Low-field magnetic resonance imaging study on carpal arthritis in systemic sclerosis - low-grade erosive arthritis of carpal bones is an unexpected and frequent disease manifestation.

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by  Akbayrak, Elif

Akbayraketal.ArthritisResearch&Therapy2013,15:R2
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RESEARCH ARTICLE Open Access
Low-field magnetic resonance imaging study on
carpal arthritis in systemic sclerosis - low-grade
erosive arthritis of carpal bones is an unexpected
and frequent disease manifestation
Elif Akbayrak, Robert Dinser, Ulf Müller-Ladner and Ingo H Tarner*
Abstract
Introduction: The aim of the present study was to assess the prevalence and characteristics of subclinical arthritis
of carpal and metacarpophalangeal joints in patients with systemic sclerosis (SSc).
Methods: Low-field (0.2 T) magnetic resonance imaging (MRI) was performed in consecutive patients with SSc
attending our center between January 2010 and March 2011. Results were assessed in a standardized manner
using the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) and standardized assessments of all
hand joints. Patients with arthritis due to overlap syndromes were excluded.
Results: Of 38 inpatients and eight outpatients who were screened for inclusion, 30 patients participated in the
study and 26 patients could be evaluated. Erosions, bone marrow edema, synovitis, and joint effusions were found
in 87%, 37%, 68%, and 58%, respectively, and 24% of patients had additional tenovaginitis. Arthritis affected only a
low number of joints per analyzed hand. All bones and joints could be affected, but synovitis and bone marrow
edema occurred predominantly in the proximal row of carpal bones, most frequently affecting the lunate bone.
The extent of inflammatory changes measured with the RAMRIS correlated significantly with the functional status
assessed with the validated German functional score questionnaire Funktionsfragebogen Hannover.
Conclusion: Low-grade arthritic changes on low-field MRI are frequent in patients with pure SSc. The features of
arthritis in SSc differ from rheumatoid arthritis. The distribution, the MRI pattern and the predilection for the lunate
bone raise the hypothesis that arthritis in SSc may be caused not only by immunological inflammation but also by
ischemic mechanisms.
Introduction Registerstudies [5,6] and retrospective clinical studies
In the clinical evaluation of systemic sclerosis (SSc), including a meta-analysis of existing data [7] have
attention is predominantly given to changes of the skin, recentlysuggestedthatinflammatoryarthritismay bean
Raynaud’sphenomenonanditscomplications,andinter- underestimatedprobleminSSc.Thissuggestioncouldbe
nalorganinvolvement.Whilearthritishasbeenobserved of therapeutic importance because disease-modifying
inSSc[1],itisfrequentlyconsideredtoindicateanover- antirheumatic drugs available for inflammatory arthritis
lap between rheumatoid arthritis (RA) and SSc [2,3], mightalsobeusefultodelayorpreventjointdamageand
whereasjointpaininpatientswithsoleSSciscommonly lossoffunctioninSScpatients.
regarded as non-inflammatory arthralgia caused by skin We therefore performed a prospective magnetic reso-
tightnessandflexioncontractures[4]. nance imaging (MRI)study of the handsinpatientswith
SSc, excluding patients with clinical or immunological
signs suggesting an overlap with other forms ofarthritis.
