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Case ReportImages in Rheumatology

No Enthesis Should Be Overlooked When Psoriatic Arthritis Is Suspected: Enthesitis of the Extensor Digitorum Tendons

GEORGIOS FILIPPOU, VALENTINA DI SABATINO, ANTONELLA ADINOLFI, ILARIA BERTOLDI, VALENTINA PICERNO, GIOVANNI BIASI, MAURO GALEAZZI and BRUNO FREDIANI
The Journal of Rheumatology March 2013, 40 (3) 335; DOI: https://doi.org/10.3899/jrheum.121123
GEORGIOS FILIPPOU
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
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  • For correspondence: g_filippou@virgilio.it
VALENTINA DI SABATINO
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
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ANTONELLA ADINOLFI
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
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ILARIA BERTOLDI
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
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VALENTINA PICERNO
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
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GIOVANNI BIASI
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
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MAURO GALEAZZI
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
Roles: Professor
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BRUNO FREDIANI
Rheumatology Section, Department of Clinical Medicine and Immunology, University of Siena, Viale Bracci 16, 53100 Siena, Italy.
Roles: Professor
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A common and well-documented feature of spondyloarthropathies is inflammation of the peripheral enthesis1. Ultrasound (US) imaging is useful when assessing enthesitis, and many investigators have described its features2,3.

A 50-year-old man with psoriasis developed morning stiffness, tenderness, and swelling of small joints in the hands asymmetrically during the last month. Clinical examination revealed tenderness and swelling of the proximal interphalangeal joints (PIP) of the second, third, and fourth fingers of the left and second finger of the right hand and the metacarpophalangeal (MCP) joints of the second and third fingers of the right hand. US of both hands was carried out to analyze the inflammation. The principal finding on US was swelling and hypoechogenicity of the enthesis of the extensor tendons on the involved PIP, with a medium-severe signal within the enthesis on power Doppler analysis, typical of enthesitis. Peritendinous edema and power Doppler signal at the second and third MCP joints were also found, as described by Gutierrez, et al4. The authors reported a high specificity of this sign for psoriatic arthritis even though the same US picture was present in patients with rheumatoid arthritis as described by Backhaus, et al5.

In our investigation, we focused on the enthesitis of the extensor digitorum tendons at the PIP (Figure 1). To our knowledge, this has not been documented as a US finding previously. Further studies are needed to expose enthesitis of the hands when differentiating rheumatoid arthritis from psoriatic arthritis.

Figure 1.
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Figure 1.

The ultrasonographic aspect of enthesitis of the extensor tendon of the proximal interphalangeal joint in greyscale (panel 1) and with power Doppler scan (panel 2) and peritendinous inflammation of the extensor digitorum at the metacarpophalangeal (MCP) joint (panel 3). Note thickening of the insertional tract of the extensor tendon (ET, arrowheads, panel 1) and the presence of power Doppler signal within the tendon (panel 2). A small amount of liquid (*) and a slight synovial proliferation (s), without a Doppler signal, were also present. In panel 3, severe peritendinous inflammation of the extensor tendon at the MCP is visible, as described in patients with psoriatic arthritis4. Even in that case, mild synovial proliferation with a few spots of power Doppler signal was present.

REFERENCES

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    . Differential diagnosis between rheumatoid arthritis and psoriatic arthritis: The value of ultrasound findings at metacarpophalangeal joint level. Ann Rheum Dis 2011;70:1111–4.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
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    7. et al.
    Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project. Arthritis Rheum 2009;61:1194–201.
    OpenUrlCrossRefPubMed
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No Enthesis Should Be Overlooked When Psoriatic Arthritis Is Suspected: Enthesitis of the Extensor Digitorum Tendons
GEORGIOS FILIPPOU, VALENTINA DI SABATINO, ANTONELLA ADINOLFI, ILARIA BERTOLDI, VALENTINA PICERNO, GIOVANNI BIASI, MAURO GALEAZZI, BRUNO FREDIANI
The Journal of Rheumatology Mar 2013, 40 (3) 335; DOI: 10.3899/jrheum.121123

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No Enthesis Should Be Overlooked When Psoriatic Arthritis Is Suspected: Enthesitis of the Extensor Digitorum Tendons
GEORGIOS FILIPPOU, VALENTINA DI SABATINO, ANTONELLA ADINOLFI, ILARIA BERTOLDI, VALENTINA PICERNO, GIOVANNI BIASI, MAURO GALEAZZI, BRUNO FREDIANI
The Journal of Rheumatology Mar 2013, 40 (3) 335; DOI: 10.3899/jrheum.121123
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