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Does Rheumatoid Synovitis Activity Vary During The Day? A sonographic
and Doppler evaluation.
A. Lhoste-Trouilloud1, B. Pereira2, M. Couderc3, S Mathieu3 , M. Soubrier3
1 Radiology; 2DRCI; 3 Rheumatology Department, CHU Gabriel Montpied,
We read with interest the report of Semerano et al who describe a diurnal variation of power Doppler ultrasonography in the met...
We read with interest the report of Semerano et al who describe a diurnal variation of power Doppler ultrasonography in the metacarpophalangeal joints of patients with Rheumatoid arthritis (RA) (1). They reported a higher activity in the morning than in the afternoon or evening which mirrors the circadian variation in joint stiffness and pain (1). We conducted a similar survey but obtained completely opposite results.
Sonographic evaluation with B-mode and Color Doppler using the same unit, with the same transducer and settings was performed twice, before 9 am and at 4 pm by a single experienced radiologist (ALT) in 27 patients with
definite (1987 ACR criteria) and active RA (DAS28 4.66 ? 1.32). 22 synovial areas were scanned on each wrist, hand and forefoot, including 15 joints and 7 tendon sheaths. "Synovitis" was defined as abnormal hypoechoic synovial hypertrophy. Synovial vascularization was visualized by color Doppler and scored semi-quantitatively from 0 to 3[0=normal (no detectable Doppler signal inside the joint); 1=mild (Doppler signal involving < 1/3 of synovium); 2=moderate (Doppler signal involving >
1/3 but < 2/3 of synovium); 3=marked (> 2/3 of synovium involved)].
Of the 1188 imaged joints and sheaths, 328 showed synovitis in the morning, and 381 in the afternoon (p = 0.05). This number increased in 20 patients, remained the same in 6, and decreased in one. This increase was
significant in right forth PIP (p = 0.02). There was a trend to increase in right second MCP (p = 0.08), but tenosynovitis was stable (p = 1). The activity of synovitis was modified in 26 patients. This change involved several joints in 21 patients, and only one in 5. Activity significantly increased in the left second MCP (p = 0.02) and right fifth MCP (p = 0.04) and had a tendency to increase in the third and fourth right PIP and in
the left radio-carpal joint (p = 0.08). Some inactive or mild synovitis (S0 and S1) may progress to moderate or marked (S2 or S3): This was significant in the second right MCP (p = 0.013) and in the combination of all explored hand and wrist joints of the right side (p = 0.002) and of the left side (p = 0.026). Our findings, unlike those of Semerano et al, show that the number and activity of synovitis do not follow a circadian
rhythm. The increase number of activity in the hands, preferentially the dominant hand, could be explained by regular daily use. Further data are needed to confirm with a larger cohort including patients in clinical remission. Sonography often shows active synovitis in patients who are considered to be in clinical remission (2-4). However in these studies sonographic evaluation was performed only in the dominant hand which, in our results, showed the most variation over the day (2-4). Future studies should be able to determine when and which joints should be analyzed in the sonographic follow-up of RA patients, in particular in those who are in remission.
1. Semerano L, Gutierrez M, Falgarone G, et al. Diurnal variation of power Doppler in metacarpophalangeal joints of patients with rheumatoid arthritis: a preliminary study. Ann Rheum Dis 2011;70:1699-700.
2. Brown AK, Quinn MA, Karim Z, et al. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug -induced clinical remission: evidence from an imaging study may explain structural progression. Arthritis Rheum 2006;54:3761-73.
3. Saleem B, Brown AK, Keen H, et al. Disease remission state in patients treated with the combination of tumor necrosis factor blockade and methotrexate or with disease-modifying antirheumatic drugs: a clinical and imaging comparative study. Arthritis Rheum 2009;60:1915-22.
4. Saleem B, Brown AK, Keen H, et al. Should imaging be a component of rheumatoid arthritis remission criteria? A comparison between traditional and modified composite remission scores and imaging assessments. Ann Rheum