rspНаучно-практическая ревматологияRheumatology Science and Practice1995-44841995-4492IMA-PRESS, LLC10.14412/1995-4484-2013-1539rsp-1334Research ArticleСтатьиArticlesДиагностическая значимость клинического осмотра и ультразвукового исследования энтезисов для раннего выявления псориатического и ревматоидного артрита (исследование РЕМАРКА)THE DIAGNOSTIC VALUE OF CLINICAL EXAMINATION AND ULTRASOUND STUDY OF ENTHESES FOR EARLY DETECTION OF PSORIATIC AND RHEUMATOID ARTHRITIS: REMARC STUDYКоротаеваТ. В.KorotaevaTatiana Viktorovnatatianakorotaeva@gmail.comLoginovaE YuLoginovaE Yutatianakorotaeva@gmail.comЛучихинаЕ. Л.LuchikhinaE Ltatianakorotaeva@gmail.comPushkovaO VPushkovaO Vtatianakorotaeva@gmail.comAkhmetovaE MAkhmetovaE Mtatianakorotaeva@gmail.comGlazkovA AGlazkovA Atatianakorotaeva@gmail.comВолковА. В.VolkovA Vtatianakorotaeva@gmail.comКаратеевДмитрий ЕвгеньевичKarateevD Etatianakorotaeva@gmail.comНасоновЕвгений ЛьвовичNasonovE Ltatianakorotaeva@gmail.comФГБУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой» РАМН, МоскваРоссияV.A. Nasonova Research Institute of Rheumatology, Russian Academy of Medical Sciences, MoscowRussian FederationМосковский государственный университет им. М.В. Ломоносова, факультет фундаментальной медицины, МоскваРоссияFaculty of Fundamental Medicine, M.V. Lomonosov Moscow State University, MoscowRussian Federation201330112013515495499Copyright © Коротаева Т.В., Loginova E.Y., Лучихина Е.Л., Pushkova O.V., Akhmetova E.M., Glazkov A.A., Волков А.В., Каратеев Д.Е., Насонов Е.Л., 20132013Коротаева Т.В., Loginova E.Y., Лучихина Е.Л., Pushkova O.V., Akhmetova E.M., Glazkov A.A., Волков А.В., Каратеев Д.Е., Насонов Е.Л.Korotaeva T.V., Loginova E.Y., Luchikhina E.L., Pushkova O.V., Akhmetova E.M., Glazkov A.A., Volkov A.V., Karateev D.E., Nasonov E.L.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://rsp.mediar-press.net/rsp/article/view/1334

Диагностика энтезита может помочь в разграничении раннего псориатического (рПсА) и раннего ревматоидного артрита (рРА). Цель – оценить диагностическую значимость выявления энтезита при клиническом осмотре и ультразвуковом исследовании (УЗИ) при рПсА и рРА. Материал и методы. В исследование вошли 36 пациентов с рПсА и 33 – с рРА. Энтезисы оценивали по Leeds Enthesitis Index (LEI): справа и слева латеральный надмыщелок плечевой кости, медиальный мыщелок бедренной кости (ММБК), место прикрепления ахиллова сухожилия (МПАС) и в точке подошвенной фасции (ПФ). По УЗИ энтезитом считали утолщение, снижение эхоплотности и васкуляризацию при энергетическом допплеровском картировании. Рассчитывали DAS, DAS28, SDAI, CDAI, М±SD, Me [25-й; 75-й перцентили], t-тест, точный критерий Фишера, χ2, U-тест, коэффициенты корреляции Спирмена (R), статистически значимым считали различие р<0,05. Результаты. Приклиническом осмотре энтезиты найдены у41,6% пациентов срПсА и39,4% срРА (р>0,05). Не выявлено значимых различий между рПсА ирРА по LEI (0,5 [0; 2] и1 [0; 2]) ипо LEI+ПФ (1 [0; 2,5] и1 [0; 2] соответственно). Энтезиты МПАС иПФ значимо чаще выявляли при рПсА, чем при рРА,– 12 (33,3%)/2 (6,1%) и10 (27,8%)/2 (6,1%) больных соответственно. ПрирРА значимо чаще, чем при рПсА, обнаруживали энтезит ММБК–16 (48,4%) и8 (22,2%) больных соответственно. УЗИ не выявило значимых различий между группами по воспалению энтезисов. ПрирПсА найдена значимая корреляция между DAS, DAS28, SDAI, CDAI, LEI иLEI+ПФ. Выводы. УЗИ энтезисов не позволяет разграничить рПсА и рРА. При клиническом осмотре энтезит в области коленных суставов чаще обнаруживают при рРА, а в пяточной области – при рПсА.