*Correspondence:[email protected] We aimed to determine the prevalence of MRI signs of
DepartmentofInternalMedicineandRheumatology,Justus-Liebig-University
arthritisincludingsynovitis,bonemarrowedema,effusions,
Giessen,DepartmentofRheumatologyandClinicalImmunology,Kerckhoff-
Klinik,Benekestraße2-8,D-61231BadNauheim,Germany
©2013Akbayraketal.;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
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and erosionsaswellasto characterizethedistribution of Images were assessed systematically using two
joint involvement. MRIwas chosen because it is an ima- approaches.InthefirstapproachtheRheumatoidArthri-
gingtoolwithhighsensitivityforthedetectionofinflam- tisMagneticResonanceImagingScore(RAMRIS)[16,17]
matoryjointchanges,ashasbeendemonstratedverywell developedforRAandhigh-fieldMRIwasappliedbytwo
inRA[8]andalsoinSSc[9,10]. independent investigators, and scores were calculated
using the average score of both investigators for each
Materials and methods item. Owing to the technical lack of fat suppression for
Consecutive patients with SSc treated as inpatients or T1-weighted images in low-field MRI, synovitis was
outpatientsinourdepartmentbetweenJanuary2010and assessedbycomparingsignalintensitiesofthesynovium
March2011were consideredforthisstudy.Patientshad before and after the application of Gadodiamide side by
to fulfill the LeRoy criteria for limited cutaneous SSc or side.Thickeningofthesynoviumwithenhancementafter
diffuse cutaneous SSc [11]. We excluded patients with applicationofthecontrastagentwasjudgedassynovitis,
the clinical picture of an overlap syndrome (such as which was assessed only if contrast agent could be
Sharp’s syndrome) or a clinical association with other applied. Erosions were defined to be present if the con-
rheumaticdiseasessuchasankylosingspondylitisorRA. tour of the cortical bone was interrupted in at least two
We also excluded patients in whom antibodies against anatomicalplanesandifenhancementofthedefectwith
U1-ribonucleoproteinsoranti-citrullinatedpeptideanti- Gadodiamidewasdetected.Inserieswithoutapplication
bodies(ACPA) hadbeendetected eitherwithinthe pre- of contrast agent, the first criterion was deemed suffi-
viousyear or when screened for enrolment. Outpatients cient.Thepresenceofbonemarrowedemawasscoredas
had to live within a radius of 50 km to be able to return definite ifa hyperintense signal couldbe detected in the
for the study assessments. To address the problem of short-tau inversion recovery sequence image and a
subclinicalarthritis,thepresenceorabsenceofjointpain hypointensesignal couldbedetectedintheT1-weighted
orswellingwasnotconsideredforinclusion. image.
Afterobtainingwritteninformedconsent,thefollowing AstheRAMRISdoesnotjudgeeffusionsandpreselects
assessments were performed: tender and swollen hand joints involved in RA, a second descriptive systematic
andfingerjointcounts;fullskinstatususingthemodified analysis for the presence of synovitis, bone marrow
Rodnan skin score; and functional assessment using the edema,erosions,jointeffusion,andtenovaginitiswasper-
German-language questionnaire Funktionsfragebogen formed for the following areas: radiocarpal, ulnocarpal,
Hannover(FFbH)withvaluesrangingfrom0to100,the radioulnar,intercarpalandfirstcarpometacarpaljointsas
latterreflecting completely normalfunction[12]. Use of wellasmetacarpophalangealjoints1to5.Forbonemar-
theFFbHisstandardatour centerandFFbHvaluescan row edema and erosions, bones ofthe carpusand meta-
be converted into health assessment questionnaire carpuswereanalyzedseparately(distalulna,distalradius,
(HAQ)valuesusingtheformula: scaphoid, lunate, triquetral, pisiform, trapezium, trape-
zoid,capitate, hamate,basesofmetacarpal bones1to5,
HAQ = 3.16 − (0.028×FFbH). heads of metacarpal bones1to 5,andbasesofproximal
phalanges1to5).Flexorandextensortendonswereana-
The calculated HAQ is therefore also presented [13]. lyzedfortenovaginitis.
Theerythrocytesedimentationrateand,ifnotdocumen- EachMRIfeaturewasclassifiedasabsentorquestion-
ted previously, ACPA were measured. Morbidity and able, clearly present, or severe. If the increase in signal
SSc-relatedtreatmentswerealsorecorded. intensityafter contrastinjectionwasobviouseveninthe
Patientsunderwentlow-fieldMRI(0.2T,EsaoteC-scan; absenceofacomparisonwiththebaselineimage,synovi-
Esaote,Cologne,Germany)ofthecarpusandthemetacar- tiswas classified assevere. Severe erosionswere defined
pophalangealjointsineither themorepainfulhandor,if asdefectsoccupyingmorethan50%ofthebonysurface.
notapplicable,thedominanthand[14,15].Athree-dimen- Effusionswereanalyzedintheshort-tauinversionrecov-
sional, gradient-echo T1-weighted sequence, a fat-satu- ery sequence, with a convex contour of the fluid signal
ratedshort-tauinversionrecoveryT2-weightedsequence, withinthejointcapsuleconsidereddefinite,andadisten-
and a second three-dimensional, gradient-echo T1- tion of the overlying skin contour considered severe.
