Published on July 11, 2016
1. Dr. Tejas Tamhane JRIII 11/07/2016 Noninfective Inflammatory Arthritis- RHEUMATOID ARTHRITIS
2. INTRODUCTIO N Noninfective inflammatory arthritides comprise a group of different, mostly systemic disorders that have one important feature in common; Inflammatory granulation tissue eroding and destroying articular cartilage.
3. These include Rheumatoid Arthritis (Seropositive) Seronegative Spondyloarthropathies Ankylosing spondylitis, Psoriatic arthropathy, Reiter’s syndrome Enteropathic arthritis.
4. A systematic approach with evaluation of various radiological abnormalities helps in arriving at the correct diagnosis. Various features to be evaluated include: a. Distribution of affected joints b. Presence of soft tissue swelling c. Bone density d. Cartilage space narrowing e. Reactive bone formation f. Site and character of erosions g. Subarticular cystic lesions h. Presence of soft tissue calcification i. Joint deformities
5. Rheumatoid Arthritis Most common inflammatory arthritis affecting approximately 0.5 to 1 % of the world’s adult population. It is a progressive, chronic, systemic inflammatory disease affecting primarily the synovial joints which can lead to considerable disability and morbidity. Peak age of onset- 4th- 6th decades. Women >>> men
6. Etiology is unknown but appears to be multifactorial. Genetic predisposition with over 70 percent of patients expressing HLA-DR4. Classical presentation is of a Symmetrical Polyarthritis affecting the small joints of the hands and feet. The axial skeleton is later and less often affected. Characteristically, joints which communicate with one another tend to be affected together. e.g. Uniform tricompartmental involvement in the knee
7. The American College of Rheumatology revised criteria require that 4 out of 7 of the following are present: 1. Morning stiffness lasting at least 1 hour before maximal improvement. 2. Soft tissue swelling of 3 or more joints observed by a physician. 3. Swelling of the PIP, MCP or wrist joints. 4. Symmetric swelling 5. Rheumatoid nodules 6. Rheumatoid factor 7. Radiographic erosions and/or periarticular osteopenia in
8. Pathophysiolog y The RA factors are Anti-gamma-globulin Antibodies which are elaborated by the synovium in response to unknown antigens. These antibodies are believed to be the initiating factor that triggers RA. Immune complex deposition in the synovium activates the complement system with invasion by neutrophils and macrophages. This leads to synovial proliferation, pannus formation and ultimate cartilage and subchondral bony destruction. In advanced cases, there may be fibrous ankylosis
9. Imaging The radiologic features of RA may be divided into “early” and “late” changes. Since early changes are nonosseous in nature, Sonography and MR imaging can detect disease earlier than conventional radiography and CT
10. Radiographic Features- EARLY CHANGES The earliest changes include joint space widening and soft tissue swelling. Joint space widening is the earliest but a transient radiographic abnormality, sometimes lasting for only a few weeks. This finding is due to edema and swelling of the synovium and joint effusion. Joint space widening is best detected at the metacarpophalangeal (MCP) joints, especially in the
11. Soft tissue swelling represents a combination of joint effusion, synovial edema, and proliferation and tenosynovitis which invariably precedes cartilaginous and osseous changes. In the hand, periarticular fusiform swelling may be seen over the proximal interphalangeal (PIP) and 2nd and 5th MCP joints.
12. Osteopenia In RA is of two types: 1. Local juxta-articular osteopenia is due to synovial inflammation and hyperemia and is seen EARLY in the course of the disease. 2. Generalized osteopenia is due to limitation of movement due to pain, muscle wasting or steroid therapy and is therefore seen LATE in the disease
13. X-ray hand reveals the early changes of rheumatoid arthritis with classical juxta- articular osteopenia and uniform narrowing of the distal radioulnar, radiocarpal and intercarpal joints. Subluxations at the 1st MCP and IP joints cause the classical “Hitch-hiker’s” deformity.
14. Joint Space Narrowing is due to destruction of the articular cartilage and is virtually always uniform. Presence of uniform narrowing is an important feature of RA that helps to differentiate it from osteoarthritis in which the joint space narrowing is characteristically nonuniform or
16. Erosions The most important diagnostic feature of RA but may not be seen when the patient presents initially. The detection of erosions indicates irreversible damage. In the hands, erosions usually involve the wrist, MCP and PIP joints. In the feet, erosions appear earlier and are most often seen at the 5th MTP joint.
