Psoriatic Arthritis and Rheumatoid Arthritis: Findings in Contrast-Enhanced MRI

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1 MRI Evaluation of rthritis Musculoskeletal Imaging Original Research C D E M N E U T R Y L I M C I G O F I N G Helmut Schoellnast 1 Hannes. Deutschmann 1 Josef Hermann 2 Gottfried J. Schaffler 1 Pia Reittner 1 Fritz Kammerhuber 3 Dieter H. Szolar 4 Klaus W. Preidler 4 Schoellnast H, Deutschmann H, Hermann J, et al. Keywords: arthritis, bone, joint, MRI, musculoskeletal system DOI: /JR Received November 19, 2004; accepted after revision May 25, Department of Radiology, Medical University Graz, Graz, ustria. 2 Department of Internal Medicine, Medical University Graz, Graz, ustria. 3 Division of Radiology, Hospital of Barmherzige Brueder, Graz, ustria. 4 Diagnostikum Graz Sued West, Weblinger Guertel 25, 8054 Graz, ustria. ddress correspondence to K. W. Preidler. CME This article is available for 1 CME credit. See CME data for this article at or visit for more information. JR 2006; 187: X/06/ merican Roentgen Ray Society Psoriatic rthritis and Rheumatoid rthritis: Findings in Contrast-Enhanced MRI OBJECTIVE. Our objective was to define typical MRI findings of the wrist and the hand in patients with psoriatic arthritis (Ps) and rheumatoid arthritis (R). MTERILS ND METHODS. Eighteen Ps and 21 R patients with arthralgia of the wrist or hand joints underwent gadolinium-enhanced MRI of the wrist and hand. Two experienced radiologists interpreted abnormalities in consensus with respect to periarticular soft-tissue swelling, synovitis with or without effusion, periostitis, bone edema, bone erosions, bone cysts, and tenosynovitis. The distribution of the abnormalities also was evaluated. RESULTS. Erosions were statistically more frequent in patients with R (p < 0.05). Periostitis was statistically seen more frequently in patients with Ps (p < 0.05). No statistically significant difference was found in the frequency of synovitis, bone marrow edema, bone cysts, and tenosynovitis between the two groups (p > 0.05). The radiocarpal joint, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints were significantly affected more frequently in patients with R than in patients with Ps (p < 0.05), whereas the proximal interphalangeal joints were significantly more frequently affected in patients with Ps (p < 0.05). CONCLUSION. Periostitis and synovitis of the proximal interphalangeal joints are typical MRI findings in patients with Ps, whereas synovitis with erosions of the wrist, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints are typical findings in patients with R. n rheumatoid arthritis (R) and I in psoriatic arthritis (Ps), the finger joints are usually the first joints affected [1, 2]. lthough diagnosis is based primarily on clinical findings, it is sometimes difficult even for the trained rheumatologist to differentiate between these entities. This is especially true in cases of Ps sine psoriase. Radiographic changes in Ps are specific and differ from those in R, but conventional radiography may also be normal in acute arthritis. Several studies that evaluated MRI in patients with R [3 8] or with Ps [5, 9, 10] showed that MRI is more sensitive than conventional radiography in detecting early inflammatory joint processes. To our knowledge, no study has been performed comparing MRI findings of the wrist and hand in patients with Ps and R. Therefore, the aim of our study was to define typical MRI findings in these patients. Materials and Methods Patient Population In a retrospective study, all patients diagnosed with Ps according to the criteria of Moll and Wright [11] and R according to the revised merican College of Rheumatology criteria [12], and who had undergone MRI of the wrist and hand in the past year as part of routine clinical care were recruited for the study. The study population consisted of 18 patients (six men and 12 women; mean age, 52 years; age range, years) with clinically proven Ps and 21 patients (four men and 17 women; mean age, 59 years; age range, years) with R. Rheumatoid factor was tested for and found negative in all patients with Ps. The mean time between the onset of disease and MRI examination was 64 months in patients with Ps and 76 months in patients with R. The indication for MRI examinations was reoccurrence of arthralgia. ll examinations were part of routine clinical care and were performed within the clinical standard of our institutions. ccording to the guidelines of our institutional review board for retrospective studies, formal approval and informed consent were not required. JR:187, ugust