The diagnosis of enthesitis can help in differentiating early psoriatic arthritis (ePsA) from early rheumatoid arthritis (eRA).

Objective

Objective. To estimate the diagnostic value of detecting enthesitis during clinical examination and ultrasound in ePsA and eRA.

Subjects and methods

Subjects and methods. The trial included 36 patients with ePsA and 33 with eRA. Entheses were evaluated using the Leeds Enthesitis Index (LEI): lateral humeral epicondyle and medial femoral condyle (MFC), Achilles tendon insertion site (ATAP), and plantar fascia (PF) point on the right and on the left. Enthesitis (on ultrasound) presented with thickening, reduced echo density, and vascularization at Doppler energy imaging. DAS, DAS28, SDAI, CDAI, M±SD, Me [25th, 75th percentile], t-test, Fisher's exact test, χ2test, U test, and Spearman correlation coefficients (R) were calculated; the value p < 0.05 was considered statistically significant.

Results

Results. Clinical examination revealed enthesitis in 41.6% of the patients with ePsA and in 39.4% of those with eRA (p >0.05). No significant differences were found between ePsA and eRA according to LEI (0.5 [0; 2] and 1 [0; 2] and to LEI+PF (1 [0; 2] and 1 [0; 2], respectively). Enthesitis of MFC and PF was significantly more frequently detected in ePsA than in eRA – 12 (33.3%)/2 (6.1%) and 10 (27.8%)/2 (6.1%) patients, respectively. In eRA versus ePsA, enthesitis of MFC was more frequently found (16 (48.4%) and 8 (22.2%) patients), respectively. Ultrasound revealed no significant differences between the groups in enthesitis. In ePsA, there was a significant correlation between DAS, DAS28, SDAI, CDAI, LEI, and LEI+PF.

Conclusion

Conclusion. Enthesis ultrasound cannot differentiate ePsA from eRA. Clinical examination more frequently detects enthesitis in the knee joints in eRA and in the calcaneal region in ePsA.

