Psoriatic Arthritis: the Role of Radiologic Assessment in Diagnosis and Management

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1 Psoriatic Arthritis: the Role of Radiologic Assessment in Diagnosis and Management Stephanie W. Hu, HMS IV BIDMC Department of Radiology August 25, 2008

2 Overview Patient AC Psoriatic arthritis (PsA( PsA) Epidemiology Pathogenesis Clinical and radiographic features Dx and DDx Role of imaging in PsA Patient AC Classic radiographic manifestations Other modalities Summary

3 Patient AC 24 year-old gentleman referred to BWH Center for Skin and Related Musculoskeletal Diseases >10-year h/o severe cutaneous psoriasis and 8-year 8 h/o arthritis Failed topical Rx, plaquenil,, and MTX; lost insurance at age 18 persisted on Tylenol and Ibuprofen for pain Now complains of flaring psoriasis, inability to bear weight on his L foot x 3 mos,, and inability to work due to involvement of L hand H/o anxiety and depression

4 Patient AC: Cutaneous Manifestations Courtesy of A. Qureshi, BWH Dermatology

5 Patient AC: Cutaneous Manifestations Courtesy of A. Qureshi, BWH Dermatology

6 Patient AC: Hands Courtesy of A. Qureshi, BWH Dermatology

7 Patient AC: Feet Courtesy of A. Qureshi, BWH Dermatology

8 PsA: : Epidemiology Psoriasis is estimated to affect at least 7 million people in the United States Between 5% and 42% of this group will develop PsA PsA significantly impacts health-related quality of life There is greater role limitations associated with PsA than RA due to emotional problems and more bodily pain PsA is a lifelong condition and carries ~60% higher risk of mortality relative to the general population, correlated w/ radiologic damage at presentation The course of PsA is unpredictable, with periods of relapse and remission

9 PsA: : Pathogenesis Genetic factors: susceptibility genes, HLA- B27 and others (-B17,( -Cw6, -DR4, -DR7) Environmental factors: viral (HIV) and bacterial infections implicated as triggers Immunologic factors: Deposition of immune complexes Agents that inhibit T-cell T function or proliferation improve PsA Clonal and oligoclonal expansions of both CD8+ and CD4+ T cells in skin and synovium Elevated levels of TNF in serum and synovial fluid cytokines induce activation and proliferation of keratinocytes and synovial fibroblasts (Mease and Goffe, 2005)

10 PsA: : Clinical Features PsA belongs to the seronegative spondyloarthropathies, which share characteristics: Asymmetric peripheral arthritis Axial involvement (esp. sacroiliitis) The usual absence of RF Unique radiologic features A greater degree of involvement of males Moll and Wright s Distinctive HLA patterns Classification of PsA In addition, PsA also demonstrates: 1. DIP joint predominant Enthesitis 2. Arthritis mutilans 3. Polyarticular symmetrical Dactylitis (up to 30% of pts) sausage (RA-like) digits 4. Oligoarticular asymmetrical Joint deformities, subluxations 5. Spondylitis and sacroiliitis Psoriatic skin lesions

11 PsA: : Radiographic Features Osteolysis (bony erosion) Esp. paramarginal erosions Pencil-in-cup deformity Loss of joint space Enthesitis Asymmetric sacroiliitis Ankylosis Joint subluxation Periostitis Spur formation, whiskering Plain film of pelvis, AP view: asymmetric sacroiliitis (Jacobson et al., 2008) Plain film of R foot, lateral view ** Radiographs are the study of choice for Dx of PsA due to cost-effective detection of bony changes (erosions and proliferation)** spur PACS, BIDMC

12 Let s s Review Synovial Joint Anatomy! Diagram of normal and inflamed synovial joint: Plain film of IP joint in finger, AP view: f = joint fluid, c = articular cartilage (Jacobson et al, 2008) Marginal erosions (arrows) are seen where subchondral bone plate is exposed to intraarticular synovitis.

13 Patient AC: Plain Film of Hands Centricity, BWH Frontal views: joint space narrowing; subluxation, pencil-in-cup deformities, erosions

14 Patient AC: Plain Film of Feet Centricity, BWH Frontal views: pencil-in-cup deformities

15 PsA: : Diagnosis and Differential Diagnosis Signs and Sx PsA RA OA (Adapted from Mease and Goffe, 2005) AS Peripheral dz Asymmetric Symmetric Varies DIP involvement + +, Heberden nodes Sacroiliitis Asymmetric Symmetric Stiffness Peripheral joints, some spine, morning Morning With activity Significant spine Enthesitis + +

16 PsA RA OA AS Radiographic changes Erosions, synovitis, periarticular osteopenia Osteophytes, subchondral sclerosis and cysts Erosions, paramarginal, absence of osteopenia, pencil-in in-cup, asymmetric syndesmophytes Squaring of vertebral bodies, symmetric syndesmophytes,, spinal osteopenia Gender bias 1:1, male to female 3:1, female to male Hand and toe OA more frequent in females 3:1, male to female RF + HLA asso. B27, Cw6 DR4 B27 Extraarticular manifestations Onychodystro- phy, iritis,, PSO Nodules, vascu- litis,, renal dz

