Psoriatic arthritis: clinical and ultrasound parallels

Objective: to assess the relationship of the clinical characteristics and laboratory inflammatory markers to the ultrasound signs of synovitis and enthesitis in patients with psoriatic arthritis (PsA).

Patients and methods. Examinations were made in 63 patients diagnosed with PsA according to the 2006 Classification Criteria for Psoriatic Arthritis (CASPAR) criteria. Among the patients, the majority were females (54.2%); the mean age was 42.9±10.3 years; the median (Me) PsA duration was 7 [3; 10] years; Me Disease Activity in Psoriatic Arthritis (DAPSA) was 16.5 [11.6; 25] years.
All the patients underwent estimation of tender joint count, swollen joint count, tender entheseal count, inter alia using the Leeds Enthesitis Index (LEI), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), and Spondyloarthritis Research Consortium of Canada (SPARCC). The investigators determined PsA activity by DAPSA and the prevalence and severity of psoriasis by the Psoriasis Area and Severity Index (PASI) and also estimated erythrocyte sedimentation rate (ESR) and high-sensitivity CRP (hs-CRP) levels. Ultrasonography was used to assess bilateral upper and lower limb joints, by calculating joint counts (JC) with synovitis signs (SJC), as well as tendon and ligament entheses (a total number of 54 in one patient), by determining the presence of vascularized enthesis count (VEC) and structurally changed enthesis count (SCEC) and using the ultrasound indices (Glasgow Ultrasound Enthesitis Scoring System (GUESS), Belgrade Ultrasound Enthesitis Score (BUSES), Madrid Sonography Enthesitis Index (MASEI), Sonographic Enthesitis Index (SEI)).

Results and discussion. There were no significant differences in the frequency of damage to the upper (15.7%) and lower (19.3%) limb joints (p>0.05), whereas inflammation in the entheses of the lower limbs (23.2%) was significantly more common than that in the upper limbs (15.3%) (p<0.01). A weak relationship was established between SPARCC and SEI (r=0.276; p<0.05). A positive correlation was found between VEC and hs-CRP levels (r=0.323, p=0.01), ESR (r=0.332, p<0.01). Ultrasound imaging showed that SJC (p<0.01), enthesitis count (p<0.01), and SCEC (p<0.05) increased with age. The relationship between SCEC and GUESS (r=0.724; p<0.01) and that between the VEC and BUSES (r=0.562, p<0.01) proved to be more pronounced.

Conclusion. Ultrasound imaging indicates that the entheses of the lower limbs are more frequently affected in patients with PsA. There is no relationship between DAPSA and ultrasound inflammatory changes in the joints and extra-articular structures. A strong relationship is established between enthesiseal structural and inflammatory changes and GUESS and BUSES, respectively, which allows one to recommend the use of these indices for assessing enthesitis in PsA. Entheseal vascularization associated with inflammatory markers (hs-CRP, ESR) (p<0.05) is a manifestation of PsA activity regardless of age and DAPSA.

1. Korotaeva TV, Korsakova YuL, Loginova EYu, et al. Psoriatic arthritis. Clinical guidelines for diagnosis and treatment. Sovremennaya revmatologiya = Modern Rheumatology Journal. 2018;12(2):22-35. (In Russ.). doi: 10/14412/1996-7012-2018-2-22-35.

2. Gladman DD. Clinical features and diagnostic considerations in psoriatic arthritis. Rheum Dis Clin North Am. 2015 Nov;41(4): 569-79. doi: 10.1016/j.rdc.2015.07.003. Epub 2015 Sep 5.

3. Haddad A, Johnson SR, Somaily M, et al. Psoriatic arthritis mutilans: clinical and radiographic criteria. A systematic review. J Rheumatol. 2015 Aug;42(8):1432-8. doi: 10.3899/jrheum.141545. Epub 2015 Jun 15.

4. Ritchlin CT, Colbert RA, Gladman DD. Psoriatic arthritis. N Engl J Med. 2017 Mar 9; 376(10):957-70. doi: 10.1056/NEJMra1505557.

5. Koolaee RM, Takeshita J, Ogdie A. Epydemiology and natural history of psoriatic arthritis: an update. Curr Derm Rep. 2013;(2): 66-76. doi: 10.1007/s13671-012-0032-8.

6. Polachek A, Chandran V, Gladman DD, et al. Clinical Enthesitis in a Prospective Longitudinal Psoriatic Arthritis Cohort: Incidence, Prevalence, Characteristics, and Outcome. Arthritis Care Res (Hoboken). 2017 Nov;69(11):1685-91. doi: 10.1002/acr.23174. Epub 2017 Sep 21.