ранний псориатический артритранний ревматоидный артритэнтезитыультразвуковое исследованиеearly psoriatic arthritisearly rheumatoid arthritisenthesitisultrasound studyReferences<div><p>Ревматология: Клинические рекомендации. 2-е изд., испр. и доп. Москва: ГЭОТАР-Медиа; 2010. 752 c. [Revmatologiya: Klinicheskie rekomendatsii. 2-e izd., ispr. i dop. Moscow: GEOTAR-Media; 2010. 752 p.]</p><p>Scarpa R, Cuocolo A, Peluso R et al. Early psoriatic arthritis: the clinical spectrum. J Rheumatol. 2008;35(1):137–41.</p><p>Rudwaleit M, van der Heijde D, Landewe R et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011;70(1):25–31. DOI: 10.1136/ard.2010.133645.</p><p>Taylor W, Gladman D, Helliwell P et al.; CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665–73. DOI: http://dx.doi.org/10.1002%2Fart.21972.</p><p>Sieper J, Rudwaleit M, Baraliakos X et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009;68 Suppl 2:ii1–44. DOI: 10.1136/ard.2008.104018.</p><p>Healy PJ, Helliwell PS. Measuring clinical enthesitis in psoriatic arthritis: assessment of existing measures and development of an instrument specific to psoriatic arthritis. Arthritis Rheum. 2008;59(5):686–91. DOI:10.1002/art.23568.</p><p>Aletaha D, Smolen J. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): a review of theirusefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol. 2005;23(5 Suppl 39):S100–8.</p><p>Freeston JE, Coates LC, Helliwell PS et al. Is there subclinical enthesitis in early psoriatic arthritis? A clinical comparison with power doppler ultrasound. Arthritis Care Res (Hoboken). 2012;64(10):1617–21. DOI: 10.1002/acr.21733.</p><p>D’Agostino M, Said-Nahal R, Hacquard-Bouder C et al. Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross–sectional study. Arthritis Rheum. 2003;48(2):523–33. DOI: http://dx.doi.org/10.1002%2Fart.10812.</p><p>Pineda C, Amezcua-Guerra LM, Solano C et al. Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study. Arthritis Res Ther. 2011 Jan 17;13(1):R4. DOI: 10.1186/arc3223.</p><p>Falsetti P, Frediani B, Fioravanti A et al. Sonographic study of calcaneal entheses in erosive osteoarthritis, nodal osteoarthritis, rheumatoid arthritis and psoriatic arthritis. Scand J Rheumatol. 2003;32(4):229–34. DOI: http://dx.doi.org/10.1080%2F03009740310003721.</p><p>Hatemi G, Fresko I, Tascilar K, Yazici H. Increased enthesophathy among Behcet,s syndrome patients with acne and arthritis: an ultrasonography study. Arthritis Rheum. 2008 May;58(5):1539–45. DOI: 10.1002/art.23450.</p><p>Naredo E, Moller I, De Migue E et al. High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: a prospective case control study. Rheumatol. 2011;50:1838–48. DOI: 10.1093/rheumatology/ker078.</p><p>Paramarta JE, van der Leij C, Gofita I et al. Peripheral joint inflammation in early onset spondyloarthritis is not specifically related to enthesitis. Ann Rheum Dis. 2013 Apr 25. DOI:10.1136/annrheumdis-2012-203155.</p><p>Mease P. Measures of Psoriatic arthritis. Arthritis Care Res. 2011;63(S11):S64–S85. DOI: 10.1002/acr.20577.</p><p>Ibrahim G, Groves C, Chandramohan M et al. Clinical and Ultrasound Examination of the Leeds Enthesitis Index in Psoriatic Arthritis and Rheumatoid Arthritis G. ISRN Rheumatol. 2011;2011:731917. DOI: 10.5402/2011/731917.</p><p>D`Agostino MA, Aegerter P, Bechara K et al. How to diagnose spondyloarthritis early? Accuracy of peripheral enthesitis detection by power Doppler ultrasonography. Ann Rheum Dis. 2011 Aug;70(8):1433–40. DOI:10.1136/ard.2010.138701.</p><p>De Miguel E, Munoz-Fernandez S, Castillo C et al. Diagnostic accuracy of enthesitis in the diagnosis of early spondyloarthritis. Ann Rheum Dis. 2011;70(3):434–9. DOI: 10.1136/ard.2010.134965.</p><p>Naredo E, Wakefield R, Iagnocco A et al. The OMERACT ultrasound task force: status and perspectives. J Rheumatol. 2011 Sep;38(9):2063–7. DOI: 10.3899/jrheum.110425.</p><p>De Miguel E, Cobo T, Munoz-Fernandez S et al. Validity of enthesis ultrasound assessement in spondyloarthropathy. Ann Rheum Dis. 2009;68(2):169–74. DOI: 10.1136/ard.2007.084251. Epub 2008 Apr 7.