jd laredo spa-spondyloarthritis jfim hanoi 2015

Spondyloarthritis (Spa)

JFIM 14th edi-on HANOI 2015

Pr Jean Denis LAREDO Hôpital Lariboisière -‐ Paris

ü Ankylosing spondylitis ü Reactive arthritis ü Psoriatic arthritis ü Inflammatory bowel disease-related arthritis ü Undifferentiated spondyloarthritis

ü SAPHO syndrome


•  No biological diagnos-c test •  Diagnosis needs first to rule out tumor and infec-on


Case 1

•  19 y-‐o chinese woman •  Long history of back pain diagnosed as Scheuermann’s disease

Typical Spa

•  Romanus lesions

Spa 1.  Marginal ostei-s/vertebral enthesi-s

Erosive

Constructive E C

Enthesitis:

Early phase Intermediate phase Late phase

Erosive

Constructive E C

Synovial Joints

Case 2

•  52 yo man •  Back pain day and night •  CRP : 17

T1 T2 fat Sat

Cas 2

T1 T2 fat Sat

CAS N° 2 : Disc osteoarthri,s with Modic 1

mimicking “Romanus lesions”

Message

Magne3c Romanus : non-‐specific Increase specificity with many

lesions in many sites

Sacroiliitis active : definition according ASAS/OMERACT

Rudwaleit M. Ann Rheum Dis 2009;68(10):1520-‐1527

Sensibilité 82% Spécificité 84%

Rudwaleit M, ARD 2009

Recent (<5y) Spa

Posi-ve Sacroiliac joint MRI: only 30%

Look for other sites of involvement

Right Lec

Case 3

•  26y-‐o woman with back pain and anterior thoracic pain night and day for many years

•  Cardiologist : normal heart

Cliché 1

STIR

Cliché 2

STIR

Cliché 3

STIR

Cliché 5

Cliché 4

STIR

Mise au point sur la sémiologie radiologique Anatomie-‐radiologique de l’ar3cula3on costo-‐vertébrale

T2 Fat Sat

Case 3

•  26y-‐o woman with back pain and anterior thoracic pain night and day for many years

•  Cardiologist : normal heart

Cliché 6

Cas 3

Erosive

E+C

Constructive

Suspicion of Spa

Look for other sites of involvement Carefully listen to the pa-ent Perform full body imaging : bone scin-graphy

Anterior thoracic wall involvement

Spa 1.  Marginal ostei-s/vertebral enthesi-s

2.  Other distant lesions: •  Bone scin-graphy or PET-‐scan •  MRI of the thoracolumbar spine and pelvis

•  Anterior thoracic wall

Case 4

•  19 yo man •  Hip pain at night improved by NSAID •  RBC sedimenta-on rate 57 •  CRP 62mm •  Referred for Laser therapy for osteoid osteoma

T1 T1G

SAPHO Syndrome Skin disease (acne) + Bone disease

•  Syndrome •  Arthri-s •  Pustulosis •  Hyperostosis •  Ostei-s

SAPHO Syndrome

•  Mysterious disease •  Close to spondyloarthri-s but different: No HLA B27 an-gen

•  Caricatural Spa: increased erosion and increased bone contruc-on

•  Mimics bone tumor and joint infec-on

Case 5: 57 y-‐o man with back pain at night

Marginal ostei-s/vertebral enthesi-s: Progressive extension around the vertebra

Erosion Construc-on

SAPHO Sd: Clinical clues

1.  Cutaneous lesions

Case report: 33 y-‐o main with back pain at night

T11, T12 & L1 bone sclerosis

•  1st bone biopsy : no tumor. An--‐tuberculous treatment

•  Second biopsy : no tumor, no infec-on. Working diagnosis: SAPHO syndrome

STIR T1

Ini-al MRI

T1 T1 Gado FS

1-‐year follow-‐up MRI

3rd biopsy: epidermoid carcinoma

Case report: 33 y-‐o main with back pain at night

SAPHO Syndrome

•  No biological diagnos-c test •  Diagnosis needs first to rule out tumor and infec-on

