Ultrasound in practice

Clinical case studies

How might ultrasound add value to aid diagnosis, assessment of therapeutic response and the assessment of disease state?

Background
  • Rheumatoid Arthritis (RA) of six-months duration
  • Rheumatoid factor (RF) positive
  • Anti-citrullinated protein/peptide antibodies (ACPA/anti-CCP) positive
  • Disease Activity Score 28 (DAS28) using erythrocyte sedimentation rate DAS28-ESR: 5.6
  • Methotrexate 25 mg/week (escalated from 15 mg/week at three months)
  • Clinical assessment at six months:
    • Tender 28-joint count (TJC28): 1 (right wrist)
    • Swollen 28-joint count (SJC28): 0
    • Global Visual Analogue Scale (VAS) score: 15
    • Erythrocyte sedimentation rate (ESR): 30 mm/hour
    • DAS28-ESR: 3.25
  • EULAR response: good
  • No structural damage
Ultrasound findings
  • B-mode synovitis grade 2, power Doppler grade 1 in left elbow
  • B-mode synovitis grade 2, power Doppler grade 3 in right wrist
  • B-mode synovitis grade 1, power Doppler grade 3 in right metacarpophalangeal joint (MCP) 2
  • Erosion at right ulnar styloid, right MCP 2 and left metatarsophalangeal
    (MTP) 5
Summary and suggested management
  • Evidence of aggressive, sub-clinical disease, predictive of flare and radiological damage
  • Suggested management: initiate biologic therapy
Clinical assessment findings at nine months
  • TJC28: 0
  • SJC28: 0
  • VAS: score 0
  • ESR: 10 mm/hour
  • DAS28-ESR: 1.6

 

Summary
Clinical remission

Ultrasound assessment findings at nine months
  • B-mode synovitis grade 1, power Doppler 0 in left elbow
  • B-mode synovitis grade 1, power Doppler 0 in right MCP joint 2

 

Summary
Clinically unimportant synovitis in patient; clinical remission on biologic

How did ultrasound add value?
  • Ultrasound was reassuring but not essential, as biologics provide protection against radiological damage. This is when an ultrasound examination is of questionable value, as a patient is clinically very well and under biological “protection”.

Case study 2

Therapeutic Response

Case study 3

Remission

Case study 1

Diagnosis

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