2 Data cquisition MRI was performed with 1.5-T scanners (Magnetom Symphony, Siemens Medical Solutions). The slew rate was 86 T/msec; the gradient amplitude was 34 mt/m. Coronal T1-weighted spin-echo sequences (TR/TE, /20 23; bandwidth, 65 MHz; matrix size, ; section thickness, 3 mm), transverse inversion time or coronal T1-weighted fast lowangle shot (FLSH) sequences with fat saturation ( /11; bandwidth, 70 MHz; flip angle, 60 ; matrix size, ; section thickness, 3 5 mm), and coronal contrast-enhanced (gadodiamide; Omniscan, Nycomed mersham) T1-weighted spinecho sequences with fat saturation ( /23; bandwidth, 65 MHz; matrix size, ; section thickness, 3 mm) were obtained. In addition, coronal T2-weighted turbo inversion recovery magnitude (TIRM) sequences (3,000/127; inversion time, 150 milliseconds; bandwidth, 130 MHz; flip angle, 170 ; matrix size, ; turbo factor, 13; section thickness, 4 mm) were available in 10 patients. The field of view was between 150 and 180 mm. Data nalysis Data analysis was performed on a Magic View 1100 workstation (Siemens Medical Solutions) in consensus by two experienced radiologists blinded to the patients history. nalysis was performed with special respect to joint abnormalities (periarticular soft-tissue swelling and synovitis with or without intraarticular effusion), bone changes (bone marrow edema, focal bone erosions, bone cysts, and periostitis), and tenosynovitis. Synovitis and periostitis were defined as thickened synovial membrane or thickened periosteum with pronounced contrast enhancement compared with adjacent joints or bones, respectively. Bone erosions were diagnosed in patients who had evidence of a combination of focal bone marrow edema and destruction of the cortex. In each patient, analysis was performed for the radiocarpal joint, the midcarpal joints, the carpometacarpal joints, the metacarpophalangeal joints, the proximal interphalangeal joints, and the interphalangeal joint of the thumb. The distal interphalangeal joints were not evaluated because they were not sufficiently depicted in many patients. nalysis of bone changes was performed for the distal radius and ulna, the carpal bones, the metacarpal bones, the proximal phalanges, and the middle phalanges. The distal phalanges were not depicted sufficiently. Statistical nalysis Statistical analysis was performed using the SPSS software package. The significance of differences in frequency and localization between both groups was tested using the chi-square test. Two-tailed values were used, and probability values of less than 0.05 were considered significant. Results Table 1 shows the MRI findings in patients with Ps and R. Periostitis was statistically more frequent in patients with Ps than in patients with R (p < 0.05). Seventy-eight percent of the patients with Ps showed periostitis; however, none of the patients with R did (Fig. 1). Erosions were statistically more frequent in patients with R (p < 0.05) (Fig. 2). Eighty-six percent of patients with R showed erosions compared with 17% of patients with Ps. No statistically significant difference was noted in the frequency of synovitis (Fig. 3), bone marrow edema, bone cysts, and tenosynovitis between the two groups (p > 0.05). The radiocarpal joint, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints were significantly more frequently affected in patients with R than in patients with Ps (p < 0.05). Thirty-nine percent of patients with R showed synovitis, bone marrow edema, erosions, or cysts of the radiocarpal joint compared with 6% of patients with Ps. The midcarpal joints were affected in 78% of the patients with R compared with 11% of patients with Ps. The carpometacar- TBLE 1: Frequency of Findings in Joints and Bones of Patients with Rheumatoid rthritis and Psoriatic rthritis Clinical Finding Rheumatoid rthritis (%) Psoriatic rthritis (%) Periarticular soft-tissue swelling Synovitis Bone marrow edema Bone erosions a Bone cysts Periostitis a 0 78 Tenosynovitis a p <0.05. pal joints were affected in 62% of patients with R and in 17% of patients with Ps. The metacarpophalangeal joints were affected in all patients with R compared with 72% of patients with Ps. The proximal interphalangeal joints were significantly affected more frequently in patients with Ps. Seventy-eight percent of patients with Ps had affected proximal interphalangeal joints compared with 43% of patients with R. Discussion The diagnosis of R or Ps is primarily based on clinical findings and laboratory tests, but sometimes it is difficult to differentiate among R, Ps, or other chronic inflammatory joint diseases. The 1987 merican Rheumatism ssociation (R) revised criteria [13] described a method to classify patients having an R or non-r condition based on a combination of variables that are sensitive and specific to the classification of R. The variables are morning stiffness; soft-tissue swelling of three or more joint areas; swelling of the proximal interphalangeal, metacarpophalangeal, or radiocarpal joints; symmetric swelling; rheumatoid nodules; the presence of rheumatoid factor; and erosions in any peripheral joint on radiographs. Radiographic changes in Ps differ from those in R, as evidenced by a lower frequency of periarticular osteopenia and a higher prevalence of distal interphalangeal erosions along with the presence of tuft changes, pencil-in-cup changes, bone proliferations, and bone ankylosis [14]. However, conventional radiography may be normal in patients with acute R or Ps. In contrast, MRI has reportedly enabled physicians to detect bone marrow edema and active synovitis visually long before changes are detectable on conventional radiographs [3, 6, 7, 15 18]. It is reported that introducing MRI into the diagnostic criteria for early R may contribute to a more accurate diagnosis in patients suspected of having R. Sugimoto et al. [8] achieved a sensitivity of 96% and a specificity of 86% for the diagnosis of R using MRI. In their study, the MRI criterion for R was gadolinium enhancement with a bilateral distribution in the wrist, metacarpophalangeal joint, proximal interphalangeal joints, or all three. In the same patient population, R-revised criteria for R showed sensitivities of 69% and 77% and specificities of 96% and 91% for the traditional format and classification tree format, respectively. Mc- Queen et al. [15, 16] reported that a high pro- 352 JR:187, ugust 2006

