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Dactylitis also involving the synovial sheaths in the palm of the hand: two more cases studied by magnetic resonance imaging
  1. ANGELA PADULA,
  2. CARLO SALVARANI
  1. Rheumatic Disease Unit, Arcispedale S Maria Nuova, Reggio Emilia, Italy
  2. Department of Diagnostic Radiology, S Orsola-Malpighi Hospital, Italy
  3. Rheumatic Disease Unit, Hospital of Prato, Italy
  4. Rheumatic Disease Unit, S Orsola-Malpighi Hospital, Italy
  1. Dr I Olivieri, Servizio di Reumatologia, Policlinico S Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy.
  1. LIBERO BAROZZI,
  2. MASSIMO DE MATTEIS,
  3. PIETRO PAVLICA
  1. Rheumatic Disease Unit, Arcispedale S Maria Nuova, Reggio Emilia, Italy
  2. Department of Diagnostic Radiology, S Orsola-Malpighi Hospital, Italy
  3. Rheumatic Disease Unit, Hospital of Prato, Italy
  4. Rheumatic Disease Unit, S Orsola-Malpighi Hospital, Italy
  1. Dr I Olivieri, Servizio di Reumatologia, Policlinico S Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy.
  1. FABRIZIO CANTINI
  1. Rheumatic Disease Unit, Arcispedale S Maria Nuova, Reggio Emilia, Italy
  2. Department of Diagnostic Radiology, S Orsola-Malpighi Hospital, Italy
  3. Rheumatic Disease Unit, Hospital of Prato, Italy
  4. Rheumatic Disease Unit, S Orsola-Malpighi Hospital, Italy
  1. Dr I Olivieri, Servizio di Reumatologia, Policlinico S Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy.
  1. IGNAZIO OLIVIERI
  1. Rheumatic Disease Unit, Arcispedale S Maria Nuova, Reggio Emilia, Italy
  2. Department of Diagnostic Radiology, S Orsola-Malpighi Hospital, Italy
  3. Rheumatic Disease Unit, Hospital of Prato, Italy
  4. Rheumatic Disease Unit, S Orsola-Malpighi Hospital, Italy
  1. Dr I Olivieri, Servizio di Reumatologia, Policlinico S Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy.

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We previously reported on the case of a 37 year old woman suffering from B27 positive psoriatic arthritis and showing dactylitis of the middle finger also involving the uncommon synovial sheaths communicating with the ulnar bursa.1 The continuity of flexor synovial sheath involvement was shown by ultrasonography. We have recently seen two similar cases, which we studied by magnetic resonance imaging (MRI). One patient also had synovitis together with pitting oedema of the dorsum of the hand, which has been described in elderly patients with spondyloarthritis (SpA).2-5

We previously reported on the case of a 37 year old woman suffering from B27 positive psoriatic arthritis and showing dactylitis of the middle finger also involving the uncommon synovial sheaths communicating with the ulnar bursa.1 The continuity of flexor synovial sheath involvement was shown by ultrasonography. We have recently seen two similar cases, which we studied by magnetic resonance imaging (MRI). One patient also had synovitis together with pitting oedema of the dorsum of the hand, which has been described in elderly patients with spondyloarthritis (SpA).2-5

The first patient was a 65 year old woman with a 20 year history of asymmetric erosive peripheral arthritis of the metatarsophalangeal, midfoot, hindfoot, radiocarpal, midcarpal, metacarpophalangeal (MTP), and proximal and distal hand interphalangeal joints and enthesitis of the quadriceps and patellar tendons on both patellae.

In October 1994 she was referred to us because of a reoccurrence of her peripheral arthritis in the right hand of two months’ duration.

Her family history was negative for SpA and other B27 related diseases.

Physical examination showed dactylitis of the fourth right finger together with synovitis with a large pitting oedema of the dorsum of the right hand. The painful swelling of the synovial sheaths of the flexor tendons of the fourth finger extended as far as the palm of the hand.

HLA typing showed A24, A29, B27, DR7, DR11, DQ2, DQ7 antigens. Tests for the rheumatoid factor and the antinuclear antibodies were negative. Spinal and pelvic radiographs were normal.

MRI performed according to the methods previously described6 showed flexor tenosynovitis of the right fourth finger extending without any interruption into the palm of the hand. On the dorsum of the hand oedema in the subcutaneous and peritendinous soft tissues and fluid in the extensor tendon synovial sheaths were observed (fig 1).

Figure 1

Proton density axial section images at the middle of the palm of the hands showing the intense signal caused by fluid distending and encircling the right extensor (arrows) and IV flexor synovial sheaths (arrowheads). An overlaying subcutaneous and peritendinous soft tissue oedema is visible (white open arrow). The normal contralateral structures are shown for comparison.

The second patient, a 53 year old woman with a 12 year history of erosive asymmetric arthritis of the MTP joints, came to our unit in November 1995 showing dactylitis of the third right finger and planter fasciitis of the left foot.

Physical examination showed that the swelling and tenderness present along the flexor tendon course of the “sausage shaped” third right finger extended as far as the middle part of the palm of the hand. There was no limitation of spine movement and chest expansion.

Laboratory investigation showed negative tests for rheumatoid factor and antinuclear antibodies and A1, B8, B27, Cwl, Cw2, DR3, DR12, DQ2, DQ7 HLA antigens.

MRI showed fluid collection in the synovial flexor sheath of the third left finger continuing into the middle part of the hand (fig 2). Spinal and sacroiliac joint radiography were normal.

Figure 2

Coronal T2 weighted image showing the high signal intensity caused by fluid collection in the III left flexor synovial sheaths continuing into the middle part of the palm of the hand.

Both our patients have a B27 positive undifferentiated SpA.4 7 During the course of the disease they developed a destructive peripheral arthritis, peripheral enthesitis, and dactylitis.

SpA dactylitis results from flexor tenosynovitis.6 These two cases confirm our hypothesis that when flexor tenosynovitis involves a finger with synovial sheaths communicating with the ulnar palmocarpal sheaths, the sausage swelling also extends into the palm of the hand.1

Patient 1 also showed synovitis with pitting oedema of the dorsum of the hand, which has recently been described in elderly patients with SpA.2-5 The aspect of the inflammatory oedema in late onset SpA is similar to that seen in the RS3PE (remitting seronegative symmetrical synovitis with pitting oedema) syndrome8 and in polymyalgia rheumatica.9 Unlike RS3PE syndrome, the pitting oedema of late onset undifferentiated SpA is usually unilateral and more frequent in the feet.3-5 7 Schaeverbekeet al have recently suggested that the oedema may be ascribed to an increase in capillary permeability as a result of focal inflammation.5 The MRI findings in our patient confirm this hypothesis. The examination showed fluid in the subcutaneous and peritendinous soft tissues and inflammation of the extensor tendon synovial sheaths. Our cases suggest that the inflammatory oedema of the dorsum of hands and feet of elderly patients with SpA may result from extensor sheath synovitis rather than joint synovitis. The same might occur in hand inflammatory oedema of other rheumatic diseases of the elderly.10

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