Ultrasonographic and Clinical Assessment of Peripheral Enthesitis in Patients with Psoriatic Arthritis, Psoriasis, and Fibromyalgia Syndrome: The ULISSE Study

Abstract

Objective.The purpose of the ULISSE study was to evaluate the prevalence of clinical and ultrasonographic (US) entheseal involvement in patients with psoriatic arthritis (PsA), psoriasis, and fibromyalgia syndrome (FMS).Methods.In this cross-sectional multicenter study, patients with PsA and psoriasis (not taking systemic therapy) and FMS underwent a clinical evaluation of the entheses, and a B-mode and power Doppler examination of 6 pairs of entheses.Results.The study analyzed 140 patients with PsA, 51 with psoriasis, and 51 with FMS. Clinical and US examinations were performed in 1960 and 1680 entheses in the PsA group, and 714 and 612 entheses both in the psoriasis group and in the FMS group. In both per-patient and per-enthesis evaluation, the frequency of entheseal tenderness was higher in patients with FMS (92% of the patients and 46% of the entheses, compared with 66%/23% in the PsA group and 59%/18% in the psoriasis group). With US examination, signs of entheseal involvement were more frequent in both the per-patient and per-enthesis evaluation in PsA and psoriasis (about 90% of patients in both the PsA and psoriasis groups and 75% of patients in the FMS group had at least 1 site affected, and 54%, 41%, and 27% of the pairs of entheses in, respectively, PsA, psoriasis, and FMS patients showed at least 1 enthesis involved).Conclusion.The ULISSE study indicated that enthesitis is a common feature in patients with PsA, those with psoriasis, and in those with FMS if only clinical examination is used. US entheseal assessment showed findings more consistent with the 3 disorders.

Peripheral spondyloarthritis: a neglected entity—state of the art

“…Both ultrasound (US) and MRI are able to provide objective evidence of inflammation at entheses, certainly when there is patient–evaluator discordance, since a significant proportion of patients with PsA may have coexisting central sensitisation syndrome, which may bias clinical outcome measures. 20 In recent years, several enthesitis US scoring systems have been published; however, as each is different by incorporating different US elementary lesions, comparison across studies and the use of US as outcome measurement instrument of enthesitis in multicenter studies are problematic. 21 In 2018, the OMERACT US enthesitis Working Group produced a final reliable US score and definition of enthesitis in SpA/PsA.…”

Assessment of Enthesitis in Psoriatic Arthritis

“…The DAS28 score is inappropriate for assessing joint disease activity in PsA because joints below the knee are not counted 5 . And the authors also correctly point out that the groups were not matched for age, sex, and body mass index, all of which can influence US scores, although regression analysis allowed for these differences 4 .…”

“…In this issue of The Journal, Macchioni and colleagues provide some further insights 4 . In a well-designed multicenter study they examined entheses of patients with PsA, psoriasis, and FM, both by clinical examination and with US.…”

“…What are the strengths and weaknesses of this study? The authors correctly state that because none of the patients with PsA were taking disease-modifying drugs or steroids, it is likely that they represent a milder spectrum of disease, and this is reflected in the 28-joint count Disease Activity Score (DAS28) 4 . Nor do we have data on skin severity, an important omission in any study of PsA and psoriasis.…”

Defining Pre-Clinical Psoriatic Arthritis in an Integrated Dermato-Rheumatology Environment

“…Lastly, a prodromal symptomatic transition phase may exist characterized by nonspecific musculoskeletal pain, recently defined as psoriatic arthralgia, and fatigue [ 8 , 20 ]. This prodromal phase can be difficult to identify due to non-specific symptoms and possible PsA disease mimics, such as incipient or concomitant osteoarthritis, fibromyalgia, or chronic pain related to psoriatic comorbidities [ 21 , 22 , 23 ]. There are preliminary evidences that sonographic determined enthesitis might be associated with subsequent clinical disease evolution [ 20 , 24 , 25 ], but these results are preliminary and require further validation.…”