weighted sequence were acquired after application of a Bone marrow edema of more than 50% of the existing
gadolinium-based contrast agent (Gadodiamide, Omnis- bone area was considered severe. Examples for typical
can™;GEHealthcare,Munich, Germany). Inconsenting findings for each assessment are shown in Figure S1 in
patients,theotherhandwasmeasuredafteratimeinterval Additionalfile1.
ofatleast1daytoallowforcompletewashoutofthecon- Forstatisticalanalysis, theWilcoxonranktestorFish-
trastagent. er’sexacttestwereusedwhereappropriate.Correlations
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wereanalyzedusingKendall’stauranktest[18],whichis exhibitanyclinicalpainorswellinginthejointsassessed
similartoSpearman’sRhorankcorrelationtest butdoes byMRI.Only21%ofallhandsdidnotshowanysignsof
notimplyalinearcorrelationbetweenvalues. current arthritis on MRI (synovitis, effusion, bone mar-
The study was approved by the ethics committee of rowedema).
the University of Giessen. Whileeffusionsand erosionswerefrequent,theywere
rarelysevere(Table3;forreference,seealsoFigureS1in
Results Additionalfile1).Strongsynovialenhancementwaspre-
Atotalof52inpatientswerescreenedforenrolment.Four sent in 13% of analyzed patients. Severe bone marrow
patients were excluded due to overlap with other rheu- edema occurred in 15% of patients, suggesting a strong
maticdiseases,andthreepatientswereexcluded because association of this feature of arthritis with SSc. In the
theirclinicalconditiondidnotpermitMRImeasurements. majority of patients, arthritis affected only a few joints
Sevenpatientswereunabletoparticipateduetoorganiza- withinonehand.
tional difficulties. Of the 38 inpatients enrolled in the When analyzing the localization of affected joints and
study,27agreedtoundergoMRImeasurementsinoneor bones, synovitis was found more frequently in the inter-
bothhands.Eightoutpatientswerealsofoundtobeeligi- carpal joints than in the metacarpophalangeal joints
ble,threeofwhomagreedtoparticipate. (Table 3), with severe synovitis occurring in up to 6% of
Three patients had to be excluded from the analysis carpal joint areas. While bone marrow edema could
after acquisitionofMRImeasurements,becausepositive affect most bones of the carpus and metacarpus, it most
results for ACPA became available in two of them and frequently and most severely affected the lunate, with a
the diagnosis had to be revised to Sharp’s syndrome in definite edema occurring in 18% of lunate bones and
thethirdpatient.ThesignalqualityoftheMRImeasure- severe edema in 11%. The scaphoid and triquetrum
mentswasinadequateforinterpretationinonepatient. were also prone to bone marrow edema. The predilec-
A total of 26 patients could therefore be analyzed, of tion of the proximal row of carpal bones for bone mar-
whom12agreedtomeasurementsinbothhandsandthe row edema was also reflected in the frequency of
other14onlytomeasurementsinonehand.Atotalof38 erosions in these bones (Table 3). No synovitis could be
hands could thus be examined. Owing to difficulties in found in 27% of joint areas with bone marrow edema.
obtaining venous access, contrast agent could not be None of the patients has had previous severe trauma or
applied in seven of the 38 MRI examinations. None of fractures of the distal forearm, carpal bones, metacarpal
thepatientsfulfilledeither thecurrentAmericancollege bones, or fingers, and only one patient had a history of
ofRheumatology/EuropeanLeagueAgainstRheumatism occupational exposure to vibratory tools or machinery
ortheformerAmericanCollegeofRheumatologyclassi- (a construction worker who frequently drilled concrete).
ficationcriteriaforRA[19,20]. In the latter patient, however, only the lunate and tri-
The characteristics of our group of patients and a quetrum of the left hand each showed a small erosion
summary of the results, including the RAMRIS and the without bone marrow edema whereas the other carpal
functional FFbH and HAQ scores, are shown in Table 1. bones of both hands showed no abnormality.
