Arzu Kaya

Assessment of enthesitis in ankylosing spondylitis by power Doppler ultrasonography

ObjectiveTo evaluate the relationship between power Doppler ultrasonography (PDUS) assessment and clinical variables including enthesitis index, pain threshold and disease activity parameters, and to document grey-scale US findings of the 13 entheses examined.Design and patientsA total of 390 entheses were examined in thirty patients with AS, and clinical variables of the Maastricht Ankylosing Spondylitis Enthesitis Index (MASES), anthropometric measurements, disease activity and functional parameters were documented. A total MASES score by palpation (t-PS) and algometric pressure pain threshold (t-PPT) was obtained. Grey scale and PDUS examination of 13 entheses were performed. Grey-scale changes such as altered tendon echogenity, calcification, cortical reactive changes and bursitis were noted, and flow on PDUS was graded semi-quantitatively.ResultsCumulative power Doppler (t-PDS) score significantly correlated with t-PS and t-PPT. Ultimate correlations were found between power Doppler scores and pain, disease activity and disability parameters. Changes in grey scale combined with PDUS were more prevalent in lower-extremity entheses. The intraobserver agreement of flow signal grading was excellent (kappa=0.82). Clinical and sonographic results were concordant for three regions, but were discordant for four regions where tenderness was accepted as the sole clinical manifestation of enthesis.ConclusionPain or tenderness is associated with increased vascularity of entheses. Power Doppler US examination of the entheses may be useful and complementary to the clinical evaluation, and further research is needed to assess its role in diagnosis and follow-up of disease course.

Familial Mediterranean fever responds well to infliximab: single case experience

The most common arthritic involvement in familial Mediterranean fever (FMF) is acute recurrent monoarthritis; however, sometimes spondyloarthropathy-like findings or typical ankylosing spondylitis may also ensue. Reported here is our favorable experience with infliximab in an FMF patient who had been resistant to colchicine and disease-modifying antirheumatic drugs (sulfasalazine and methotrexate) treatments. A 72-week follow-up of the patient yielded complete remission of the febrile abdominal episodes, and spondylitis responded well. The patient’s bilateral aseptic necrosis of the femoral head deteriorated and caused hip pain, discomfort, and disability. Overall, we believe that tumor necrosis factor (TNF) alpha has an important role in the disease pathogenesis and also that anti-TNF may represent a promising robust treatment alternative in FMF.

Pattern of Disease Onset, Diagnostic Delay, and Clinical Features in Juvenile Onset and Adult Onset Ankylosing Spondylitis

Objective. To assess the frequency of juvenile onset ankylosing spondylitis (JOAS) in Turkish patients with AS and to compare with adult onset AS (AOAS) in a cross-sectional study design. Methods. A total of 322 patients were recruited from the joint database of 5 university hospitals in eastern Turkey. Results. Patients with JOAS (n = 43, 13.4%) had significantly longer diagnostic delay (9.21 vs 5.08 yrs), less severe axial involvement and more prevalent uveitis (OR 2.92, 95% CI 1.25–6.79), and peripheral involvement at onset (OR 3.25, 95% CI 1.51–6.98, adjusted for current age; and OR 2.26, 95% CI 1.07–4.76, adjusted for disease duration). Patients with AOAS had higher radiographic scores and more restricted clinimetrics but similar functional limitations and quality of life. Conclusion. JOAS and AOAS had distinctive courses and Turkish patients with AS had similar features compared to other Caucasian patient populations.

Discrimination ability of ASDAS estimating disease activity status in patients with ankylosing spondylitis.

Objectives:  To investigate discrimination ability of the Assessment of Spondyloarthritis International Society (ASAS) endorsed disease activity score (ASDAS) versions evaluating low and high disease activity in an unselected group of patients with ankylosing spondylitis (AS).

Bone Loss in Ankylosing Spondylitis: Does Syndesmophyte Formation Have an Influence on Bone Density Changes?