17 Classic Radiographic Features of PsA: : Spine Companion patient #1: Companion patient #2: Ankylosis Compare with a non-pathological C-spine: Asymmetric, syndesmophytes Plain film of thoracolumbar spine, AP view Plain film of cervical spine, lateral view BrighamRAD PACS, BIDMC

18 Classic Radiographic Features of PsA: : Pelvis Companion patient #3: Asymmetric Syndesmophyte Companion patient #4: Sacroiliitis Plain film of pelvis, AP view Plain film of pelvis, AP view PACS, BIDMC Whiskering

19 Patient AC: Treatment AC was started on etanercept (Enbrel) 50 mg SC twice per week Sx improved in just 2 months: : began to regain motion of some of his L fingers and toes, able to make a fist with L hand, and almost completely able to bear weight on his L foot His skin is completely clear except for 2 dime-sized spots on the back of the R leg F/u plain films reveal no radiographic progression of joint dz His CRP (60) and ESR (52.2) are now WNL Started etanercept Working fulltime, could walk around mall Shoveled snow! Could run up steps to house, got 2 nd job as crossing guard Months

20 PsA: : Role of Plain Films in Clinical Trials Modified Sharp Scoring Method: assessment of baseline and posttreatment disease severity Etanercept: showed inhibition of radiographic disease progression compared to placebo at 1 year FDA approval for PsA in 2002 (Mease and Goffe, 2005)

21 PsA: : Role of Ultrasound and Magnetic Resonance Imaging U/S is not as validated for PsA as it is for RA Useful for enthesitis,, joint effusions, synovial proliferation, and erosions Doppler U/S can help detect hyperemia as an indirect sign of inflammation and differentiate acute synovial proliferation from effusion U/S and MRI are more sensitive to inflammatory and destructive changes than radiographs and clinical exam MRI can detect inflammation and bone destruction in joints earlier than projection radiography in PsA MRI has also revealed evidence of subclinical arthritis in a large proportion of pts with psoriasis alone PsA could be much more common than previously suspected

22 PsA: Role of Ultrasound Companion patient #5: Ultrasound with color Doppler of MCP joint, dorsal longitudinal view Inflammation Synovial proliferation (Kleinert, Feuchtenberger, Kneitz, Tony, 2007)

23 PsA: Role of Magnetic Resonance Imaging A) Short tau inversion recovery (STIR) B) T1-weighted pre-contrast C) T1-weighted post-contrast sagittal view sagittal view sagittal view Companion patient #6: enthesitis, synovitis, bony erosions in ankle region (McQueen, Lassere, Ostergaard, 2006)

24 Summary PsA has been defined as a unique, progressive, and often destructive form of seronegative inflammatory arthritis associated with psoriasis Radiologic imaging plays a key role in the diagnosis and management of PsA pts U/S and MRI may be increasingly utilized as sensitive tools for assessment of disease progression and in clinical trials

25 Acknowledgements Dr. Abrar A. Qureshi Brigham and Women s s Hospital, Dermatology Dr. Jim S. Wu Beth Israel Deaconess Medical Center, Radiology Dr. Ferris Hall Beth Israel Deaconess Medical Center, Radiology Dr. Gillian Lieberman Beth Israel Deaconess Medical Center, Radiology Maria Levantakis Beth Israel Deaconess Medical Center, Radiology

26 References 1. Mease P, Goffe BS. Diagnosis and treatment of psoriatic arthritis. J Am Acad Dermatol 2005; 52: Gladman DD< Antoni C, Mease P, Clegg DO, Nash P. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis 2005; 64 (Suppl II): ii14-ii17. ii Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Ann Rheum Dis 2005; 64 (Suppl( II): ii3-ii8. ii8. 4. Jacobson JA, Girish G, Jian Y, Resnick D. Radiographic evaluation of arthritis: inflammatory conditions. Radiology 2008; 248: Kleinert S, Feuchtenberger M, Kneitz C, Tony HP. Psoriatic arthritis: clinical spectrum and diagnostic procedures. Clin Dermatol 2007; 25: Wiell C, Szkudlarek M, Hasselquist M, Moller JM, Vestergaard A, Norregaard J, Terslev L, Ostergaard M. Ultrasonography,, magnetic resonance imaging, radiography, and clinical assessment of inflammatory and destructive tive changes in fingers and toes of patients with psoriatic arthritis. Arth Res Ther 2007; 9: McQueen F, Lassere M, Ostergaard M. Magnetic resonance imaging in psoriatic arthritis: a review of the literature. Arth Res and Ther 2006; 8: Weiner SM, Jurenz S, Uhl M, Lange-Nolde A, Warnatz K, Peter HH, Walker UA. Ultrasonography in the assessment of peripheral joint involvement in psoriatic arthritis. Clin Rheumatol 2008; 27:

27 Thank you!

Psoriatic Arthritis. Ewa Olech, MD Division of Rheumatology University of Nevada School of Medicine Las Vegas

Psoriatic Arthritis. Ewa Olech, MD Division of Rheumatology University of Nevada School of Medicine Las Vegas Psoriatic Arthritis Ewa Olech, MD Division of Rheumatology University of Nevada School of Medicine Las Vegas The Spectrum of Spondyloarthritis Characteristics of the Spondyloarthritis Sacroiliac & spinal