</p></div><br /><div><p>Ревматология: Клинические рекомендации. 2-е изд., испр. и доп. Москва: ГЭОТАР-Медиа; 2010. 752 c. [Revmatologiya: Klinicheskie rekomendatsii. 2-e izd., ispr. i dop. Moscow: GEOTAR-Media; 2010. 752 p.]</p><p>Scarpa R, Cuocolo A, Peluso R et al. Early psoriatic arthritis: the clinical spectrum. J Rheumatol. 2008;35(1):137–41.</p><p>Rudwaleit M, van der Heijde D, Landewe R et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis. 2011;70(1):25–31. DOI: 10.1136/ard.2010.133645.</p><p>Taylor W, Gladman D, Helliwell P et al.; CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665–73. DOI: http://dx.doi.org/10.1002%2Fart.21972.</p><p>Sieper J, Rudwaleit M, Baraliakos X et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis. 2009;68 Suppl 2:ii1–44. DOI: 10.1136/ard.2008.104018.</p><p>Healy PJ, Helliwell PS. Measuring clinical enthesitis in psoriatic arthritis: assessment of existing measures and development of an instrument specific to psoriatic arthritis. Arthritis Rheum. 2008;59(5):686–91. DOI:10.1002/art.23568.</p><p>Aletaha D, Smolen J. The Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI): a review of theirusefulness and validity in rheumatoid arthritis. Clin Exp Rheumatol. 2005;23(5 Suppl 39):S100–8.</p><p>Freeston JE, Coates LC, Helliwell PS et al. Is there subclinical enthesitis in early psoriatic arthritis? A clinical comparison with power doppler ultrasound. Arthritis Care Res (Hoboken). 2012;64(10):1617–21. DOI: 10.1002/acr.21733.</p><p>D’Agostino M, Said-Nahal R, Hacquard-Bouder C et al. Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross–sectional study. Arthritis Rheum. 2003;48(2):523–33. DOI: http://dx.doi.org/10.1002%2Fart.10812.</p><p>Pineda C, Amezcua-Guerra LM, Solano C et al. Joint and tendon subclinical involvement suggestive of gouty arthritis in asymptomatic hyperuricemia: an ultrasound controlled study. Arthritis Res Ther. 2011 Jan 17;13(1):R4. DOI: 10.1186/arc3223.</p><p>Falsetti P, Frediani B, Fioravanti A et al. Sonographic study of calcaneal entheses in erosive osteoarthritis, nodal osteoarthritis, rheumatoid arthritis and psoriatic arthritis. Scand J Rheumatol. 2003;32(4):229–34. DOI: http://dx.doi.org/10.1080%2F03009740310003721.</p><p>Hatemi G, Fresko I, Tascilar K, Yazici H. Increased enthesophathy among Behcet,s syndrome patients with acne and arthritis: an ultrasonography study. Arthritis Rheum. 2008 May;58(5):1539–45. DOI: 10.1002/art.23450.</p><p>Naredo E, Moller I, De Migue E et al. High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: a prospective case control study. Rheumatol. 2011;50:1838–48. DOI: 10.1093/rheumatology/ker078.</p><p>Paramarta JE, van der Leij C, Gofita I et al. Peripheral joint inflammation in early onset spondyloarthritis is not specifically related to enthesitis. Ann Rheum Dis. 2013 Apr 25. DOI:10.1136/annrheumdis-2012-203155.</p><p>Mease P. Measures of Psoriatic arthritis. Arthritis Care Res. 2011;63(S11):S64–S85. DOI: 10.1002/acr.20577.</p><p>Ibrahim G, Groves C, Chandramohan M et al. Clinical and Ultrasound Examination of the Leeds Enthesitis Index in Psoriatic Arthritis and Rheumatoid Arthritis G. ISRN Rheumatol. 2011;2011:731917. DOI: 10.5402/2011/731917.</p><p>D`Agostino MA, Aegerter P, Bechara K et al. How to diagnose spondyloarthritis early? Accuracy of peripheral enthesitis detection by power Doppler ultrasonography. Ann Rheum Dis. 2011 Aug;70(8):1433–40. DOI:10.1136/ard.2010.138701.</p><p>De Miguel E, Munoz-Fernandez S, Castillo C et al. Diagnostic accuracy of enthesitis in the diagnosis of early spondyloarthritis. Ann Rheum Dis. 2011;70(3):434–9. DOI: 10.1136/ard.2010.134965.</p><p>Naredo E, Wakefield R, Iagnocco A et al. The OMERACT ultrasound task force: status and perspectives. J Rheumatol. 2011 Sep;38(9):2063–7. DOI: 10.3899/jrheum.110425.</p><p>De Miguel E, Cobo T, Munoz-Fernandez S et al. Validity of enthesis ultrasound assessement in spondyloarthropathy. Ann Rheum Dis. 2009;68(2):169–74. DOI: 10.1136/ard.2007.084251. Epub 2008 Apr 7.</p></div><br />

The authors declare that there are no conflicts of interest present.