jd laredo spa-spondyloarthritis jfim hanoi 2015
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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
Spondyloarthritis (Spa)
• No biological diagnos-c test • Diagnosis needs first to rule out tumor and infec-on
Spondyloarthritis (Spa)
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
1
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
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
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 5
Cliché 4
STIR
Mise au point sur la sémiologie radiologique Anatomie-‐radiologique de l’ar3cula3on costo-‐vertébrale
T2 Fat Sat
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
Cliché 6
Cliché 6
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
Cas 4
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
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 3: 57 y-‐o man with back pain at night
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
SAPHO Syndrome : Radiological clues
1. Marginal ostei-s/vertebral enthesi-s
Marginal ostei-s/vertebral enthesi-s
32-‐y-‐o man with neck pain
Marginal ostei-s/vertebral enthesi-s
Gad-‐E. T1-‐W. T1-‐W.
Marginal ostei-s/vertebral enthesi-s
71%
T2 57-‐y-‐o woman with back pain
Marginal ostei-s/vertebral enthesi-s
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
Case report : 16 y-‐o man
STIR images
Case report : 16 y-‐o man
Case report : 16 y-‐o man
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
Case 3: 57 y-‐o man with back pain at night
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
SAPHO Syndrome : Radiological clues
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
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
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