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  1. 8/29/2012 Outline 1. Classification and symptoms (ILAR-International league of Associations for Rheumatology) Juvenile idiopathic arthritis 2. Imaging J. Herman Kan, M.D. Section chief, musculoskeletal imaging Edward B Singleton Department of Radiology Texas Children’s Hospital Houston, TX 3. Targeted intervention with image guided therapy Page 1 Page 2 1. JIA classification (JRA) 1. Classification-ILAR ILAR North?American ILAR Symptoms Juvenile?idiopathic? arthritis?(JIA) Juvenile?rheumatoid?arhtirits (JRA) Systemic?arthritis (Still’s?disease)?Fever,?rash?hepatosplenomegaly,? lymphadenopathy Juvenile?ankylosing spondyloarthritis Reactive arthritis?(Reiter’s? disease) oligoarthritis 4?or?less?joints?involved Inflammatory bowel?disease? related?arthritis polyarthritis 5?or?more?joints?involved?(RF+, RF?) Psoriatic arthritis Page 3 Page 4 1. JIA classification (Spondyloarthropathies) 1. Classification-clinical diagnosis •JIA-diagnostic criteria ?16 years or younger ?Greater than 6 weeks of symptoms ILAR Enthesitis related?arthritis Symptoms (ankylosing spondylitis,?IBD?related? arthritis,?Reactive?arthritis)?Enthesitis, tenosynovitis,?axial?skeletal?involvement? rare,?boys?most?commonly?affected Psoriatic?arthritis Arthritis?and?psoriasis (arthritis?may? precede?skin?changes) Page 5 Page 6 1

  2. 8/29/2012 1. Classification-clinical diagnosis 1. Classification-clinical diagnosis •Enthesitis related arthritis (meets JIA criteria)- 2 OF THE FOLLOWING ?Sacroiliac or spinal pain ?HLA-B27 positive ?HLA-B27 family history ?Anterior uveitis ?Arthritis in a boy 8 years or older •Psoriatic arthritis (meets JIA criteria)- THE FOLLOWING ?Dactylitis (sausage digit) ?Nail pitting or onycholysis (nail bed separation) ?Psoriasis in a first degree relative 2 OF Page 7 Page 8 Problems with radiographs for assessing disease 2. Imaging •Radiographs-used to provide baseline and prognostic information •Bone erosions are a late finding compared with adult patients •MRI and US-guides early intervention and treatment •Epiphyseal ossification is surrounded by: ?Spherical growth plate ?Epiphyseal cartilage ?Articular cartilage Page 9 Page 10 Problems?with?radiographs Pathway?to?erosions?is? articular,?epiphyseal,?and? spherical?growth?plate? cartilage Pathway?to?erosions?is?only Articular cartilage Spherical?growth?plate 5?yo 5?yo 37?yo Epiphyseal cartilage physis E Articular cartilage Page 11 Page 12 2

  3. 8/29/2012 MRI imaging features MRI imaging features Mild Severe Mild Severe Page 13 Page 14 Effusions-15 year old-JIA MRI imaging features Mild Severe Page 15 Page 16 Pre-erosive osteitis MRI imaging features Mild Severe Page 17 Page 18 3

  4. 8/29/2012 15 year old-JIA with erosions and subchondral marrow edema MRI imaging features Mild Severe Page 19 Page 20 15 year old-JIA metacarpal erosions-old 16 year old-JIA-erosions may be called when there is subjacent osteitis present post Page 21 Page 22 Erosions versus normal undulations about the metacarpal and carpal bones When in Doubt… •Look for subchondral marrow edema •Erosions have sharp borders concave borders •Enhancement at the area of questionable erosion versus normal undulation •Normal undulations have smooth borders •In betweeners (a little of both) Page 23 Page 24 4

  5. 8/29/2012 Normal undulations are usually smooth Normal undulations versus erosions Erosions Normal?undulations Page 25 Page 26 Pre-erosive subchondral marrow edema versus erosions-use T1W sequences MRI imaging features Pre?erosive?osteitis Erosions Mild Severe Page 27 Page 28 15 year old-severe JIA, with joint space loss Features suggesting chronicity •Erosions •Pannus •Rice bodies Page 29 Page 30 5

  6. 8/29/2012 12 year old-JIA-Rice bodies 16 year old-Pannus and erosions post T2?FS Page 31 Page 32 Enthesitis related arthropathies Tenosynovitis •Most commonly affected tendons are the patella and Achilles tendon mild severe •Tenosynovitis is common Page 33 Page 34 18 year old-enthesitis-Achilles 18 year old-enthesitis-plantar origin Page 35 Page 36 6

  7. 8/29/2012 3 year old-sausage digit 3 year old sausage digit Page 37 Page 38 Role of MRI to guide treatment 13 year old-JIA •Targeted treatment of affected joints •Decrease systemic therapy •May control flares up to 6 months Page 39 Page 40 16 year old-JIA- Page 41 Page 42 7

  8. 8/29/2012 MRI roadmaps intervention Summary •Juvenile spondyloarthropathies rarely presents with axial symptoms, hence ILAR terminology of enthesitis related arthropathies •Radiographs are helpful for providing prognostic and baseline information for the patient, but insufficient for guiding early intervention Page 43 Page 44 8