Indian Journal of Rheumatology

EDITORIAL
Year
: 2019  |  Volume : 14  |  Issue : 2  |  Page : 96--97

Musculoskeletal ultrasound in juvenile idiopathic arthritis - A future not too far


N Sajjan Shenoy 
 Department of Clinical Immunology and Rheumatology, KMC Hospital, Mangaluru, Karnataka, India

Correspondence Address:
Dr. N Sajjan Shenoy
Department of Clinical Immunology and Rheumatology, KMC Hospital, Mangaluru, Karnataka
India




How to cite this article:
Shenoy N S. Musculoskeletal ultrasound in juvenile idiopathic arthritis - A future not too far.Indian J Rheumatol 2019;14:96-97


How to cite this URL:
Shenoy N S. Musculoskeletal ultrasound in juvenile idiopathic arthritis - A future not too far. Indian J Rheumatol [serial online] 2019 [cited 2019 Jul 23 ];14:96-97
Available from: http://www.indianjrheumatol.com/text.asp?2019/14/2/96/260822


Full Text



That Musculoskeletal ultrasound (MSUS) is an effective, cheap, and safe “point of care” imaging technique in the diagnosis and management of rheumatological disorders needs no discussion. When dealing with pediatric patients, MSUS has added advantages of lack of radiation, avoidance of sedation for magnetic resonance imaging or computed tomography, rapid painless screening of multiple and contralateral joints with potential to add to the clinical assessment. In the field of adult MSUS, definitions (normal and pathologic) involving sonologic terminologies, qualitative and quantitative techniques for the measurement of synovial abnormalities, and power Doppler (PD) signals have been in place for many years now.[1],[2] Pediatric MSUS has relatively lacked in literature, but rapid advances have been made in the past 3 years. Standardized examination techniques have been described in pediatric patients.[3] Definitions of healthy joint sonographic features and synovitis have been proposed.[4],[5] The EULAR-PReS “points to consider” now includes the use of MSUS within the assessment of juvenile idiopathic arthritis (JIA) in clinical practice.[6] These have improved the quality of MSUS examination in routine care and in research work, but work remains to be done in developing validated scoring systems for use in children.

One important consideration for the practicing pediatric rheumatologist performing or ordering MSUS examination for picking up abnormalities and features of inflammation in children with JIA is-“Does it add to what I already know after seeing the child?” This translates to the research question of “Is MSUS more sensitive than physical examination and/or plain radiography for the detection of synovitis or other abnormalities in children with JIA?” Few studies have addressed this issue.[7],[8],[9] All of them were carried out before sonology was used widely and before sonologic definitions of synovitis and other pathologies were described in the pediatric population. We have previously described higher sensitivity of sonology in the detection of enthesitis in ERA subtype of JIA.[10] Given the paucity of data in this area, work by Dev et al., published in this edition of the IJR is timely and reassuring.[11]

Dev et al. describe the use of MSUS in the detection of synovitis and related pathologies – synovial hypertrophy, effusion, increased vascularity (using PD) and erosions, in a cohort of JIA patients and then compare the findings with clinical examination. Reassuringly enough, they observed that the MSUS examination was considerably more sensitive than physical examination in picking up features of synovitis. Subclinical synovitis was picked up in most patients. A direct implication of the same is a change of diagnosis subclassification from oligoarticular to polyarticular JIA – a huge leap in terms of the treatment paradigm for an individual patient. They suggest that asymptomatic large joints in children with the initial diagnosis of JIA should be screened by MSUS for subclinical synovitis-definitely a feasible option in real-world clinics given the ease of use and low cost of MSUS. We could point out some drawbacks in the work, for example, only one radiologist performed all the scans, leaving no room for the assessment of interobserver variability. The age range of the participants was restrictive (range 11–15 years) and small joints (metacarpophalangeal, metatarsophalangeal, and interphalangeal joints) were excluded. Nevertheless, the good effort is laudable.