Objective: The aim of this study was to assess bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) in a group of patients with ankylosing spondylitis (AS) and the factors which have an impact on bone mass. Also, a subgroup of patients not treated with anti-osteoporotic or disease-modifying anti-rheumatic drugs was followed for 24 months to assess potential influencing factors on BMD changes. Subjects and Methods: Fifty-five patients (42 males, 13 females) with AS were enrolled in the study. Clinical examinations were performed. BMD was measured using DXA at lumbar spine (L2–L4) and proximal femur (femur neck BMD and total femur BMD). Lumbar spine radiographs were scored using the Stoke Ankylosing Spondylitis Spine Score (SASSS). Twenty-one of 55 patients who completed 24 months of follow-up without using the aforementioned medications were reassessed. Results: Active patients (Bath Ankylosing Spondylitis Disease Activity Index >4, n = 22) had significantly lower femur neck and total BMD compared to inactive patients (n = 33), whereas spinal BMD was not different. Follow-up data revealed a 3.4% increase in spinal BMD but 0.9% and 0.25% decreases in femur neck BMD and total femur BMD, respectively. Percent changes in BMD measurements and SASSS scores were not significantly different between active (n = 10) and inactive (n = 11) patients. Conclusion: Significant increase in spinal BMD in parallel with increased SASSS revealed that spinal involvement prominent with new bone formation, sclerosis and syndesmophytes may influence spinal BMD measurements using DXA methods in AS. Proximal femur measurements seem to be less affected from disease-related new bone formation.

Glucocorticoid iontophoresis for Achilles tendon enthesitis in ankylosing spondylitis: significant response documented by power Doppler ultrasound

Enthesitis is a characteristic feature of ankylosing spondylitis (AS) and related spondyloarthropathies [1, 2]. Treatment of refractory heel pain caused by Achilles enthesopathy, plantar fasciitis, or retrocalcaneal bursitis is one of the most challenging issues in AS or related spondyloarthropathies [3]. Heel pain in young patients with AS may cause severe disability and discontinuation of their jobs, and this therapy-resistant condition carries a socioeconomic burden [2, 4, 5]. Recurrent local steroid injections to the sites of enthesitis, particularly the Achilles tendon insertion, have potential risks such as rupture of the tendon or subcutaneous atrophy. Achilles tendon has a superficial bone-tendon attachment and thin surrounding subcutaneous tissue which make steroid injections much more complicated and challenging but iontophoresis much more feasible. Iontophoresis is a method of introducing topically applied, physiologically active ions through the body surface using continuous direct current of low amperage, and it has become a popular alternative to injected or oral corticosteroids. Iontophoresis is atraumatic, painless, and noninvasive, and several clinical studies have reported pain relief after its administration in patients with soft-tissue inflammatory conditions [6, 7]. A 21-year-old man with therapy-resistant AS for 4 years presented with persistent bilateral heel pain for nearly 4 years. His prior history of treatment consisted of NSAIDs, methotrexate, azathioprine, multiple intraarticular and local injections to the enthesitis sites, and synovectomy of the right knee for recurrent synovitis. He had a high discontinuation rate at school because of disabling disease. There were bilateral tenderness and swelling at the Achilles tendon insertion. Pain levels on a 100-mm visual analog scale were 82 mm for his right heel and 80 mm for the left. He had C-reactive protein of 23 mg/l and erythrocyte sedimentation rate of 65 mm/h. Power Doppler ultrasonography (USG) was performed with Aplio SSA 770A high-resolution equipment (Toshiba, Tokyo, Japan) using a 7–13 MHz multifrequency linear array transducer. The settings were: pulse repetition frequency of 0.3–1.5 kHz, dynamic range of 55 dB, and a low wall filter. Regional blood flow was visualized by power Doppler USG at a gain level without background noise, and vessels with maximal color activity were selected for pulsed wave spectral Doppler imaging in which pulsatility index (PI) and resistive index (RI) were measured. The USG was performed on both Achilles tendons and calcaneal enthesitis at baseline and the end of treatment. Iontophoresis with 8% triamcinolone acetonide was performed using constant current (+ polar at 6 mA) to the right Achilles insertion and continuous constant current (6 mA) with saline was performed to the left side 20 min daily for 7 days. At the end of a 1-week course of treatment, the patient’s visual analog scale showed 14 mm for right heel pain and 55 mm for left heel pain. The C-reactive protein was 18 mg/l, and erythrocyte sedimentation rate was 56 mm/h. Ultrasonography showed disappearance of vascularity of periosteum and Achilles insertion on the right side and unchanged vascularity on the left (Fig. 1A–D). To the best of our knowledge, this case study is the first in the literature documenting the effect of steroid S. Ozgocmen Æ O. Ardicoglu Æ A. Kaya Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Firat University, Elazig, Turkey