The detailed RAMRI scores for each patient are pre- The RAMRIS validated for RA correlated moderately
sented in Table S1 in Additional file 2. with the overall functional joint status assessed by the
At the time of MRI examination, 10 patients received FFbH(correlationcoefficient=-0.48,P=0.002;Figure1)
immunomodulatory drug treatments: five patients were as well asthe calculated HAQ scores (correlation coeffi-
being treated with methotrexate, one each with lefluno- cient=0.48,P=0.002).Asummaryscorecalculatedfrom
mide, mycophenolate, and etanercept, respectively, and the secondary systematic assessment correlated strongly
twopatientswere beingtreatedwithcyclophosphamide. with the RAMRIS (correlation coefficient = 0.80, P <
All patients on prednisolone took ≤ 5 mg/day. Iloprost 0.0001).Clinicaltenderorswollenjointcountresults did
(Ilomedin™; Bayer Vital GmbH, Leverkusen, Germany) not match with MRI findings. The arthritis score was
wasappliedto46%ofpatientsatthetimeofMRIexami- more severe in patients with more widespread disease
nationbecauseofaclinicalworseningoftheirRaynaud’s involvement, reflected by the number of affected organ
syndrome. Nineteen patients were onlong-termvasodi- systems(correlationcoefficient=0.43,P<0.01),butthere
latingdrugs(calciumchannelblockers,bosentanandsil- wasnoassociationwiththedegreeofskininvolvementas
denafil), and three patients had concomitant measured by the modified Rodnan skin score, systemic
arteriosclerotic disease (two coronary heart disease, one inflammation as assessed by erythrocyte sedimentation
peripheralarterialdisease). rate,diseaseduration,orage.TheRAMRISdidnotdiffer
Whenanalyzingallmeasuredhands,everyMRIfeature betweenpatientswithshortdiseaseduration≤3yearsand
ofarthritiswasobservedinahighproportionofpatients patients with longer-standing disease (mean ± standard
(Table2)even though64% ofallhandsanalyzeddidnot deviation RAMRIS, 6.3 ± 4.3 vs. 6.6 ± 5.0, P = 0.918).
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Table 1Patient characteristics
Parameter AllSSc(n=26) DiffusecutaneousSSc(n=6) LimitedcutaneousSSc(n=20)
Age(years) 56±13(32to75) 50±9(40to66) 46±14(32to75)
Sex(%female) 77 67 80
Diseaseduration(years) 7.9±5.3(1to19) 7.7±6.0(3to19) 8.0±5.2(1to18)
ModifiedRodnanskinscore 8.3±6.1(2to19) 16.3±3.3(12to19) 5.8±4.3†(2to18)
Organandtissueinvolvement
Pulmonaryfibrosis 11(42) 6(100) 5(25)**
Pulmonaryhypertension 5(19) 3(50) 2(10)
Cardiacinvolvement 6(23) 1(17) 5(25)
Gastrointestinalinvolvement 2(8) 1(17) 1(5)
Activedigitalulcer 7(27) 0(0) 7(30)
Historyofdigitalulcer 16(62) 4(83) 12(55)
Arterioscleroticdisease 3(12) 0(0) 3(15)
ESR(mm/hour) 19±14 28±20 16±11
Antinuclearantibodypositivity 23(89) 5(83) 18(90)
Anti-centromereantibody 11(42) 0(0) 11(55)*
Anti-Scl70antibody 9(35) 2(33) 7(35)
Medication
Immunomodulatorydruga 10(38) 2(33) 8(40)
Steroids 6(23) 1(17) 5(25)
Iloprost 12(46) 3(50) 9(45)
Calcium-channelblockers 9(35) 2(33) 7(35)
Betablockers 1(4) 0(0) 1(5)
Bosentan 7(27) 3(50) 4(20)
Sildenafil 3(12) 0(0) 3(15)
Low-doseaspirin 5(19) 0(0) 5(25)
RAMRIS 6.5±4.7(0to14) 5.4±4.1(1to12) 7.0±5.0(0to14)
Radiographsofthehands 21(81) 4(67) 17(85)
Signsofarthritis 2(10) 0(0) 2(12)
Acroosteolysis 9(43) 2(50) 7(41)
Soft-tissuecalcifications 11(52) 1(25) 10(59)
FFbH(%functionalcapacity) 68.7±22.8(33to100) 58.2±25.2(39to100) 71.9±21.7(33to100)
HealthAssessmentQuestionnaireb 1.24±0.64(0.36to2.25) 1.54±0.7(0.36to2.08) 1.15±0.61(0.36to2.25)
Datapresentedasmean±standarddeviation(range)orn(%).OnlytheRheumatoidArthritisMagneticResonanceImagingScore(RAMRIS)fortheclinically
dominantlyaffectedhandwasanalyzed.Percentageswererounded.ESR,erythrocytesedimentationrate(Westergren’smethod);FFbH,Funktionsfragebogen
Hannover(German-languagestandardizedassessmentquestionnaireonphysicalfunction);SSc,systemicsclerosis.Significantdifferences:*P<0.05and**P<0.01
betweenthegroupswithlimitedanddiffuseskindiseaseasassessedbyFisher’sexacttest;†P<0.01asassessedbytheMann-WhitneyUtest.Allother
comparisonswerenonsignificant.aIncludingmethotrexate,leflunomide,mycophenolate,etanercept,andcyclophosphamide.bValuescalculatedfromtheFFbH
usingtheformula:HAQ=3.16-(0.028×FFbH)).