17. Rheumatoid arthritis- magnified view of the CMC joints demonstrates multiple erosions in the bases of the metacarpals and trapezium giving a cystic
18. Hands and wrists There is a predilection for: PIP and MCP joints (especially 2nd and 3rd MCP), ulnar styloid, triquetrum As a rule, the DIP joints are spared. Late changes include: Subchondral cyst formation: destruction of cartilage presses synovial fluid into the bone Subluxation causing: ulnar deviation of the MCP joints boutonniere and swan neck deformities Hitchhiker’s thumb deformity Carpal Instability: scapholunate dissociation, ulnar translocation Ankylosis
19. Magnified view of the wrist joint demonstrating late changes of RA with severe osteopenia, gross destruction of the distal ends of the radius and ulna with ankylosis of the carpal bones
20. Boutonniere deformity
21. Hitchhiker thumb deformity
22. The Z deformity is- Radial deviation at the wrist Ulnar deviation of the digits, Often palmar subluxation of the proximal phalanges.
23. Feet Similar to the hands, there is a predilection for the PIP and MTP joints (especially 4thand 5th MTP) Involvement of subtalar joint Hammertoe deformity Hallux valgus
24. X-ray of the forefoot shows more advanced changes of RA with gross erosions of the metatarsal heads with subluxations at the MTP and IP joints with hallux valgus
25. Spine The cervical spine is involved in approx. 50% RA. Findings include: Erosion of the dens Atlantoaxial subluxation atlantoaxial distance in more than 3 mm on a flexion radiograph Atlantoaxial impaction (cranial settling): Cephalad migration of C2 Osteoporosis and osteoporotic fractures
26. Sagittal reformatted 3D CT images of the craniovertebral junction in (A) Extension and (B) Flexion Show increase in the atlantoaxial distance on flexion with erosion of the odontoid peg due to RA
27. OTHER IMAGING MODALITIES Ultrasonography- Detect early synovial inflammation in the form of synovial thickening and joint effusion. Power doppler has the capability to detect and measure changes in the vascularity of the synovium due to inflammation.
28. (A) Ultrasound image of the carpal bones shows diffuse synovial thickening in a case of RA. (B) Power Doppler in another case shows synovial thickening extending along the tendon sheaths with increased vascularity.
29. 29-year-old woman with early rheumatoid arthritis and tenosynovitis. Dorsal transverse sonogram of wrist shows hypoechoic thickening (asterisks) and hyperemia around extensor carpi ulnaris tendon on power Doppler imaging, representing tenosynovitis. Note also heterogeneous appearance of tendon on sonography.
30. Computed Tomography Not frequently used routinely in RA as it is inferior to MR and USG for the detection of early disease. Its main use lies in the diagnosis and management of upper cervical spine abnormalities.
31. Radionuclide Scanning Scanning with 99mTc-MDP is highly sensitive for detection of the inflammatory changes of arthritis but shows poor specificity. Findings include increased flow in the synovium in the early or blood pool phase and increased uptake in the delayed 3 hours scans.
32. Magnetic Resonance Imaging (MRI) MR is considered to be the best imaging modality for RA. Synovial thickening extending along the tendon sheaths with increased vascularity followed by bone marrow edema and finally bony erosion are well demonstrated on MRI. MR is also a useful imaging modality for the follow-up of RA to evaluate progression or remission
33. Synovial Imaging 34-year-old woman with early rheumatoid arthritis and synovitis. Transverse fat suppressed gadolinium- enhanced T1-weighted MR images show synovitis (arrows) in wrist (A) and metatarsophalangeal joints (B).
34. 29-year-old woman with early rheumatoid arthritis and tenosynovitis. Transverse fat-suppressed gadolinium-enhanced T1- weighted spin-echo MR image shows significant enhancement (arrows) around extensor carpi ulnaris tendon that represents tenosynovitis. Note also mild
35. 38-year-old woman with early rheumatoid arthritis and bone erosions. Transverse fat- suppressed gadolinium- enhanced 3D gradient- echo MR image shows bone erosion on radial aspect of third metacarpal bone (arrowhead). Note also presence of significant bilateral synovitis in 2nd & 3rd MCP joints and flexor digitorum tenosynovitis (arrows).
