K. Mizushina

Global assessments of disease activity are age-dependent determinant factors of clinical remission in rheumatoid arthritis

OBJECTIVE The aim of the study is to assess the factors associated with clinical remission of patients with rheumatoid arthritis (RA) in daily clinical practice. METHODS This analysis was based on the data of 304 RA patients in our center between May 2014 and March 2015. The following information was included: tender, swollen, and symptomatic joint counts, patients and physicians global assessments, functional disability, laboratory and radiographic data, and RA treatments received. RESULTS The patients were predominantly female (77.6%), with a median age of 71 years and a median disease duration of 5.8 years. Clinical remission rate, determined using the simplified disease activity index (SDAI), was 49.7%. Patients and physicians global assessments (/10cm) showed a higher score among patients who did not achieve SDAI remission than among those who did (median: 3.2 versus 0.3, p < 0.0001; and median: 1.8 versus 0.3, p < 0.0001, respectively). The contribution of serum C-reactive protein values (mg/dL) to SDAI was limited (median: 0.19 versus 0.06; p < 0.0001), as well as tender or swollen joint counts (median = 0 or 1). On multivariate analysis of factors not directly related to the disease activity, age was an independent risk factor for non-remission, and global assessment scores by patients and physicians showed an age-dependent increase, while counts of tender, swollen and symptomatic joints were comparable among elderly and non-elderly patients. CONCLUSION Global assessment of disease activity was age-dependent and independent of joint counts, and it provides a critical determinant of clinical non-remission.

Comparison of ultrasonographic joint and tendon findings in hands between early, treatment-naïve patients with systemic lupus erythematosus and rheumatoid arthritis:

Although both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) may lead to joint deformity, SLE arthritis is typically non-erosive and often accompanied by Jaccoud’s deformity. Therefore, we examined characteristics of joint and tendon lesions in patients with SLE and RA by ultrasonography. Fifteen treatment-naïve SLE patients and 40 treatment-naïve RA patients with joint symptoms were included in this study. The hand joints and related tendons were ultrasonographically examined using grey-scale (GS) and power Doppler (PD). Joint involvement was comparably observed in patients with SLE and RA (80% versus 95%, p = 0.119). However, tendon involvement was more frequent in SLE than in RA (93% versus 65%, p = 0.045), especially in the wrist joints (73% versus 40%, p = 0.037). When we investigated the intensity of US findings, the joint synovitis score (GS + PD) per affected joint was lower in SLE than RA (2.0 versus 2.6, p = 0.019), while tendon inflammation score was not significantly different (2.1 versus 2.2, p = 0.738). Finally, the examination of concordance between joint and tendon involvement in the same finger revealed that joint lesion appeared in only 49% of fingers having tendon involvement in the SLE group, which was significantly less than 74% in the RA group (p = 0.010). Thus, as compared with RA, SLE arthropathy is characterized by the predominance of tenosynovitis/periextensor tendon inflammation, which is likely to develop independently from joint synovitis.

Concordance between patient-reported joint symptoms, physician-examined arthritic signs and ultrasound-detected synovitis in rheumatoid arthritis.

Ultrasonography has been prevalently used as a valid and objective modality for joint examination in patients with rheumatoid arthritis (RA). This study aimed to examine and compare the concordance between ultrasound, clinical assessment, and patient‐reported assessment of joint synovitis in RA.

Possible preventive effect of salazosulfapyridine against development of Pneumocystis pneumonia in methotrexate-receiving patients with rheumatoid arthritis

Sir,Pneumocystis pneumonia (PCP) is a serious and potentially fatal complication of systemic rheumatic diseases, particularly in patients taking high doses of glucocorticoids (GCs). Recently, espec...

182 Acute myositis as a flare manifestation of systemic lupus erythematosus

Background and aims Myositis, especially acute myositis, is a rare manifestation of systemic lupus erythematosus (SLE). Here we report a case of acute myositis concomitant with lupus pleuritis. Methods a case report and review of literature. Results A 29-year-old woman with an 8 year history of SLE was admitted to our hospital because of pleuritic chest pain. Her initial diagnosis as SLE was made by malar rash, photosensitivity, oral ulcer, oligoarthritis, leukopenia and the positivity for antinuclear antibodies as well as anti-Sm. She has shown recurrent pleuritis afterwards. The Chest CT revealed bilateral pleural and pericardial effusion. Bacterial cultures and viral antibody tests were negative, and the daily dose of prednisolone was increased from 5 mg to 20 mg. Despite the improvement in the pleuritic chest pain, she developed acute myalgia with the elevated value of serum muscle enzymes, positive signals in the muscle/fascia by the ultrasound and MRI, and myopathic changes in the electromyogram examination. After the administration of intravenous steroid pulse therapy for 3 days followed by prednisolone 40 mg/day, all the myositic signs and symptoms subsided, which was also confirmed by the ultrasound. Conclusions The present case suggests that acute myositis may develop as a manifestation of SLE exacerbation and the ultrasound evaluation may be useful in the diagnosis and the follow-up of myositis.