Important message

•  SAPHO & Spa: no marginal ostei-s : danger

Dossier JB Thorel, Lorient

•  45 y-‐o woman •  December 2009: small (<1cm) breast carcinoma

•  Bone scin-graphy: increased uptake at T11-‐T12

•  PET-‐scan : normal

Case 6

scan T1

Case 6 : 45 y-‐o woman

Scan T1 T2

Scan T1 T2 T1+G

Case 6 : 57 y-‐o man

Anterior hyperostosis of the vertebral body

Spa & SAPHO Syndrome: Clinical clues

1.  Cutaneous lesions

Spa & SAPHO Syndrome : Radiological clues

1.  Marginal ostei-s/vertebral enthesi-s

2.  Other distant lesions 3.  Hyperostosis with increased size of the

bone

The bread theory to explain all bone diseases

1. Diseases ea-ng both the crust and the inside of the bread

1. Diseases ea-ng both the crust and the inside of the bread

Bone metastases

2.Diseases ea-ng the inside only

2.Diseases ea-ng the inside only

Myeloma, Plasmacytoma, Giant Cell Tumor

Diseases ea-ng the crust only

Diseases ea-ng the crust only

Spondyloarthri-s, SAPHO Syndrome

Case 1: 19 y-‐o chinese woman

•  Hip joint arthri3s •  Hip joint aspira3on: no microorganism •  Long history of back pain diagnosed as Scheuermann’s disease

Typical Spa

•  Romanus lesions •  Costovertebral arthri-s •  Sacroilii-s •  Hip arthri-s

Message

Spa: Coexistence of lesions of different age

Cas 4

•  39 y-‐o man with acute permanent back pain

Case 4: facet joint staphylococcus infec-on

Message

•  Be careful with very subtle MR findings •  Spa diagnosis requires clear-‐cut MR findings

SAPHO Sd: Clinical clues

1.  Cutaneous lesions 2.  Non-‐steroid an--‐inflammatory drugs very effec-ve on pain 3. No clinical & biological inflamma-on

SAPHO Syndrome : Radiological clues

?

Case 1

T1 T1 T1 Gado STIR

T1 T1

T1 gado T1 gado

T1 Gado Fat Sat

T1 Gado Fat Sat

Case 1: 61 y-‐o man with back and bunock pain at night


1. Marginal ostei-s/vertebral enthesi-s

Marginal ostei-s/vertebral enthesi-s

32-‐y-‐o man with neck pain


Gad-‐E. T1-‐W. T1-‐W.


71%

T2 57-‐y-‐o woman with back pain


71%

T1 T1 Gado T2

T1 T1 Gado T1 Gado STIR

Case 1

Case report : 16 y-‐o man Posterolateral thoracic pain for 2 weeks, maximal when waking up. Improved with NSAID Severe acne No biological inflamma-on: VS 6, CRP 1.4

Case report : 16 y-‐o man

T2 STIR


STIR images


Genre 10F/3H

Age at first symptoms (years) 17-‐53 (median : 32 ; Q1 :21 ; Q3 :43)

Age at diagnosis (years) 17-‐64 (median : 38 ; Q1 :29,5 ; Q3 :48)

Age at first spine MRI(years) 17-‐63 (median : 33 ; Q1 :28 ; Q3 :44)

Cutaneous involvement 7 (54%)

Palmo-‐Plantar Pustulosis 5 (39%)

Severe acne 2 (15%)

Other (extra-‐vertebral) bone lesions 9 (69%)

Sacro-‐iIiac joint involvement 2 (15%)

Anterior thoracic wall 3 (23%)

Sacro-‐iliac & Anterior thoracic wall 1 (8%)

Ostei3s 2 (15%)

Peripheral joint & Anterior thoracic wall 1 (8%)

Spondyloarthropathies

Erosive

E+C

Constructive

SAPHO

Erosive Bone destruc-on Vertebral collapse Disc space infec-on

E+O

Ossifiant Bone sclerosis Hyperostosis

Erosion Sclerosis

Pa-ente de 28 ans 2509051472

•  Sacro-‐iliite droite depuis 2008 •  Talalgie droite et arthralgies des mains •  Scia-que S1 droite depuis 2010, d’horaire inflammatoire