36. 51-year-old man with early rheumatoid arthritis and bursitis. Transverse fat-suppressed gadolinium- enhanced 3D gradient-echo MR image shows submetatarsal (asterisk) and intermetatarsal (boxes) bursitis. Note also presence of bone erosion (arrow) associated with synovitis in third metatarsophalangeal
37. Patient with RA: (A) X-ray both hands PA view shows diffuse loss of the joint spaces at the radiocarpal, intercarpal joints. (B) T1-weighted coronal image demonstrates multiple erosions in the carpal bones, distal ulna and radius
38. (A) X-ray pelvis of a patient with RA shows uniform loss of joint space with irregularity of the articular surface in bilateral hip joints. Note the medial migration of the femoral heads, (B) Coronal T2-weighted image better demonstrates the erosions. Note the bone marrow edema manifesting as ill defined hyperintense signal
39. Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) This MR imaging study group is an international, multidisciplinary group setup for the purpose of standardizing techniques and definitions of joint pathologies in RA. According to their recommendations, MR scan for RA should include at least the following: (i) Imaging in two planes (axial and coronal) (ii) T1-weighed sequences before and after gadolinium and (iii) A fat saturated T2-weighted or a short inversion recovery (STIR) sequence.
40. On MRI at present, the most frequently used method is the OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS). 1. SYNOVITIS 2. BONE MARROW EDEMA 3. EROSIONS
41. 1. SYNONITIS Assessed in three wrist regions: distal radioulnar joint, radiocarpal joint and the intercarpal, carpometacarpal and MCP joints on a scale of 0 to 3 SCORE SYNOVITIS 0 NORMAL 1 MILD 2 MODERATE 3 SEVERE
42. 2. BONE MARROW EDEMA Scored from 0 to 3 based on the volume. VOLUME EDEMA 0 NO EDEMA 1 1-33% 2 34-66% 3 67-100%
43. 3. EROSIONS Seen in the carpal bones, distal radius and ulna and the bases of the metacarpal bones are scored separately. The scores range from 0 to 10 on the basis of the volume of erosion. The maximum score in the wrist is 150.
44. However, using the RAMRIS score is difficult, requiring years of dedicated work, is subject to high interobserver variability and is not practical in clinical practice.
45. Non-Musculoskeletal features of RA tend to occur late in the disease and include: Cardiovascular disease Accelerated coronary artery and cerebrovascular atherosclerosis which contribute significantly to the excess mortality of RA Pricarditis Vasculitis: occurs more commonly with a severe erosive disease, rheumatoid nodules, high RF titres Cutaneous involvement Rheumatoid nodules are usually seen in pressure areas: elbows, occiput, lumbosacral Occurs in RF-positive patients Ocular involvement Keratoconjunctivitis sicca Uveitis Episcleritis
46. Pulmonary involvement Pulmonary manifestations are relatively common in rheumatoid arthritis, and like many of its non- articular manifestations, tend to develop later in the disease.
47. Radiographic features Patterns of lung involvement include interstitial, airway and pleural disease. Pleural involvement is a common manifestation of RA, although usually asymptomatic. Pleural thickening: is seen more commonly than pleural effusions Pleural effusions: occur late in the disease, are often unilateral and associated with pericarditis and subcutaneous nodules. Radiograph Chest radiograph may show: Pleural effusion Lower zone predominant reticular or reticulonodular pattern Volume loss in advanced disease Skeletal changes, e.g. erosion of clavicles, glenohumeral erosive arthropathy,superior rib notching
48. HRCT demonstrates reticular/ground glass opacities, traction bronchiectasis and extensive honeycombing with peripheral and basal predominance. In addition the presence of anterior upper lobe honeycombing (red arrows) is a more common finding in rheumatoid arthritis and
49. CONCLUSION Both the imaging findings and the typical pattern of involvement enable the radiologist to diagnose RA with a high degree of accuracy. The value of soft-tissue imaging modalities, especially MR, in evaluating symptomatic body regions cannot be overstressed in respect to the utmost need for very early detection of abnormalities, since the prognosis depends heavily on the immediate administration of a proper therapeutic regimen. The key issue in state-of-the-art management of RA on the radiologist’s side is to image the early manifestations before any destructive changes occur. Thus, the frequent initial radiologic approach in a suspected case of arthritis, the use of conventional
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