Table 2Proportion ofhands showing different featuresofarthritis onmagnetic resonance imaging
Erosion Bonemarrowedema Synovitis Jointeffusion Tenovaginitis
Signsofarthritis
Notpresent/indeterminate 13 63 32 42 76
Present 87 37 68 58 24
Severe 3 16 13 0 0
Affectedjointsinaffectedhands 2.2±1.6(1to6) 1.6±1(1to4) 4.1±2.6(1to9) 4.2±2.6(1to10) N/A
Datapresentedaspercentageormeannumber±standarddeviation(range).FordefinitionofdefiniteorseverepleaserefertoMaterialsandmethods.N/A,not
applicable.
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Table 3Distribution ofmagnetic resonance imaging lunatebonesbutnodefinitiveerosionsonX-ray,whereas
findings in individual joints and bonesofthe hand low-fieldMRIclearlyshowedbilaterallunateerosions.In
Synovitis Jointeffusion all other patients with lunate erosions on MRI, no
Definitive Severe Definitive Severe abnormalitiesweredetectedbyX-rayscan.Ofnote,none
of the patients with bone marrow edema of the lunate
Joint
bonehadradiographicabnormalities.Acroosteolysisand
Radiocarpal 19 3 8 -
extraarticular soft-tissue calcifications were observed in
Radioulnar 23 - - -
43% and 52% of the radiographs, respectively (Table 1).
Ulnocarpal 48 6 - -
The presence and severity of MRI features of arthritis,
Intercarpal 52 3 47 -
however, were not correlated with the finding of either
Carpometacarpaljoint1 6 - 3 -
acroosteolysisorcalcifications.
Metacarpophalangeal 13 - 11 -
joint1
Metacarpophalangeal 6 - 3 - Discussion
joint2 This prospective systematic low-field MRI study shows
Metacarpophalangeal 23 - - - thatsubclinicalarthritisofthecarpusand metacarpusis
joint3
a frequent manifestation in patients with SSc, which is
Metacarpophalangeal 16 - 5 -
underestimated by clinical examination as well as plain
joint4
radiographs. The relevance of this observation isunder-
Metacarpophalangeal 16 - 5 -
joint5 lined by the correlation of a quantitative assessment of
Bonemarrow Erosion arthriticchanges,theRAMRIS,withvalidatedfunctional
edema assessments, the FFbH and HAQ. The arthritis score is
Definitive Severe Definitive Severe also associated with severity of disease estimated by the
Bone numberofaffectedorgansystems.
Ulna/radius - - 3 - The presence of arthritis in SSc has been suggested in
Scaphoid 3 - 13 - largeregisterstudies[5,6].Aretrospectivecohortanalysis
Lunate 18 11 45 3 with supplementary meta-analysis from our group also
Triquetral 8 - 50 - supportsahighprevalenceofclinicalanderosivearthritis
Pisiform - - - - as agenuinefeature of SSc[7].Registercohorts havethe
Trapezium 5 3 13 - drawbackthat data are frequently collected by nonrheu-
Trapezoid - - 5 - matologists,resultinginahighheterogeneityinclassifica-
Capitate 3 - 24 - tion of joint findings [5]. Furthermore, a definite
Hamate - - 3 - differentiationbetweenoverlapsyndromesandpureSScis
Metacarpalbase1to5 2 1 2 - difficult withinregister studies, retrospective approaches
Metacarpalhead1to5 1 - 8 - ormeta-analyses[7].