Another important area of interest is the assessment and implication of detection of subclinical synovitis in children who are already on therapy and who are clinically considered to be in “remission” or low disease activity state. Conflicting results have been obtained in MSUS studies regarding the prediction of flares and disease outcomes using sonologic synovitis or positive PD signal.[7],[12] Quantification of synovitis in children is another active area of research which may aid in answering these questions, but studies are far and few.[13] These research questions are open and are currently receiving much attention.[14]

Considering that MSUS is poised as an imaging tool for “resource constrained” settings, the implications of answers to these questions are obvious for rheumatologic practice in our country. It does not require an oracle to predict that MSUS is going to be a game-changer, both for JIA patients and their care providers.

References

1Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D'Agostino MA, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005;32:2485-7.
2Bruyn GA, Hanova P, Iagnocco A, d'Agostino MA, Möller I, Terslev L, et al. Ultrasound definition of tendon damage in patients with rheumatoid arthritis. Results of a OMERACT consensus-based ultrasound score focussing on the diagnostic reliability. Ann Rheum Dis 2014;73:1929-34.
3Collado P, Vojinovic J, Nieto JC, Windschall D, Magni-Manzoni S, Bruyn GA, et al. Toward standardized musculoskeletal ultrasound in pediatric rheumatology: Normal age-related ultrasound findings. Arthritis Care Res (Hoboken) 2016;68:348-56.
4Roth J, Jousse-Joulin S, Magni-Manzoni S, Rodriguez A, Tzaribachev N, Iagnocco A, et al. Definitions for the sonographic features of joints in healthy children. Arthritis Care Res (Hoboken) 2015;67:136-42.
5Roth J, Ravagnani V, Backhaus M, Balint P, Bruns A, Bruyn GA, et al. Preliminary definitions for the sonographic features of synovitis in children. Arthritis Care Res (Hoboken) 2017;69:1217-23.
6Colebatch-Bourn AN, Edwards CJ, Collado P, D'Agostino MA, Hemke R, Jousse-Joulin S, et al. EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice. Ann Rheum Dis 2015;74:1946-57.
7Magni-Manzoni S, Scirè CA, Ravelli A, Klersy C, Rossi S, Muratore V, et al. Ultrasound-detected synovial abnormalities are frequent in clinically inactive juvenile idiopathic arthritis, but do not predict a flare of synovitis. Ann Rheum Dis 2013;72:223-8.
8Magni-Manzoni S, Epis O, Ravelli A, Klersy C, Veisconti C, Lanni S, et al. Comparison of clinical versus ultrasound-determined synovitis in juvenile idiopathic arthritis. Arthritis Rheum 2009;61:1497-504.
9Spârchez M, Fodor D, Miu N. The role of power Doppler ultrasonography in comparison with biological markers in the evaluation of disease activity in juvenile idiopathic arthritis. Med Ultrason 2010;12:97-103.
10Shenoy S, Aggarwal A. Sonologic enthesitis in children with enthesitis-related arthritis. Clin Exp Rheumatol 2016;34:143-7.
11Dev S, Verma A, Singh A. Musculoskeletal Ultrasonography in Detecting Disease Activity in Patients of Juvenile Idiopathic Arthritis: A Cross-Sectional Study. Ind J Rheumatol 2019.
12Miotto E, Silva VB, Mitraud SA, Furtado RN, Natour J, Len CA; Terreri MTSELRA. Patients with juvenile idiopathic arthritis in clinical remission with positive power Doppler signal in joint ultrasonography have an increased rate of clinical flare: A prospective study. Pediatr Rheumatol Online J 2017;15:80.
13Collado P, Naredo E, Calvo C, Gamir ML, Calvo I, García ML, et al. Reduced joint assessment vs. comprehensive assessment for ultrasound detection of synovitis in juvenile idiopathic arthritis. Rheumatology (Oxford) 2013;52:1477-84.
14Windschall D, Collado P, Vojinovic J, Magni-Manzoni S, Balint P, Bruyn GA, et al. Age-related vascularization and ossification of joints in children: An international pilot study to test multi-observer ultrasound reliability. Arthritis Care Res (Hoboken) 2017. doi: 10.1002/acr.23335.