3 MRI Evaluation of rthritis portion of R patients develop MRI erosions very early in their disease when conventional radiography is frequently normal and that MRI scans of the wrist, taken when patients first present with R, can predict radiographic erosions at 2 years. In a study by Ostergaard et al. [17], MRI detection of new radiographic erosions preceded conventional radiography detection by a median of 2 years. Few studies have investigated MRI findings of the hand in patients with Ps [5, 10]. Offidani et al. [10] showed that in patients with psoriasis but without clinically evident arthritis, joints were frequently affected. They reported periarticular edema and synovitis/intraarticular effusion as the two most frequent findings (36% and 44%, respectively). Periostitis, a frequent finding in our patient population with Ps, was not addressed as a typical finding in the study by Offidani et al. [10]. We consider the different patient populations (absence of acute clinical arthropathy in the study by Offidani et al. versus acute clinical arthropathy in our study) as the reason for this. Savnik et al. [5] reported that MRI of the wrist and finger joints in inflammatory joint disease at 1-year intervals predicts bone erosions in patients with R but not in patients with Ps. In another study [19], the authors reported a significantly higher frequency of bone marrow edema in patients with established R (> 3 years) compared with patients with early R (< 3 years), arthritis other than Fig year-old man with clinically proven psoriasis., Coronal T1-weighted spin-echo fat-saturated MR image after administration of contrast agent (TR/TE, 620/20) reveals periosteal enhancement of proximal phalanx of third digit (arrows) as sign of periostitis. B, Radiograph obtained 2 months after MRI shows proximal phalanx of third digit (arrows) without evidence of preceding periostitis. Note that radiographs are provided for case illustration. Systematic comparison between MRI and radiographs was not performed because of lack of radiographs in temporal proximity to MRI examination. B JR:187, ugust

