8/29/2012. Outline Juvenile idiopathic arthritis. 1. Classification-ILAR. 1. Classification-clinical diagnosis. 1. JIA classification

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1 Outline Juvenile idiopathic arthritis 1. Classification and symptoms (ILAR-International league of Associations for Rheumatology) 2. Imaging J. Herman Kan, M.D. Section chief, musculoskeletal imaging Edward B Singleton Department of Radiology Texas Children s Hospital Houston, TX 3. Targeted intervention with image guided therapy Page 1 Page 2 1. Classification-ILAR 1. JIA classification (JRA) ILAR North American Juvenile idiopathic arthritis (JIA) Juvenile rheumatoid arhtirits (JRA) ILAR Symptoms Juvenile ankylosing spondyloarthritis Systemic arthritis (Still s disease) Fever, rash hepatosplenomegaly, lymphadenopathy Reactive arthritis (Reiter s disease) oligoarthritis 4 or less joints involved Inflammatory bowel disease related arthritis polyarthritis 5 or more joints involved (RF+, RF ) Psoriatic arthritis Page 3 Page 4 1. JIA classification (Spondyloarthropathies) ILAR Enthesitis related arthritis Symptoms (ankylosing spondylitis, IBD related arthritis, Reactive arthritis) Enthesitis, tenosynovitis, axial skeletal involvement rare, boys most commonly affected 1. Classification-clinical diagnosis JIA-diagnostic criteria 16 years or younger Greater than 6 weeks of symptoms Psoriatic arthritis Arthritis and psoriasis (arthritis may precede skin changes) Page 5 Page 6 1

1. Classification-clinical diagnosis Enthesitis related arthritis (meets JIA criteria)- 2 OF THE FOLLOWING Sacroiliac or spinal pain HLA-B27 positive HLA-B27 family history Anterior uveitis Arthritis

2 1. Classification-clinical diagnosis Enthesitis related arthritis (meets JIA criteria)- 2 OF THE FOLLOWING Sacroiliac or spinal pain HLA-B27 positive HLA-B27 family history Anterior uveitis Arthritis in a boy 8 years or older 1. Classification-clinical diagnosis Psoriatic arthritis (meets JIA criteria)- 2 OF THE FOLLOWING Dactylitis (sausage digit) Nail pitting or onycholysis (nail bed separation) Psoriasis in a first degree relative Page 7 Page 8 2. Imaging Radiographs-used to provide baseline and prognostic information Problems with radiographs for assessing disease Bone erosions are a late finding compared with adult patients MRI and US-guides early intervention and treatment Epiphyseal ossification is surrounded by: Spherical growth plate Epiphyseal cartilage Articular cartilage Page 9 Page 10 Problems with radiographs physis 5 yo Spherical growth plate Epiphyseal cartilage Pathway to erosions is articular, epiphyseal, and spherical growth plate cartilage 5 yo Pathway to erosions is only Articular cartilage 37 yo E Articular cartilage Page 11 Page 12 2

3 Page 13 Page 14 Effusions-15 year old-jia Page 15 Page 16 Pre-erosive osteitis Page 17 Page 18 3

15 year old-jia with erosions and subchondral marrow edema Page 19

subjacent osteitis present 15 year old-jia metacarpal erosions-old

metacarpal and carpal bones When in Doubt Look for subchondral

undulations have smooth borders Enhancement at the area of

4 15 year old-jia with erosions and subchondral marrow edema Page 19 Page year old-jia-erosions may be called when there is subjacent osteitis present 15 year old-jia metacarpal erosions-old post Page 21 Page 22 Erosions versus normal undulations about the metacarpal and carpal bones When in Doubt Look for subchondral marrow edema Erosions have sharp borders concave borders Normal undulations have smooth borders Enhancement at the area of questionable erosion versus normal undulation In betweeners (a little of Page both) 23 Page 24 4

5 Normal undulations are usually smooth Normal undulations versus erosions Normal undulations Erosions Page 25 Page 26 Pre-erosive subchondral marrow edema versus erosions-use T1W sequences Pre erosive osteitis Erosions Page 27 Page year old-severe JIA, with joint space loss Features suggesting chronicity Erosions Pannus Rice bodies Page 29 Page 30 5

6 12 year old-jia-rice bodies 16 year old-pannus and erosions Page 31 T2 FS Page 32 post Enthesitis related arthropathies Most commonly affected tendons are the patella and Achilles tendon Tenosynovitis Tenosynovitis is common mild severe Page 33 Page year old-enthesitis-achilles 18 year old-enthesitis-plantar origin Page 35 Page 36 6

7 3 year old-sausage digit 3 year old sausage digit Page 37 Page 38 Role of MRI to guide treatment 13 year old-jia Targeted treatment of affected joints Decrease systemic therapy May control flares up to 6 months Page 39 Page year old-jia- Page 41 Page 42 7

arthropathies Radiographs are helpful for providing prognostic and baseline

8 MRI roadmaps intervention Summary Juvenile spondyloarthropathies rarely presents with axial symptoms, hence ILAR terminology of enthesitis related arthropathies Radiographs are helpful for providing prognostic and baseline information for the patient, but insufficient for guiding early intervention Page 43 Page 44 8

37 year old male with several year history of back pain

37 year old male with several year history of back pain Inflammatory Low Back Pain Clues onset before the age of 40 years insidious onset, chronic (>3 months) pain morning stiffness for longer than 30