DOI: 10.1148/radiol.2411051682
(Radiology 2006;241:320-321.)
© RSNA, 2006
MR Imaging Findings in the Hands
Philip G. Conaghan, MBBS, PhD, FRACP, FRCP,*,
Philip O'Connor, MBBS, FRCR,
and
and Paul Emery, MA, MD, FRCP
* Department of Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, Yorkshire LS7 4SA, United Kingdom
e-mail: P.Conaghan{at}leeds.ac.uk
Department of Musculoskeletal Radiology, Leeds Teaching Hospital Trust, Leeds, United Kingdom
Department of Rheumatology, University of Leeds, Leeds, United Kingdom
Editor:
We were pleased to see the article by Dr Boutry and colleagues in the August 2005 issue of Radiology (1). The authors presented a comparison of 47 patients with early inflammatory arthritis who underwent magnetic resonance (MR) imaging of both hands and who were subsequently diagnosed with rheumatoid arthritis (RA), systemic lupus erythematosus, or Sjögren syndrome. The authors found that scores for synovitis and bone lesions were no different between the RA group and the connective tissue group. It is good to see research that expands the limited data on the usefulness of peripheral joint MR imaging in the diagnosis of early RA. We agree with the authors that the finding of a difference in tenosynovitis scores (in one finger only) would probably reflect the statistical issue of multiple comparisons.
With respect to inflammation, these findings are in accordance with our own data, in that, anecdotally, we have seen patients with both systemic lupus erythematosus and scleroderma who were found to have synovitis, indistinguishable from RA synovitis, in their metacarpophalangeal joints at the time of presentation with early inflammatory arthritis. However, we would like to add to this observation by suggesting that true intrasynovial disease, of the type seen in RA, may be more common in connective tissue disease that was previously recognized, which probably highlights the sensitivity of contrast material–enhanced MR imaging for low-level synovitis when compared with clinical examination. In the future, this may change our concepts of "overlap" syndromes of RA and connective tissue diseases, including therapeutic strategies. It is important to note though, given the overlap of current classification criteria, that genetic markers and specific autoantibodies (such as anti-cyclic citrullinated peptide antibodies) will be more important in early diagnosis.
It is perhaps not surprising that erosion scores are not helpful in distinguishing early RA, even at an average of 5 months from onset of symptoms, as in the study by Dr Boutry and colleagues. Despite the increased sensitivity of MR imaging over radiography, it can be seen that the overall bone damage scores were low even in the RA group and reflect the absence of prolonged inflammation and subsequent damage. The finding of increased levels of bone edema in the metacarpophalangeal joints of patients with RA is intriguing. We have previously reported that the presence of bone edema is related to adjacent synovitis severity (2). On the basis of results of the study by Dr Boutry and colleagues, it is tempting to speculate, in the absence of histologic confirmation, that the severity of this presumed "osteitis" is the key factor in progression to erosions at MR imaging in RA compared with systemic lupus erythematosus.
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References
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- Boutry N, Hachulla E, Flipo RM, Cortet B, Cotten A. MR imaging findings in hands in early rheumatoid arthritis: comparison with those in systemic lupus erythematosus and primary Sjögren syndrome. Radiology 2005;236(2):593–600.[Abstract/Free Full Text]
- Conaghan PG, O'Connor P, McGonagle D, et al. Elucidation of the relationship between synovitis and bone damage: a randomised MRI study of individual joints in patients with early rheumatoid arthritis. Arthritis Rheum 2003;48:64–71.[CrossRef][Medline]
Response
Nathalie Boutry, MD, and
Anne Cotten, MD
Department of Musculoskeletal Radiology, Hôpital Roger Salengro, Centre Hospitalier Régional Universitaire de Lille, Blvd du Professeur Leclercq, 59037 Lille CEDEX, France
e-mail: nboutry{at}chru-lille.fr
We read with great interest the comments from Dr Conaghan and colleagues regarding our article (1), and we appreciate their interest in our recent work. We are glad to see that they share the same experience with us, in that patients with connective tissue diseases (systemic lupus erythematosus, primary Sjögren syndrome, or scleroderma) may have synovitis that is indistinguishable at MR imaging from that of patients with RA when they initially manifest inflammatory polyarthralgia of the hands. In our study, we observed bone erosions and bone edema more frequently in patients with early RA than in those without early RA (ie, systemic lupus erythematosus or primary Sjögren syndrome), although no significant differences were found in terms of scores. We agree with Dr Conaghan and colleagues that such results are not surprising, since, in our study, patients with RA had a short disease duration and therefore had few bone erosions. However, bone marrow edema was seen more frequently in patients with RA than in those without RA, and we fully agree with Dr Conaghan and colleagues that synovial proliferation may be more aggressive in patients with RA than in those without RA. In this regard, we are currently following up our patients by means of MR imaging in order to appreciate the course of bone erosion development in the two groups (ie, patients with RA and patients without RA). We thank Dr Conaghan and colleagues for their interest in our study and their valuable comments.
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REFERENCE
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- Boutry N, Hachulla E, Flipo RM, Cortet B, Cotten A. MR imaging findings in hands in early rheumatoid arthritis: comparison with those in systemic lupus erythematosus and primary Sjögren syndrome. Radiology 2005;236(2):593–600.[Abstract/Free Full Text]
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