an evanescent, penetrated and also impacts image resolution. nonfixed, erythematous rash, lymphadenopathy, For the best resolution, the highest possible US hepatomegaly or splenomegaly, or serositis. frequency should be used. US in rheumatology is Approximately 10% of children with systemic JIA generally performed with linear probes, with the develop a life-threatening complication known choice of probe frequency depending on the joint as macrophage activation syndrome (MAS) [7,12]. region to be examined. For instance, for small Children with enthesitis-related arthritis joints such as those of the wrist, hand, and feet, (ERA) typically have arthritis of both small frequencies of
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