•  Psoriasis personnel et chez les deux parents •  HLA B27-‐ •  Résistante aux AINS et à 2 an--‐TNF •  Surtout très gênée par la scia-que S1 droite

Karine Loua-, Caroline Rey-‐Jouvin, Anne Miquel, Saint-‐Antoine

2509051472


1.  Marginal ostei-s/vertebral enthesi-s

2.  Other distant lesions 3.  Hyperostosis with increased size of the

bone

50 y-‐o woman

•  Back pain at night for 5 years, much improved by indometacin

•  Sedimenta-on rate 62 to 96, normal CRP •  HLA B27 absent •  No other abnormality •  2 percutaneous + 1 surgical biopsy : bone sclerosis

50 y-‐o woman

Spinal MR follow-‐up of SAPHO syndrome (Emilie Dodré, Caroline Parlier-‐Cuau)

•  14 pa-ents fullfilling SAPHO syndrome criteria •  follow-‐up 4-‐157 months (median 17 months)

Evolution of Romanus spondylitis

regression extension

Evolution of SAPHO syndrome

extension

Marginal ostei-s/vertebral enthesi-s: Progressive extension around the vertebra

Follow-‐up in spinal SAPHO syndrome

–  14 pa-ents/27 lesions –  17months (mean FU) –  Extension : 20/27 (74%) –  3 types of extension :

•  Within the same vertebra (52%)

•  Adjacent vertebra (22%) •  Distant vertebra (11%)

Pa3ent 11, progression par con3guïté de part et d’autre de l’érosion ini3ale

A-‐ajeinte ini3ale : séquence T2 ; B-‐Evolu3on à 6 mois : séquence T1 Fat Sat après injec3on de gadolinium

Progression des érosions cor-cales

•  75 érosions ini-ales •  31/75 (41%) érosions: progression de proche en proche –  4 types de progression

Progression along the vertebral endplate 13 (42%)

Progression along the anterior cortex 1 (3%)

Progression along the vertebral endplate and

anterior cortex 5 (16%)

Picture frame progression 12 (39%)

Résultats Evolu3on des anomalies de signal des CV

EVOLUTION DES ANOMALIES DE SIGNAL DES FOYERS LESIONNELS (21/27 (78%))

Extension au sein du foyer 18 (67%)

Progression œdème 11 (41%)

Progression mixte, œdème et condensa3on 6 (22%)

Progression condensa3on isolée 1 (4%)

Modifica3on de signal 3 (11%)

Dispari3on de l’œdème et appari3on de graisse 2 (7%)

Dispari3on de l’œdème et appari3on d’une

condensa3on 1 (4%)

SAPHO syndrome is a progressing disease to adjacent bone

•  Progressing MR findings in 66% of the cases (mean follow-‐up: 17 months)

Bone marrow edema 41% Vertebral height loss 26% Disc space involvement 48% Soc -ssue thickening 11%

Evolu3on des anomalies discales

•  13 foyers sur 27 (48%): ajeinte discale évolu3ve

–  37% (10/27) – appari-on

ou majora-on de la perte de hauteur

–  11% (3/27) – perte de hauteur associée à des anomalies de signal (PDC ou Hypersignal T2)

Evolu3on sur 5 mois

Tuméfac3on des 3ssus mous

•  Présente sur l’IRM ini-ale: 8 foyers / 27 (30%) •  Progression pour 3 des 27 foyers ini3aux

(11%) –  Taille: 9 (+1mm), 13 (+3mm), 15 mm (+8mm)

•  Pas de nécrose (zone avasculaire)

•  Pas de masse intracanalaire

+6mois

Suivi 20 mois

Vertebral height loss (26%)

Evolu3on sur 20 mois

Evolu3on over 20 months: +22° Kyphosis

Increased thoracic kyphosis : 4/13 pa3ents (31%)

Conclusion 1

•  SAPHO syndrome: No diagnos-c test First rule out tumor and infec-on •  Diagnos-c: convergence of posi-ve and nega-ve criteria

jd laredo spa-spondyloarthritis jfim hanoi 2015

Health & Medicine