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Ultrasonographic Evaluation of Lower Limb Enthesis in Patients with Early Spondyloarthropathies

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Ultrasonographic Evaluation of Lower Limb Enthesis in Patients with Early Spondyloarthropathies The Egyptian Rheumatologist (2013) 35,29–35 Egyptian Society for Joint Diseases and Arthritis The Egyptian Rheumatologist www.rheumatology.eg.net www.sciencedirect.com ORIGINAL ARTICLE Ultrasonographic evaluation of lower limb enthesis in patients with early spondyloarthropathies Yasser Ezzat a,*, Wafaa Gaber b, Sherif F. Abd EL-Rahman c, Marwa Ezzat d, Mohammad El Sayed e a Rheumatology Department, Fayoum University, Egypt b Rheumatology Department, Cairo University, Egypt c Radiology Department, Cairo University, Egypt d Dermatology Department, Cairo University, Egypt e Endemic medicine and Hepatogastroenterology department, Cairo University Received 2 June 2012; accepted 21 September 2012 Available online 8 November 2012 KEYWORDS Abstract Introduction: The enthesopathy of seronegative spondyloarthropathies (SpA) is the hall- Spondyloarthropathy; mark of these diseases, the ultrasound examination of these entheses confirms the frequency of their Ultrasonography; involvement. Enthesitis Aim of the work: To detect entheseal abnormalities with ultrasound (US) in the lower limb of patients with early spondyloarthropathy (SpA) and to evaluate US as a valuable tool in detecting early enthesis. Patients and methods: A total of 45 patients with early disease duration of 11.7 ± 8.5 months, including 10 patients with psoriatic arthritis (PsA), 10 patients with ankylosing spondylitis (AS), 10 patients with reactive arthritis (ReA), eight patients with ulcerative colitis (UC) and seven patients with Crohn’s disease and 20 healthy controls of matched age and sex underwent ultraso- nographic evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis. Ultrasono- graphic findings were scored according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS). Results: On US examination a total of 290/450 (64.4%) of the entheseal sites were abnormal. Mean GUESS score was significantly higher in patients with SpA as compared with controls * Corresponding author. E-mail address: [email protected] (Y. Ezzat). Peer review under responsibility of Egyptian Society for Joint Diseases and Arthritis. Production and hosting by Elsevier 1110-1164 Ó 2012 Egyptian Society for Joint Diseases and Arthritis. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ejr.2012.09.004 30 Y. Ezzat et al. (p < 0.001), with a higher mean value in patients with PsA, ReA and AS. The mean thickness of all tendons examined was significantly higher in SpA patients than in controls (p < 0.0001) as well as the mean number of enthesophytes and bursitis in all sites examined (p = 0.002, p = 0.003), with a higher prevalence amongst patients with PsA and ReA. The GUESS score was correlated to dura- tion of the disease and the anti-tumour necrosis factor alpha medications. Conclusion: Enthesis involvement occurs early in spondyloarthritis, the enthesis US score appears to be reliable and useful for improving the diagnostic accuracy of early SpA, further studies are needed as US is an evolving technique. Ó 2012 Egyptian Society for Joint Diseases and Arthritis. Production and hosting by Elsevier B.V. All rights reserved. 1. Introduction evaluation of the tendon and its insertional pathology [9,10] with a sensitivity comparable to MRI [11,12]. The seronegative spondyloarthropathies comprise a group of The first extensive description of entheseal involvement in related inflammatory arthritides, the principal clinical entities SpA patients by ultrasound was initially provided by Lehtinen of this group include ankylosing spondylitis (AS), psoriatic et al. [8] in 1994 followed by Balint et al. [6] in 2002 and arthritis (PsA), reactive arthritis (ReA), enteropathic spondyli- D’Agostino et al. [7] in 2003. Grey-scale enthesitis was mostly tis (inflammatory bowel disease). All of them demonstrate the characterised by the loss of normal fibrillar echogenicity of the absence of serum rheumatoid factor (seronegativity), associa- tendon insertion (83%) with or without an increase in tendon tion with the human leucocyte antigen B27 (HLA-B27), famil- thickness or by intralesional focal changes at the tendon inser- ial clustering, predominant axial and peripheral asymmetric tion, such as calcium deposits, fibrotic scars and periosteal joint involvement, and extra-articular manifestations [1]. changes (erosions or new bone formation). The anatomical Enthesis is defined as a site of insertion of tendons, liga- borders of the enthesis are of capital importance. Some ultra- ments, fascia, or articular capsule into bone. The involvement sound studies studied enthesitis in the concept of ‘enthesis or- of the entheses in any pathologic process, whether metabolic, gan’ leading sonographers to include the involvement of inflammatory, traumatic, or degenerative, is referred to as surrounding structures far from the bony attachment (i.e. ten- enthesopathy, while