Phalangealbase1to5 - - 2 - MRI is considered a very sensitive method for the
detection of arthritis. High-field MRI has thus far been
Foreachmagneticresonanceimagingfeature,frequenciesofdefiniteand
severemanifestationareindicatedasapercentage.-,notpresent.Joint used to examine hand joints in SSc patients in two
effusion,bonemarrowedemaanderosionscouldbedeterminedin38hands smaller studies. One retrospective study on 17 patients
fromour26patients.Synovitiscouldonlybeassessedin31hands,dueto
lackofvenousaccessfortheapplicationofcontrastagent. with joint pain and SSc observed inflammatory changes
in 59% of patients [9]. In this study, bone marrow
There was also no correlationbetween immunosuppres- edema was even more prominent (53%) than in our
sivedrugtreatment,iloprosttreatment,long-termvasodi- cohort (37%), whereas the proportion of patients with
latingdrugtreatment,b-blockeruse,low-doseaspirinuse, erosions was much lower (41%) compared with our
or concomitant arteriosclerotic disease and the presence study (87%). Unfortunately, no details are provided on
of MRI features of arthritis. Neither was affection of the the localization of bone marrow edema in the different
lunate bone correlatedwitharteriosclerosisorthe use of patients [9]. Another prospective study analyzed 17
vasodilatingdrugs,b-blockersorlow-doseaspirin. patients with arthralgias and SSc by ultrasound, eight of
Radiographs of the hands were obtained as part of the whom also underwent MRI [10]. Joint synovitis was
diagnostic work-up in 21 of the 26 patients (81%; Table found by ultrasound in one of 17 patients initially, in
1). Two patients had radiographic changes of the lunate. three of 13 patients after 6 months, and in eight of eight
One of these patients had a small erosion that corre- patients analyzed by MRI. Of these eight patients, five
sponded to the erosion seen on low-field MRI. The also exhibited bone marrow edema and six patients had
other patient exhibited small cystic changes of both erosions [10]. Ultrasound thus appears to underestimate
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Figure1Correlationofthearthritisscorewithglobalfunction.CorrelationoftheRheumatoidArthritisMagneticResonanceImagingScore
(RAMRIS)withglobalfunctionassessedbytheGermanFunktionsfragebogenHannover(FFbH)questionnaire.
arthritis manifestations in SSc even in patients with clin- MRI. The overall disease severity of SScinthese patients
ical arthralgias. wascomparable,butthisdysbalancemaybiasourfindings.
ThehighsensitivityoftheMRItechnique,therelatively The prevalence and severity oferosions,bone marrow
largenumberofpatientsforasinglecenterandtheinclu- edema,andsynovitisinourcohortwithlongstandingSSc
sionofpatientsindependent ofclinicalarthralgiaorjoint are comparable with studies on patients with early RA
swellingaswellasthestringentexclusionofknownarthri- [22]. In longstanding RA, the severity of inflammatory
tis-associated diseases are specific strengths of our study and destructive changes usually increases and affects
forthedeterminationofapointprevalenceofarthritisin more joints, thus leading to more severe MRI findings
SSc in comparison withtheother studies.Adrawbackof than those observed in our study [8]. Owing to the fact
ourstudyistheabsenceofahealthy controlgroup, since thatthepatientsinourstudydidnotfulfillanyclassifica-
erosionscanalsobeobservedinhealthysubjects[21].Even tioncriteriaofRAandthatthedetectedarthriticchanges
thoughweusedaverystringentdefinitionoferosion,the wererelativelymilddespitelong-standingdiseasewithout
prevalenceoferosionsmaythusbeoverestimated.Onthe disease-modifying anti-rheumatic drug treatment in the
contrary,thelow-fieldtechniqueunderestimatesbonemar- majority of cases, we conclude that arthritis in SSc does
rowedemacomparedwithhigh-fieldMRI[14],whichmay notreflectanoverlapsyndromewithRA[2,3],butrepre-
explain the difference in comparison with the results of sentsagenuinediseasemanifestation.