7. Zabotti, P. Mandl, G. Zampogna, et al. One year in review 2018: ultrasonography in rheumatoid arthritis and psoriatic arthritis. Clin Exp Rheumatol. Jul-Aug 2018;36(4): 519-25. Epub 2018 Jul 19.

8. Perrotta FM, Astorri D, Zappia M, et al. An ultrasonographic study of enthesis in early psoriatic arthritis patients naive to traditional and biologic DMARDs treatment. Rheumatol Int. 2016 Nov;36(11):1579-83. doi: 10.1007/s00296-016-3562-8. Epub 2016 Sep 6.

9. Mease PJ. Measures of psoriatic arthritis: Tender and Swollen Joint Assessment, Psoriasis Area and Severity Index (PASI), Nail Psoriasis Severity Index (NAPSI), Modified Nail Psoriasis Severity Index (mNAPSI), Mander/Newcastle Enthesitis Index (MEI), Leeds Enthesitis Index (LEI), Spondyloarthritis Research Consortium of Canada (SPARCC), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), Leeds Dactylitis Index (LDI), Patient Global for Psoriatic Arthritis, Dermatology Life Quality Index (DLQI), Psoriatic Arthritis Quality of Life (PsAQOL), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Psoriatic Arthritis Response Criteria (PsARC), Psoriatic Arthritis Joint Activity Index (PsAJAI), Disease Activity in Psoriatic Arthritis (DAPSA), and Composite Psoriatic Disease Activity Index (CPDAI). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11: S64-85. doi: 10.1002/acr.20577.

10. Balint PV, Terslev L, Aegerter P, et al. Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: an OMERACT US initiative. Ann Rheum Dis. 2018 Dec;77(12):1730-35. doi: 10.1136/annrheumdis-2018-213609. Epub 2018 Aug 3.

11. Balint PV, Kane D, Wilson H, et al. Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis. 2002 Oct;61(10):905-10. doi: 10.1136/ard.61.10.905.

12. Milutinovic S, Radunovic G, Veljkovic K, et al. Construct validity and sensitivity to change of Belgrade Ultrasound Enthesitis Score in patients with spondyloarthritis: a pilot study. Rheumatol Int. 2018 Mar;38(3): 383-91. doi: 10.1007/s00296-017-3898-8. Epub 2017 Dec 13.

13. Eder L, Jayakar J, Thavaneswaran A, et al. Is the Madrid Sonographic Enthesitis Index useful for differentiating psoriatic arthritis from psoriasis alone and healthy controls? J Rheumatol. 2014 Mar;41(3):466-72. doi: 10.3899/jrheum.130949. Epub 2014 Feb 1.

14. Alcalde M, Acebes, JC, Cruz M, et al. A Sonographic Enthesitic Index of lower limbs is a valuable tool in the assessment of ankylosing spondylitis. Ann Rheum Dis. 2007 Aug;66(8):1015-9. doi: 10.1136/ard.2006. 062174. Epub 2006 Dec 7.

15. Puksic S, Bolton-King P, Sexton J, et al. DAPSA and ultrasound show different perspectives of psoriatic arthritis disease activity: results from a 12-month longitudinal observational study in patients starting treatment with biological disease-modifying antirheumatic drugs. RMD Open. 2018 Nov 5; 4(2):e000765. doi: 10.1136/rmdopen-2018000765. eCollection 2018.

16. Ibrahim G, Groves C, Chandramohan M, et al. Clinical and Ultrasound Examination of the Leeds Enthesitis Index in Psoriatic Arthritis and Rheumatoid Arthritis. ISRN Rheumatol. 2011;2011:731917. doi: 10.5402/2011/731917. Epub 2011 May 4.

17. Van der Ven M, Karreman MC, Weel Aeam, et al. Adding ultrasound to clinical examination reduced frequency of enthesitis in primary care psoriasis patients with musculoskeletal complaints. Clin Exp Rheumatol. Nov-Dec 2016;34(6):1020-25. Epub 2016 Sep 8.

18. Florescu A, Vere CC, Florescu LM, et al. Clinical and Ultrasound Assessment of Enthesis in Psoriatic Arthritis in a Romanian Cohort. Curr Health Sci J. Oct-Dec 2018;44(4): 347-51. doi: 10.12865/CHSJ.44.04.04. Epub 2018 Dec 31.