147 A case of dermatomyositis with elevated serum kl-6 level associated with ovarian cancer

Background and aims Elevated serum Krebs von den Lungen-6 (KL-6) is a biomarker of interstitial pneumonia and some types of cancers. Because patients with dermatomyositis (DM) may accompany interstitial pneumonia and malignancies, serum KL-6 level has been commonly examined for patients with DM in Japan. Methods A 62-year-old woman developed myalgia in bilateral thighs in November 2014. She was admitted to our hospital in the following month because of progressive bilateral proximal muscle weakness and myalgia, elevated serum creatine kinase (CK: 5569 U/L), and Gottron’s papule. Although muscle biopsy had not been done, the diagnosis as DM was further supported by muscle MRI, electromyogram and skin biopsy. The body CT revealed pelvic mass with ascites, but not interstitial pneumonia. Results Although prednisolone 50 mg/day and intravenous immunoglobulin therapy against progressive muscle weakness including severe dysphagia only showed a partial response, the surgical resection of ovarian mass, identified as ovarian serous adenocarcinoma stage II c, followed by chemotherapy resulted in clinical remission of DM. Serum KL-6 level, as well as CA-125 decreased below the upper normal limit. Conclusions The present case suggests that the measurement of serum KL-6 may be useful in the evaluation of patients with DM.

375 Comparison of ultrasonographic joint and tendon involvements in hands between early, treatment-naïve patients with systemic lupus erythematosus and rheumatoid arthritis

Background and aims Although both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) may lead to the joint deformity, different characteristics such as the absence or the presence of bone destruction have been recognised as well. We aimed to clarify the difference of joint and tendon involvements between SLE and RA patients by using ultrasonography (US). Methods Fifteen SLE with joint symptoms and 40 RA patients, who were treatment-naïve, were enrolled in this study. The wrist, metacarpophalangeal and proximal interphalangeal joints and related extensor/flexor tendons were ultrasonographically examined. Their joints and tendons were evaluated using a gray-scale (GS) for synovial thickening and synovial fluid retention, and power Doppler (PD) for blood flow according to a semiquantitative method based on a scale of grades 0 to 3, and patients graded with GS ≥2 or PD ≥1 were judged as having joint or tendon involvement. Results Joint involvement was comparably observed in patients with SLE and RA (80% versus 95%, p=0.119). However, tendon involvement was more frequent in SLE than in RA (93% versus 65%, p=0.045), especially in the wrist joints (73% versus 40%, p=0.037). Moreover, when we investigated the intensity of US findings, the joint involvement score (GS+PD) per affected joint was lower in SLE than RA (2.0 versus 2.6, p=0.019), although tendon involvement score was similar (2.1 versus 2.2, p=0.738). Conclusions As compared with RA, joint involvement is less intense and tendon involvement is more frequent in SLE with articular symptoms.

Giant cell arteritis with polymyalgia rheumatica on FDG‐PET/CT

If there is no pain in the temporal artery, the diagnosis of giant cell arteritis (GCA) may be delayed and blindness may occur. Therefore, FDG‐PET/CT is important as a modality for diagnosis of GCA. When GCA is suspected and F‐18 FDG‐PET/CT is performed, it is worthwhile to pay attention to shoulder and hip joints as polymyalgia rheumatica commonly presents with GCA.

MTX use in Japanese patients with rheumatoid arthritis

We appreciate the letter from Dr. Carlos Antonio Moura and Dr. Carlos Geraldo Moura for their interest in our article [1]. As they noticed, that study was intended to evaluate the concordance of patient-reported joint symptoms, physician-examined arthritic signs, and ultrasound-detected synovitis in rheumatoid arthritis (RA), but not to evaluate the use of MTX. Although we described the median and range of RA duration (months) as 31 and 0-608, we should have clearly stated that 11 of 50 patients enrolled in that study were treatment-naïve. This article is protected by copyright. All rights reserved.

SAT0561 Finger Joint Cartilage Evaluated by Ultrasound and X-ray in Rheumatoid Arthritis and Control Joints

Background Joint destruction in RA includes both bone and cartilage lesions. By X-ray examination, cartilage destruction is evaluated as a joint space narrowing (JSN). However, joint space narrowing is not a direct evaluation of cartilage. Objectives The aim of the study was to examine the finger joint cartilage by ultrasound (US) imaging and to compare it with JSN score in relation to clinical relevance. Methods We enrolled 27 RA patients in low disease activity or clinical remission (DAS28-CRP <2.7) and 21 healthy controls in this study. The cartilage thickness (CT) of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of 2nd to 5th fingers was bilaterally visualized and measured from a dorsal view, with approximately 90 degrees flexion. In addition, JSN of finger were scored by van der Heijde- modified Sharp method. Results In patients with RA, CT in MCP joints ranged from 0.0 to 0.8 mm (median 0.4 mm), and CT in PIP ranged from 0.0 to 0.4mm (median 0.2mm), respectively. The sum of total CT from 8 fingers ranged from 2.7 to 6.8 mm (median 4.7 mm), and there was a significant difference in CT, but not in JSN score, between male and female patients (5.6 versus 4.6, respectively, p=0.005). Healthy controls had the sum of total CT significantly thicker as compared with RA (p≤0.001). Importantly, CT was well correlated with JSN (r=-0.696, p<0.001). Although CT was not correlated with age, disease duration, DAS28-CRP, functional disability score, positivity of rheumatoid factor and anti-CCP-antibody, CT was reduced in RA patients with elevated serum matrix metalloproteinase-3 (MMP-3) values compared with those with normal MMP-3 (3.9 versus 5.0, p=0.015). Conclusions The US method of direct visualization and quantification of cartilage in MCP and PIP joints can be valid and useful in RA, and our results may support the importance of MMP-3 in the pathophysiology of cartilage destruction. Disclosure of Interest None declared