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Symptomatic Psoriatic Dactylitis Is Associated with Ultrasound Determined Extra-Synovial Inflammatory Features and Shorter Disease Duration

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Symptomatic Psoriatic Dactylitis Is Associated with Ultrasound Determined Extra-Synovial Inflammatory Features and Shorter Disease Duration Clinical Rheumatology (2019) 38:903–911 https://doi.org/10.1007/s10067-018-4400-z ORIGINAL ARTICLE Symptomatic psoriatic dactylitis is associated with ultrasound determined extra-synovial inflammatory features and shorter disease duration Nicolò Girolimetto1 & Luisa Costa 1 & Luana Mancarella2 & Olga Addimanda2,3 & Paolo Bottiglieri1 & Francesco Santelli4 & Riccardo Meliconi2,3 & Rosario Peluso1 & Antonio Del Puente1 & Pierluigi Macchioni5 & Carlo Salvarani5,6 & Dennis McGonagle7 & Raffaele Scarpa1 & Francesco Caso1 Received: 13 November 2018 /Revised: 3 December 2018 /Accepted: 9 December 2018 /Published online: 19 December 2018 # International League of Associations for Rheumatology (ILAR) 2018 Abstract Objectives To explore the link between ultrasonographic features of dactylitis in psoriatic arthritis (PsA) and symptoms, digital tenderness and duration of dactylitis. Methods Forty-eight cases of PsA dactylitis were investigated using high frequency ultrasound (US) both in grey scale (GS) and Power Doppler (PD), evaluating the presence and the degree of flexor tenosynovitis, peri-tendinous oedema, subcutaneous PD, extensor tendon involvement, GS synovitis and intra-articular PD signal (PDS) of the involved digits. Patients were compared according to the presence of local pain and digital tenderness, the duration of dactylitis and the concomitant treatment. Results The presence of pain/tenderness was positively associated with US GS flexor tenosynovitis of grade >2(p <0.001),PD- flexor tenosynovitis (p < 0.001), peri-tendinous oedema (p < 0.001) and subcutaneous PDS (p < 0.001); moreover, it was nega- tively associated with GS synovitis (p < 0.001) and intra-articular PD (p < 0.001). The same positive and negative association with US findings were found comparing patients with duration of dactylitis shorter or longer than the median (24 weeks) (p < 0.001 for all comparisons). Conclusions Pain and digital tenderness are linked to dactylitis duration and earlier lesions are associated with extra synovial inflammatory changes. These findings suggest a hitherto unappreciated extra synovial basis for symptoms in PsA dactylitis. Keywords Dactylitis . Digital tenderness . Flexor . Oedema . Psoriatic arthritis . Tenosynovitis . Ultrasound Introduction * Raffaele Scarpa [email protected] Dactylitis, also known as sausage-digit, defined as diffuse and uniform swelling of the entire digit, is a hallmark of psoriatic 1 Department of Clinical and Experimental Medicine, Rheumatology arthritis (PsA) occurring in around 40% of cases [1, 2]. It may Research Unit, University Federico II, Via S. Pansini 5, simultaneously involve multiple digits [3] and represents a clin- 80131 Naples, Italy ical marker of disease severity [3, 4]. Dactylitis has been ob- 2 Medicine & Rheumatology Unit, Rizzoli Orthopaedic Institute, served in all forms of spondyloarthritis [5, 6], and it has been Bologna, Italy included in the ClASsification for Psoriatic ARthritis 3 Department of Biomedical & Neuromotor Sciences, University of (CASPAR) criteria due to its high specificity in PsA patients Bologna, Bologna, Italy [7, 8]. There is a lack of uniformity in the measurement of 4 Department of Social Sciences, University Federico II, Naples, Italy dactylitis ranging from a dichotomic score to the validated 5 Department of Rheumatology, Azienda USL-IRCCS di Reggio Leeds Dactylitis Index (LDI), which is a score that allows a Emilia, Reggio Emilia, Italy differentiation between tender and non-tender dactylitis [9–11]. 6 Rheumatology Unit, University of Modena and Reggio Emilia, Ultrasound (US) and magnetic resonance imaging (MRI) Modena, Italy studies showed that dactylitis is a very heterogeneous entity, 7 NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds characterized by the variable association of inflammatory in- Teaching Hospitals Trust and the University of Leeds, Leeds, UK volvement of flexor tendons (tenosynovitis), adjacent soft 904 Clin Rheumatol (2019) 38:903–911 tissue thickening/edema, synovitis of metacarpophalangeal difference in the ratio of circumference of the affected digit (MCP), proximal interphalangeal (PIP) and distal interphalan- to the contralateral) [10]. geal (DIP) joints and, to a lesser degree, extensor tendon in- A careful history was taken with a special regard to disease volvement and enthesitis [12–15]. characteristics (including age of onset, disease duration and Dactylitis may manifest as an acute/tender form (diffuse subset of disease). Clinical assessment was performed before swelling of the digit, pain reported by the patient and tender- US examination by