Juvenile arthritis
Comparison of Clinical and Ultrasonographic Evaluations for Peripheral Synovitis in Juvenile Idiopathic Arthritis

https://doi.org/10.1016/j.semarthrit.2010.12.005Get rights and content

Objectives

The characteristics of synovitis in juvenile idiopathic arthritis (JIA) are important to evaluate, as they define several clinical categories. The metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints are frequently involved. Few studies have investigated peripheral joint evaluation using ultrasonography, a sensitive tool for detecting subclinical synovitis. Our objectives here were to compare clinical and ultrasound evaluations of MCP and MTP joint synovitis and to determine the prevalence of predefined ultrasound abnormalities in JIA patients and healthy controls.

Methods

Standardized physical and ultrasound assessments of the same joints were done in 31 consecutive patients with JIA and 41 healthy volunteers. Joint pain, motion limitation, and swelling were recorded. Ultrasonography was performed on the same joints by 2 trained sonographers who recorded synovial fluid, synovial hypertrophy, erosion, and power Doppler signal. Intraobserver reproducibility of ultrasonography was assessed.

Results

Of 558 peripheral joints examined in JIA patients, 69 (12.5%) had ultrasonographic synovitis and 83 (15%) had abnormal physical findings. All the physical abnormalities were significantly associated with ultrasonographic synovitis (P < 0.0001) but agreement was low between ultrasonographic and physical findings. Ultrasonographic synovitis was most common at the feet (59.4%), where it was detected clinically in only 25% of cases. Ultrasonographic synovitis was associated with the presence of synovial fluid. Cartilage vascularization was found in 2 (4.2%) healthy controls.

Conclusion

Ultrasonography is useful for monitoring synovitis in JIA. Subclinical involvement of the MTP joints is common. Clinicians should be aware of the specific ultrasonographic findings in children.

Section snippets

Patients

Consecutive patients referred to our pediatric rheumatology center were included prospectively if they met diagnostic criteria for JIA in the Durban classification (6) and if US was performed within 3 days after a physical assessment. Standardized forms were used to collect the following data: sex, age at onset, disease duration, International League of Associations for Rheumatology category, pain intensity as evaluated on a visual analog scale by the patient and/or parents, current treatment,

Study Participants

We included 31 consecutive JIA patients with available physical and US assessments. There were 17 females and 14 males. Mean disease duration was 3.6 ± 3.3 years. Oligoarticular and enthesitis-related JIA predominated (Table 1). The treatment included methotrexate in 47% of patients, biological agents in 8.7%, and glucocorticoids in 10%.

The control group comprised 41 healthy children, including 20 females and 21 males aged 2.7 to 15.8 years. None of the controls had joint swelling, pain on

Discussion

JIA is a heterogeneous group of diseases defined as persistent arthritis for more than 6 weeks with an onset before 16 years and no other identifiable cause. Several JIA subtypes are distinguished based on symptoms in the first 6 months. The prognosis varies across subtypes and according to the number of affected joints (12). Therefore, the clinical joint evaluation is of prime importance for diagnosing JIA, monitoring disease activity, and predicting the outcome. The most common sites of

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      Haslam et al. [16] also reported a discrepancy between clinical and US examination in oligoarticular JIA, with subclinical synovitis, especially in the hands and feet small joints. Similar findings were also detected in the work of Breton et al. [17] Accordingly the use of US in JIA children may allow earlier diagnosis of joint synovitis or detect extension of arthritis to clinically normal joints. Although treating clinically normal joints based on Doppler findings only may carry the risk of overtreatment, still combining clinical and Doppler findings may be beneficial.

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