Miotto E Silva Vanessa Bugni, Mitraud Sônia de Aguiar Vilela, Furtado Rita Nely Vilar, Natour Jamil, Len Claudio Arnaldo, Terreri Maria Teresa de Sande E Lemos Ramos Ascensão
Pediatric Rheumatology Unit, Allergy, Immunology and Rheumatology Division, Pediatric Department, Universidade Federal de São Paulo/Escola Paulista de Medicina (UNIFESP/EPM), Borges Lagoa Street, 802, Vila Clementino, São Paulo, SP Zip code 04038-001, Brazil.
Imaging Diagnostics Department, UNIFESP/EPM, São Paulo, Brazil.
Pediatr Rheumatol Online J. 2017 Nov 13;15(1):80. doi: 10.1186/s12969-017-0208-7.
Ultrasonography (US) studies carried out on joints of juvenile idiopathic arthritis (JIA) patients in clinical remission demonstrate the presence of subclinical synovitis. The significance of subclinical synovitis and the positive power Doppler (PD) signal on US in JIA in clinical remission is not well understood. The objectives of this study were to assess whether the changes detected by US in patients with JIA in clinical remission can predict disease flare and to evaluate factors associated with flare and joint damage over 30 months of follow-up.
A prospective study was performed with clinical and ultrasound evaluation in 34 joints of JIA patients in clinical remission. Clinical evaluation including physical exam, functional capacity and inflammatory markers was performed at baseline and every six months thereafter, for a total period of 30 months. US evaluation included presence of synovitis, PD signal and erosion at baseline and every 12 months thereafter. Subclinical synovitis was defined when there was synovitis with or without positive PD signal in US joints of patients in clinical remission. Flare was defined as any joint presenting clinical arthritis requiring therapy modification.
We evaluated a total of 35 patients, 28 (80%) girls, 14 (40%) persistent oligoarticular subtype, 12 (34.3%) oligoarticular extended and 9 (25.7%) polyarticular and 26 (74.3%) in remission on medication. Twenty (57.1%) patients flared. The risk of flare was five times higher in patients with positive PD signal and 14 times higher in patients in remission on medication. Regarding the assessment of joints after 6 months and 12 months of US evaluation, 70/3162 (2.2%) joints and 80/2108 (3.8%) joints flared, respectively. Joints with subclinical synovitis with positive PD signal flared more after 6 and 12 months. Twenty five of 2108 (1.2%) joints showed erosion over time. Joints with subclinical synovitis with or without positive PD signal showed more erosion.
Patients in remission on medication with subclinical synovitis with positive PD signal on US have a higher risk of flare, therefore they should be monitored closely during treatment. In the same way, joints with subclinical synovitis with or without positive PD signal should be monitored due to the risk of flare and joint damage.
对临床缓解期的幼年特发性关节炎（JIA）患者关节进行的超声检查（US）显示存在亚临床滑膜炎。亚临床滑膜炎以及US上的阳性能量多普勒（PD）信号在临床缓解期JIA中的意义尚未完全明确。本研究的目的是评估临床缓解期JIA患者US检测到的变化是否能预测疾病复发，并评估随访30个月期间与复发和关节损伤相关的因素。
对临床缓解期的JIA患者的34个关节进行了临床和超声评估的前瞻性研究。在基线时以及此后每6个月进行一次临床评估，包括体格检查、功能能力和炎症标志物，为期共30个月。US评估包括基线时以及此后每12个月的滑膜炎、PD信号和侵蚀情况。当临床缓解期患者的US关节存在滑膜炎伴或不伴阳性PD信号时，定义为亚临床滑膜炎。复发定义为任何出现需要调整治疗的临床关节炎的关节。
我们共评估了35例患者，其中28例（80%）为女孩，14例（40%）为持续性少关节型亚型，12例（34.3%）为少关节型扩展型，9例（25.7%）为多关节型，26例（74.3%）在药物治疗下处于缓解期。20例（57.1%）患者复发。PD信号阳性的患者复发风险高5倍，药物治疗缓解期的患者复发风险高14倍。关于US评估6个月和12个月后的关节评估，分别有70/3162（2.2%）个关节和80/2108（3.8%）个关节复发。6个月和12个月后，伴有阳性PD信号的亚临床滑膜炎关节复发更多。2108个关节中有25个（1.2%）随时间出现侵蚀。伴有或不伴有阳性PD信号的亚临床滑膜炎关节侵蚀更多。
US上有阳性PD信号的亚临床滑膜炎且药物治疗缓解期的患者复发风险更高，因此在治疗期间应密切监测。同样，由于存在复发和关节损伤风险，对于伴有或不伴有阳性PD信号的亚临床滑膜炎关节也应进行监测。
