Zunica Fiammetta, Loiodice Martina, Riccaboni Francesca, Carlucci Patrizia, Zuccotti Gian Vincenzo, Ricci Vincenzo
Department of Pediatrics, Buzzi Children's Hospital, University of Milan, Milan, Italy.
Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
Ultrasound. 2024 Jun 24:1742271X241260248. doi: 10.1177/1742271X241260248.
Enthesitis-related arthritis is a specific subtype of juvenile idiopathic arthritis characterised by the co-presence of arthritis and enthesitis or the evidence of one of them coupled with at least two among sacroiliac joint tenderness, inflammatory back pain, presence of human leukocyte antigen-B27, acute symptomatic anterior uveitis, onset in a male child aged 6 years or older or history of spondyloarthropathy in a first-degree relative. Small joints like the sternoclavicular joint are rarely affected, and the prevalence of their involvement in enthesitis-related arthritis has been poorly assessed in the pertinent literature.
The authors report an atypical case of left sternoclavicular joint arthritis/enthesitis in a 12-year-old male child with juvenile idiopathic arthritis. The B-mode sonographic findings of articular effusion, synovial hypertrophy and capsular bulging, coupled with the microvascular mapping with colour Doppler of the sternoclavicular joint, have been crucial to optimising the pharmacological approach in clinical practice. In this sense, the sonographic examination presented as a natural extension of the physical examination to accurately define the poor control of disease activity using first-line pharmacological agents.
The present case report can be considered the first to accurately report the B-mode and the colour Doppler findings of a pathological sternoclavicular joint in a patient enthesitis-related arthritis. Ultrasound imaging demonstrated intra-articular effusion, capsular bulging and synovial hypertrophy clearly defining sternoclavicular joint arthritis. Interestingly, the hypervascularisation involved both the synovial tissue and the capsule-bone interface - that is, the enthesis of the joint capsule - suggesting a potential co-existence of arthritis and enthesitis of the sternoclavicular joint in enthesitis-related arthritis patients.
The high-resolution point-of-care ultrasound seems to be a potential 'game changer' in paediatrics to promptly optimise the pharmacological management in enthesitis-related arthritis patients. Indeed, unlike other imaging modalities such as magnetic resonance imaging, modern high-frequency ultrasound transducers guarantee a superior spatial resolution of superficial joints and allow an accurate mapping of small-size and low-flow vascular elements of synovial and capsular tissues optimising the grading of disease activity and avoiding the use of contrast agent.
附着点炎相关关节炎是幼年特发性关节炎的一种特定亚型，其特征为关节炎和附着点炎同时存在，或其中之一的证据，再加上骶髂关节压痛、炎性背痛、人类白细胞抗原-B27阳性、急性症状性前葡萄膜炎、6岁及以上男性儿童起病或一级亲属中有脊柱关节炎病史中的至少两项。像胸锁关节这样的小关节很少受累，相关文献中对其在附着点炎相关关节炎中的受累患病率评估不足。
作者报告了一名12岁患幼年特发性关节炎男性儿童的非典型左胸锁关节关节炎/附着点炎病例。关节积液、滑膜增生和关节囊膨出的B超检查结果，以及胸锁关节彩色多普勒微血管造影，对于优化临床实践中的药物治疗方法至关重要。从这个意义上说，超声检查是体格检查的自然延伸，可准确界定一线药物对疾病活动控制不佳的情况。
本病例报告可被视为首次准确报告附着点炎相关关节炎患者病理性胸锁关节的B超和彩色多普勒检查结果。超声成像显示关节内积液、关节囊膨出和滑膜增生，明确了胸锁关节关节炎。有趣的是，血管增多涉及滑膜组织和关节囊-骨界面，即关节囊的附着点，提示附着点炎相关关节炎患者的胸锁关节可能同时存在关节炎和附着点炎。
高分辨率床旁超声似乎是儿科领域潜在的“变革者”，可迅速优化附着点炎相关关节炎患者的药物治疗管理。事实上，与磁共振成像等其他成像方式不同，现代高频超声换能器保证了浅表关节的卓越空间分辨率，并能准确描绘滑膜和关节囊组织中小尺寸和低血流的血管成分，优化疾病活动分级，避免使用造影剂。