Evaluation of a quantitative scoring of enthesitis in ankylosing spondylitis.

Background:Enthesitis is inflammation at the insertion of ligaments, tendons, joint capsule, or fascia to bone, and a well-known characteristic feature of ankylosing spondylitis (AS) and related spondyloarthropathies. The clinical evaluation of enthesitis is an important outcome measure and is scored by applying pressure on entheses to elicit tenderness at these sites. Objective:This study assessed the validity of an enthesitis index calculated by algometric pressure pain threshold scoring in comparison with digital palpation scoring and intra- and interexaminer reliability of 2 grading methods of the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES). Patients and Methods:Five hundred forty six entheses were examined in AS patients. Examination was performed on enthesopathy regions proposed by MASES. All of these entheses were examined by firm palpation with the thumb, and tenderness was graded on a 4-point scale. The summed tenderness scores were expressed as total palpation pain score (t-PS). After this procedure, the same entheses were rescored by using a mechanical algometer, and the sum was expressed as total pressure pain threshold (t-PPT). Fifteen indicators of functional, disease-activity, and anthropometric measures were used including global assessment of disease activity on a 0 to 100 mm visual analogue scale (global), Bath Ankylosing Spondylitis Disease Activity Index, Health Assessment Questionnaire–SpA, Dougados Functional and Articular Index, Bath Ankylosing Spondylitis Functional Index, ESR, CRP, occiput-to-wall distance, finger-to-floor distance, finger-to-fibula distance, chest expansion, and duration of morning stiffness in minutes. Results:There was a significant correlation between clinical variables and t-PS and t-PPT, which was better for t-PS. Intraexaminer reliability was moderate to excellent for digital palpation scoring (intraclass correlation coefficients 0.55–0.96) and algometric scoring (0.54–0.96). Interexaminer reliability was fair to excellent for digital palpation scoring (0.43–0.84) and moderate to excellent (0.52–0.88) for algometric scoring. Conclusion:Our results indicate that algometric evaluation of entheses does not add extra information to clinical relevance of MASES, and grading with digital palpation is a more convenient, practical, and reliable examination method for the assessment of enthesitis.

Topical lidocaine helps reduce pain of digital ulcers in systemic sclerosis (scleroderma)

