Song Z B, Geng Y, Deng X R, Zhang X H, Zhang Z L
Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing 100034, China.
Beijing Da Xue Xue Bao Yi Xue Ban. 2021 Dec 18;53(6):1061-1066. doi: 10.19723/j.issn.1671-167X.2021.06.009.
To explore the difference in phenotype recognition of PsA patients in two clinical scenarios, physical examination with and without ultrasound assessment.
PsA patients who visited the rheumatology and clinical immunology department of Peking University First Hospital between January 2010 and October 2020, with complete data of clinical and ultrasound assessment were enrolled. The phenotypes were first identified based on physical examination only, and then combined with enthesitis and dactylitis shown on power doppler and gray-scale ultrasound. The phenotype groupings without and with ultrasound assessment were presented with Wayne diagram. The distributions of different clinical phenotypes were compared by using test or Fisher's exact test. The differences of clinical phenotypes with and without ultrasound assessment were compared by using Wilcoxon signed rank test.
A total of 227 patients with PsA were enrolled with one or more clinical domains. Physical examination revealed that psoriasis was in 209 (92.1%, 209/227) patients, nail involvement in 98 (43.2%, 98/227) patients, peripheral arthritis in 219 (96.5%, 219/227) patients, axial involvement in 25 (11.0%, 25/227) patients, dactylitis in 80 (35.2%, 80/227) patients, and enthesitis in 18 (7.9%, 18/227) patients. Besides 18 patients with clinical enthesitis, ultrasound scan revealed acute enthesitis in 80 patients, with hypoechogenicity (55 cases), tendon thickening (62 cases), and presence of Doppler signals (48 cases). Similarly, dactylitis on ultrasound was found in 18 patients besides those patients with clinical dactylitis. Compared with the phenotypes recognized based on physical examination only, the additional ultrasound assessment revealed that the most common phenotypes, peripheral arthritis was significantly less frequently recognized (49.8% . 27.8%, < 0.001), however on the other hand, the proportion of the patients with peripheral arthritis and enthesitis was significantly increased (4.4% . 18.1%, < 0.001). The phenotype of peripheral arthritis combined with enthesitis, and dactylitis was also dramatically increased (1.8% . 17.6%, < 0.001).
Ultrasound is a useful tool to identify enthesitis and dactylitis. With the aid of ultrasound assessment, rheumatologists can better identify the lesions of PsA, accurately identify the phenotypes, and further guide the subsequent treatment.
探讨在两种临床情况下，即单纯体格检查与体格检查联合超声评估时，银屑病关节炎（PsA）患者的表型识别差异。
纳入2010年1月至2020年10月期间就诊于北京大学第一医院风湿免疫科且临床和超声评估数据完整的PsA患者。首先仅基于体格检查确定表型，然后结合能量多普勒和灰阶超声显示的附着点炎和指（趾）炎确定表型。用韦恩图展示单纯体格检查和联合超声评估时的表型分组。采用卡方检验或Fisher精确检验比较不同临床表型的分布情况。采用Wilcoxon符号秩检验比较有无超声评估时临床表型的差异。
共纳入227例有一个或多个临床领域表现的PsA患者。体格检查发现，209例（92.1%，209/227）患者有银屑病，98例（43.2%，98/227）患者有指甲受累，219例（96.5%，219/227）患者有外周关节炎，25例（11.0%，25/227）患者有中轴受累，80例（35.2%，80/227）患者有指（趾）炎，18例（7.9%，18/227）患者有附着点炎。除18例有临床附着点炎的患者外，超声检查发现80例患者有急性附着点炎，表现为低回声（55例）、肌腱增厚（62例）和存在多普勒信号（48例）。同样，除有临床指（趾）炎的患者外，超声检查还发现18例患者有指（趾）炎。与仅基于体格检查识别的表型相比，额外的超声评估显示，最常见的表型外周关节炎的识别频率显著降低（49.8%对27.8%，P<0.001），然而另一方面，外周关节炎合并附着点炎的患者比例显著增加（4.4%对18.1%，P<0.001）。外周关节炎合并附着点炎和指（趾）炎的表型也显著增加（1.8%对17.6%，P<0.001）。
超声是识别附着点炎和指（趾）炎的有用工具。借助超声评估，风湿病学家可以更好地识别PsA的病变，准确识别表型，并进一步指导后续治疗。