4 Fig year-old woman with clinically proven rheumatoid arthritis., Coronal T1-weighted spin-echo MR image shows focal decreased signal intensity in head of metacarpal bone of third ray consistent with barearea bone erosion (arrow). (Fig. 2 continues on next page) R (including patients with reactive arthritis, Ps, and mixed connective tissue disease), or arthralgia. However, patients with Ps (eight patients) were only a small subgroup in this study, and therefore they were not evaluated separately. Jevtic et al. [9] reported that the degree and extent of periarticular soft-tissue involvement was greater in six of 13 patients with Ps compared with patients with R. The authors stated that the joint capsule may not be the primary target of the disease process in Ps but may become involved later in the disease course. In our study population, the difference in periarticular soft-tissue swelling between patients with Ps and those with R was 16%, with the higher incidence in the Ps group, but the difference did not reach statistical significance. However, the disease duration in the study by Jevic et al. [9] was less than 2 years; and findings in an early disease course of R and Ps cannot be transferred to established disease courses as present in our study. To our knowledge, no study has been performed comparing MRI findings in patients with Ps and R. Our results showed statistically significant differences in MRI findings of the hand and the wrist in patients with R and Ps. Periosteal contrast enhancement as a sign of periostitis was significantly more frequent in patients with Ps than in patients with R. Seventy-eight percent of patients with Ps showed periostitis; however, none of the patients with R did. Con- versely, bone erosions were significantly more frequent in patients with R than in patients with Ps. The frequency of findings in patients with R is in accordance with a study by Boutry et al. [20], who reported synovitis of the wrist and metacarpophalangeal joints in 93% and 90%, respectively, of patients with early R. In our study, 95% of patients with R showed synovitis. Bone erosions were reported in the wrist joints in 80% and in the metacarpophalangeal joints in 77% of patients. In our study, 86% of patients with R had bone erosions. The similar frequency of these findings despite the different patient population (early disease in the study by Boutry et al. [20] vs established disease in our study) can be explained by the fact that the patients in our study also had acute clinical arthropathy and thus also showed signs of acute arthritis. side from the difference in frequency of joint and bone abnormalities, patients with R and Ps also showed significant differences in articular distribution of abnormalities. The radiocarpal joint, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints were significantly more frequently affected in patients with R than in patients with Ps, whereas the proximal interphalangeal joints were more frequently affected in patients with Ps. The frequency of proximal interphalangeal joint involvement in patients with Ps seems quite high and might be explained by the long-term disease course of our study population because it is well known that in Ps the distal interphalangeal joints are affected first, followed by the proximal interphalangeal joints and the remaining joints of the hand and the wrist. The MRI protocol in this study was the standard protocol of our institutions for diagnosis of inflammatory disorders, including T1-weighted spin-echo, T1-weighted fat-saturated FLSH, and contrast-enhanced fatsaturated T1-weighted spin-echo sequences. T2-weighted TIRM sequences were also performed but were not available in all patients. However, Schmid et al. [21] reported that STIR images and T1-weighted contrast-enhanced fat-suppressed MR images show almost identical imaging patterns in bone marrow abnormalities. One can assume that this is also valid for TIRM images. Our study has several potential limitations. First, it was a retrospective analysis of a small patient population, which might have influenced the significance of the find- 354 JR:187, ugust 2006

5 MRI Evaluation of rthritis B Fig. 2 (continued) 74-year-old woman with clinically proven rheumatoid arthritis. B and C, Dorsovolar (B) and oblique (C) radiographs obtained 8 days before MRI show no evidence of bone erosion (arrows) in head of metacarpal bone of third ray. Note that radiographs are provided for case illustration. Systematic comparison between MRI and radiographs was not performed because of lack of radiographs in temporal proximity to MRI examination. ings. However, the tendency toward Ps or R was pronounced in some findings. This is especially valid for periosteal enhancement as a sign of acute periostitis, which was a frequent finding in patients with Ps and was not found in patients with R. This seems consistent because periosteal thickening and bone proliferations are typical signs of Ps on radiographs [12] and can be considered as later signs of periostitis. Second, only patients classified as having R or Ps were included in our retrospective study; therefore, the results cannot be extrapolated to all patients who complain of arthralgia or arthritis because of the assessment of selected subjects. Prospective studies are necessary to prove whether the findings shown in our study can help differentiate these two arthritides at a subclinical or early clinical stage. Third, MRI was only performed of the wrist and hand, although R and Ps are systemic diseases with the involvement of multiple joints, especially R. However, the wrist and hand joints are frequently affected in R and affected in 85% of patients with Ps. In addition, the distal interphalangeal joints were not evaluated because of lack of sufficient depiction in many patients. That might have influenced the results because Ps predominantly affects these joints. In conclusion, MRI may not only detect radiologic features supporting the development of an inflammatory disorder but may also help discriminate between R and Ps, particularly in those patients who present with a C JR:187, ugust

6 Fig year-old man with clinically proven rheumatoid arthritis., Coronal T1-weighted, turbo spin-echo, fat-saturated MR image after administration of contrast material (TR/TE, 620/20) reveals soft-tissue swelling and contrast enhancement of synovial membrane of proximal interphalangeal joint of fourth ray as sign of synovitis (arrows). B, Radiograph obtained 10 days before MRI shows soft-tissue swelling (arrows) and narrowing of joint space of proximal interphalangeal joint of fourth ray as typical finding of arthritis. Note that radiographs are provided for case illustration. Systematic comparison between MRI and radiographs was not performed because of lack of radiographs in temporal proximity to MRI examination. B polyarthritis involving the hand and wrist joints. Further studies are necessary to prove whether the findings shown in our study can help differentiate Ps and R at an early stage. References 1. Fleming, Benn RT, Corbett M, Wood PH. Early rheumatoid disease. II. Patterns of joint involvement. nn Rheum Dis 1976; 35: Torre lonso JC, Rodriguez P, rribas Castrillo JM, et al. Psoriatic arthritis (P): a clinical, immunological and radiological study of 180 patients. Br J Rheumatol 1991; 30: JR:187, ugust 2006

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