Sir, Digital ulcerations are prominent features of systemic sclerosis (SSc; scleroderma) and can occur for various reasons. Ulcerations can be very painful, thereby limiting functions, and healing with scarring and/or digital resorption and when infected can lead to serious soft tissue infections and osteomyelitis. Ulcerations reportedly occur in approximately one third of patients with SSc per year, and the etiology appears to be multifactorial. Ischemia, vasculitis, and traumas are the most commonly encountered causes for digital ulcers [1, 2]. Herein, we report a single case of a scleroderma patient whose pain of digital ulcers could be successfully managed by an application of topical lidocaine. A 47-year-old woman with a 10-year history of SSc (limited SSc) presented with very painful digital ulcers on her hands and feet. She complained of Raynaud’s phenomenon on her upper limps. The initiation of these ulcers was simultaneous with minor traumas while doing housework. She complained of sharp pain on her fingers and of knife-wound sensation over the lesions on the dorsum of the hand and foot fingers, soles, and heels. She had a history of depression, hypertension, and osteoporosis. On physical examination, she had a typical ‘sclerotic bound-down’ appearance, telangiectasia in her hands, forearms, feet, and peri-malleolar regions, and furrowing of the perioral skin. She had also Raynaud’s phenomenon, esophageal dysfunction resulting in gastroesophageal reflux, shortness of breath, and contractures of the proximal interphalangeal (PIP) joints. She had a drug history of penicillamine, pentoxifylline, glucocorticoids, calcium channel blockers, serotonin re-uptake inhibitors, angiotensin converting enzyme inhibitors, and antibiotics. She had painful ulcers of various sizes on her fingertips and 0.5×0.5 cm of cutaneous ulcer on the right second PIP joint with a thick eschar, which had developed cellulites. Superficial cutaneous ulcers were present on bilateral heels and were very painful and tender on palpation. There were fissures and cracks on some of these lesions. The patient was instructed to take ciproflaxacin orally twice daily and an antibiotic pomade (Fucidate sodium 5%, twice daily). However, the patient complained of increased sharp and unbearable pain during the application of the antibiotic pomade. Therefore, lidocaine (5%) pomade was applied to the lesions to reduce the pain and discomfort during the application. The sharp and disturbing pain experienced by the patient resolved within 5 to 10 min after lidocaine application, and the antibiotic pomade applied thereafter was well tolerated. The patient was highly satisfied with the dramatic improvement in her pain and asked that lidocaine pomade be used not only prior to the antibiotic pomade but also every 6 or 8 h. Lidocaine pomade was administered three times a day. After 10 days, erythema surrounding the ulcers on the PIP joint and pain were significantly reduced. The patient’s need of lidocaine almost entirely disappeared. Oral and topical antibiotic application was maintained for 15 days and was stopped. The patient was instructed to use protective gloves during housework and to keep her hands and feet from minor or major traumas. Digital ulcers are clinical problems in SSc that are difficult to resolve. Although various alternatives like direct vasodilators, hemorheologic agents, and endothelin receptor antagonist (bosentan) have been reported to be S. Ozgocmen . A. Kaya Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Firat University, Elazig, Turkey

Psychological status is associated with health related quality of life in patients with rheumatoid arthritis

Objective: Rheumatoid arthritis (RA) is a chronic and disabling disease frequently effects physical and psychological well being. The aim of the present study was to determine the impact of psychological status on health related quality of l ife in patients with RA and also to assess which quality of life (QoL) instrument - disease specific and generic - is more prone to t his effect. Methods: A total of 421 patients with RA recruited from joint database of five tertiary centers. Depression and anxiety risks were assessed by the Hospital Anxiety and Depression Scale (HADS); and quality of life assessed by Rheumatoid Arthritis Quality of Life (RAQoL), Nottingham Health Profile (NHP) and The Short Form 36 (SF 36) questionnaire. Results: Patients with higher risk for depression or anxiety had poorer quality of life compared to the patients without risk for depression or anxiety. Depression and anxiety scores significantly correlated with quality of life questionnaires. Th ere was significant association between anxiety and depression wit h worsening in both disease specific and generic health relat ed quality of life. However, RAQoL showed more association with depression and anxiety levels. Conclusion: Higher depression and anxiety risks showed increased deterioration in quality of life. Compared to generic QoL scales, RAQoL scale, a disease specific QoL instrument, is mu ch more influenced by depression and anxiety.

Rupture of Baker's Cyst Producing Pseudothrombophlebitis in a Patient with Reiter's Syndrome

This is an unusual case of pseudothrombophlebitis resulting from rupture of Bakers cyst in a patient with Reiters syndrome. The patient presented with a swollen, painful left calf and persistent itching on the skin of the calf. Ultrasonography showed a ruptured popliteal cyst with minimal hemorrhage and fluid collection within the fascial compartments and gastrocnemius muscle. Color Doppler ultrasound showed a patent popliteal vein and artery and duplex Doppler scans revealed a normal flow pattern. In conclusion, the clinical picture of deep vein thrombosis and that of pseudothrombophlebitis are difficult to distinguish by clinical examination and necessitate detailed examination by imaging techniques. Persistent pruritus on calf skin resulting from irritation of inflammatory synovial fluid may be an important clinical feature.