Low and colleagues [9]. The failure to inject intravenous The high prevalence of bone marrow edema in our
contrastagentin18.5%ofthe38MRIexaminationsleads cohortisofspecificinterestsincebonemarrowedemain
tounderestimationofsynovitisintheRAMRIS.Themulti- RAusuallyheraldserosions[15,22]. Thesameindication
tude of arthritis-associated MRI findings and the asso- appearstobetrueforarthritisinSScsincethefindingof
ciation of quantitative arthritis assessments with the bone marrow edema was frequently associated with ero-
functional score are arguments for the overall validity of sions in our study. The predilection of bone marrow
our findings. Another drawback is that 35% of eligible edemaanderosionsforthelunateandotherbonesofthe
patientsdeclinedparticipation,eventhoughthepositioning proximalrowofcarpalsisnoteworthyandreminiscentof
in the low-field MRI is more tolerable than in high-field earlyosteonecrosis.
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This finding raises the hypothesis that not only an
Additionalfile2:TableS1presentingasummaryoftheRAMRIS.
autoimmune process but also ischemia on the basis of ThistableprovidesanoverviewoftheRAMRISperpatient.N/A,not
the characteristic microangiopathy of SSc and the fre- applicableduetolackofvenousaccessfortheinjectionofcontrast
agent.
quent stenosis of arterial vessels of the wrist in patients
with SSc [23,24] may play a role in SSc arthritis and its
predilection for the lunate bone. Along this line, four
cases have been published [25,26] that illustrate an asso- Abbreviations
ciation between osteonecrosis of the lunate bone and ACPA:anti-citrullinatedpeptideantibodies;FFbH:Funktionsfragebogen
Hannover;HAQ:HealthAssessmentQuestionnaire;MRI:magneticresonance
SSc with severe Raynaud’s phenomenon, the clinical
imaging;RA:rheumatoidarthritis;RAMRIS:RheumatoidArthritisMagnetic
hallmark of ischemia in SSc. In addition, the severity of ResonanceImagingScore;SSc:systemicsclerosis.
Raynaud’s phenomenon has been associated previously
Authors’contributions
with the development of erosive arthritis in SSc [27].
EA,RD,andIHTdesignedthestudy.EAandIHTperformedtheexamination
The prominent affection of the lunate bone and the ofpatientsandthelow-fieldMRImeasurements.EA,RD,andIHTanalyzed
high severity of Raynaud’s phenomenon in the majority theMRIimages,RDandIHTperformedtheRAMRIS.EA,RD,UM-L,andIHT
discussedandinterpretedalldata.EAdraftedthemanuscript,andRD,UM-L,
of our patients - as indicated by the high proportion of
andIHTcriticallyreviewedandrevisedthemanuscript.Allauthorsreadand
patients complaining of clinical deterioration (62%), the approvedthesubmittedmanuscript.EA,UM-L,andIHTreadandapproved
need for intravenous iloprost despite long-term use of thefinalmanuscriptafterRDdeceased.
oral vasodilators, and the high proportion of current or
Competinginterests
previous digital ulcers - thus fit very well with the Theauthorsdeclarethattheyhavenocompetinginterests.
hypothesis that SSc arthritis is triggered by reactions to
Acknowledgements
ischemia in the context of severe Raynaud’s phenom-
Theauthorswishtoacknowledgewiththismanuscriptthelifeandworkof
enon [28] in addition to immunological mechanisms. Prof.RobertDinser,MD,whodiedinatragicaccidentshortlyafter
completionofthisworkandthefirstsubmissionofthismanuscriptto
ArthritisResearch&Therapy.Prof.Dinserdevelopedtheideaofthestudyand
Conclusion
wasthecorrespondingauthorfortheinitialsubmission.
Insummary,arthritischaracterizedbymildsynovitis,bone
marrow edema with a predilection for the lunate bone, Received:28March2012 Revised:25November2012
Accepted:2January2013 Published:4January2013
mild effusions, and low-grade erosions is a clinically
underestimatedbutfrequent,genuinefeatureofSSc.The
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