the term ‘‘enthesitis’’ is restricted to don and bursa) in the evaluation of enthesitis [13,14]. inflammation of the enthesis [2]. Our aim was to detect ultrasonographic entheseal abnor- The enthesopathy of seronegative spondyloarthropathy malities in the lower limb of patients with early spondyloarthr- (SpA) is an example of entheseal involvement in a systemic opathy and to evaluate US as an objective and reliable tool for process. Peripheral enthesitis has been repeatedly described diagnosis of early entheseal involvement. in all forms of SpA and all phases of disease evolution [2,3]. It has been suggested that the presence of fibrocartilage and 2. Patients and methods microtrauma are two major factors associated with disease localisation in SpA [4]. A hypothesis that mechanically in- Our study was performed on a total of 45 patients with a mean duced enthesopathy may trigger autoimmunity towards fibro- age of 34.3 ± 6.22 years, early disease duration of cartilage/bone in HLA B27 positive patients has been 11.7 ± 8.5 months and 20 healthy controls matched for age proposed on the basis of a strong correlation between the ex- and sex with a mean of 36.9 ± 5.7 years, the control group tent of bone pathology on MRI and the presence of HLA was without any known mechanical, inflammatory or muscu- B27, in patients with plantar fascia enthesopathy [5]. loskeletal disease. The patients included 10 with psoriatic Accordingly, the Achilles tendon and plantar fascia, which arthritis (PsA), 10 patients with ankylosing spondylitis (AS), are the most commonly implicated sites in SpA-associated 10 patients with reactive arthritis (ReA), eight patients with enthesitis, along with the spinal ligaments usually affected by ulcerative colitis (UC) and seven patients with Crohn’s disease. the disease, have a prominent fibrocartilage component [4]. All patients were diagnosed according to assessment in spond- Enthesitis may occur at any attachment site in SpA, but de- yloarthritis international society (ASAS) diagnostic criteria tected enthesitis is more frequently depicted in the entheses of [15]. the lower limbs, probably for mechanical reasons. All patients with PsA fulfilled the classification criteria for The ultrasound examination of these entheses confirms the psoriatic arthritis (CASPAR) [16]. Endoscopic and histopath- frequency of their involvement [6–8]. ologic diagnoses were performed in all patients with inflamma- Multiple imaging modalities are available to evaluate the tory bowel disease (UC and Crohn’s disease). BASDAI score seronegative spondyloarthropathies. These include conven- was done to all patients with AS. tional radiography, conventional tomography, computed Ophthalmological examination including fundus and slit tomography (CT), magnetic resonance imaging (MRI), scintig- lamp was done in all patients, in addition full laboratory and raphy, and ultrasonography (US). Ultrasound is very cost effi- X ray studies were performed to all patients that included a cient and does not convey radiation exposure that is inherent complete blood cell count, biochemistry, C-reactive protein, to CT or conventional radiography. Compared with clinical antinuclear antibodies, rheumatoid factor, HLA-B27 as well examination, ultrasound is superior in the detection of enthe- as radiographs of the pelvis, sacroiliacs, tendo achillis, cervical, seal abnormalities of the lower limbs in spondyloarthropathy dorsal and lumbar spine. Full musculoskeletal examination [6]. Previous studies reported the usefulness of US in the was done to the all study group and the controls. All subjects Ultrasonographic evaluation of lower limb enthesis in patients with early spondyloarthropathies 31 Table 1 Clinical laboratory and demographic characteristics of the studied groups of patients. Characteristics PsA AS ReA UC Crohn’s disease N =10 N =10 N =10 N =8 N =7 Demographic data Male, No. (%) 4 (40) 10 (100) 5 (50) 4 (33) 0 Female, No. (%) 7 (70) 0 0 8 (66) 7 (100) Age* 50.9 ± 13.3 30.2 ± 2.9 27.8 ± 6.4 31.8 ± 7.1 37.6 ± 4.8 Disease duration/month* 12.5 ± 5.1 8.5 ± 5.2 3.3 ± 1.2 3.2 ± 2 3.3 ± 1.9 Clinical manifestations Peripheral synovitis, No. (%) 5 (50) 4 (40) 7 (70) 2 (25) 2 (28.5) Clinical enthesitis, No. (%) 4 (40) 2 (20) 5 (50) 1 (12.5) 1 (14.2) Sacroilitis, No. (%) 4 (40) 8 (80) 4 (40) 1 (12.5) 2 (28) Nail dystrophy, No. (%) 8 (80) 0 (0) 0 (0) 0 (0) 0 (0) Spinal disease, No. (%) 3 (30) 10 (100) 3 (30) 1 (12.5) 2 (28) Slit lamp changes, No. (%) 2 (20) 5 (50) 2 (40) 0 (0) 0 (0) Laboratory manifestations ESR, mm/Hg* 43.8 ± 6.9 33.5 ± 13 27 ± 6.2 48.2 ± 17.7 52.9 ± 19.1 CRP, mg/L* 33.7 ± 33.2 13.57 ± 11.5 12.2 ± 6.7 4.8 ± 1.1 8.4 ± 3.3 Haemoglobin (g %)* 12.7 ± 0.6 12.2 ± 1.1 9.9 ± 2.8 10.7 ± 2.6 9.3 ± 1.3 WBCs (·103/mm3)* 7.8 ± 1.4 7.8 ± 0.8 6.71 ± 1.5 11 ± 3.7 7.4 ± 1.1 Platelets (·103/mm3)* 272.7 ± 36.9 244 ± 28 260 ± 13.7 335 ± 75 208 ± 54.6 AST (U/L)* 19 ± 6.2 11 ± 3.2 12 ± 3.3 18 ± 14 13 ± 2.7 ALT (U/L)* 17.5 ± 1.2 17.2 ± 4.3 16.3 ± 4.3 18.2 ± 7.7 15.5 ± 5.1 Creatinine (mg/dl)* 0.8 ± 0.2 0.6 ± 0.001 0.7 ± 0.1 0.8 ± 0.2 0.6 ± 0.2 HLA-B27 + VE, No.
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