a rheumatologist in each centre, who re- ness at physical examination) or a chronic/non-tender form corded presence or absence of local finger pain, tenderness (diffuse swelling but no tenderness, recent pain not reported and swelling of the finger joint. by the patient), also called Bcold dactylitis^ [16, 17]. In many The duration of dactylitis was based on the duration of clinical and US studies, the dactylitic fingers were not classi- diffuse digital swelling and/or pain as reported by the patients. fied as being tender or non-tender and therefore this variant Patients were divided into two groups according to the remains poorly understood. The absence of tenderness, de- dactylitis duration shorter or longer than the median duration spite obvious digital swelling, might have several potential of the sample. explanations including the specific anatomical locations of inflammation, the relative degree of inflammation and the persistence of subclinical inflammation. Ultrasound and Power Doppler examination We hypothesized that an anatomical compartmentalization of dactylitic related US abnormalities may explain patient US examination of the clinically affected finger was per- symptoms and may also in turn be linked to the durations of formed by a single rheumatologist (NG) trained and experi- disease. enced in musculoskeletal US (more than 4 years of experi- This cross-sectional study was designed to evaluate the US ence), blinded to the laboratory and clinical data (in particular abnormalities observed in tender versus non tender dactylitis about pain, tenderness and dactylitis duration), using a MyLab and to explore the association between sonographic features 70XVG machine equipped with a 6–18 MHz linear transducer and dactylitis duration. (Esaote S.p.A., Genoa, Italy). TheUSgrey-scale(GS)imaging parameters were optimised for maximal image resolution; Power Doppler Patients and methods (PD) settings were standardized at the following values: 500 Hz for pulse repetition frequency, 3 for wall filter, 4 for All PsA patients with dactylitis consecutively seen at the persistence and color gain between 45 and 55%. The window Rheumatology Research Unit of University BFederico II^ of of the color box was restricted to the areas studied. Naples between August 2016 and February 2018 entered the Measurements were conducted to the depth of 20 mm. study. Four patients were enrolled in two other Rheumatology Flexor and extensor tendons, MCP, PIP and DIP joints of Centers (Bologna and Reggio Emilia) and were examined in the affected fingers were assessed by GS and PD US evalua- Naples because they were living there. tion in longitudinal and transverse scanning views, in accor- The study was conducted in accordance with the dance with current guidelines and publications [18, 19]. Joints Declaration of Helsinki. Written informed consent was taken were examined from both dorsal and volar sides. A generous from all subjects and the study protocol was approved by the quantity of gel was used, and compression with the US probe local Ethics Committee. was avoided with the purpose of correctly evaluating vascu- Inclusion criteria were the following: (1) presence of finger larization. Each US examination took about 15 min in a dark- dactylitis, (2) dactylitis duration of more than 1 week, (3) ened room. fulfillment of CASPAR criteria and (4) age over 18 years. All US images were reassessed by a senior rheumatologist Exclusion criteria were the following: (1) current engagement (PM) with over 25 years of MSUS experience, to give a con- in heavy manual work, (2) recent history of hand trauma sensus result. (6 months), (3) concomitant treatment with biological or The following dactylitis-related sonographic lesions were targeted synthetic DMARDs and (4) previous peri-tendinous investigated: flexor tenosynovitis, flexor peri-tendinous PD or intra-articular corticosteroid injection in the involved finger. signal (PDS), peri-tendinous edema, subcutaneous PDS, ex- Before US examination, a clinical assessment was per- tensor tendon involvement (including paratenonitis and formed by clinicians (RS, RM, CS) with longstanding exper- enthesitis of extensor tendon at proximal-interphalangeal tise in the field of PsAwho recorded the presence of dactylitis, joint), joint synovitis and intra-articular PDS. swelling and tenderness of the involved finger. The diagnosis According to the Outcome Measures in Rheumatology of dactylitis was made by physical examination (diffuse swell- (OMERACT) definitions, tenosynovitis was defined in grey- ing of the digit, with or without tenderness) and was con- scale (GS) as an abnormal anechoic and/or hypoechoic tendon firmed using the Leeds Dactylitis Instrument (a 10% sheath widening [20]. Clin Rheumatol (2019) 38:903–911 905 Peri-tendinous oedema was defined as a diffuse Results hypo/isoechoic thickening of the extratendinous soft tis- sues around flexor tendon (pseudotenosynovitis)
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