J Rheum Dis.  2018 Oct;25(4):221-230. 10.4078/jrd.2018.25.4.221.

Enthesitis-related Arthritis

• Hahn YS

• KMID: 2429708
• DOI: http://doi.org/10.4078/jrd.2018.25.4.221

Abstract

Enthesitis-related arthritis (ERA) is a disease predominantly affecting the joints and entheses of the lower extremities and has the potential to eventually affect the sacroiliac joints and spine evolving to juvenile ankylosing spondylitis. ERA is also characterized by rheumatoid factor seronegativity, paucity of antinuclear antibody, and a strong association with the human leukocyte antigen-B27. ERA accounts for a higher proportion of juvenile idiopathic arthritis (JIA) cases in the Asian population compared to other populations. Advances in the understanding of ERA pathogenesis continue to progress and have led to the development of new treatments targeting pro-inflammatory cytokines. In particular, tumor necrosis factor-α inhibitors have become a mainstay of therapy for patients in whom therapy with anti-inflammatory drugs and/or disease-modifying anti-rheumatic drugs are inadequate or contraindicated. Compared to other JIA subtypes, ERA is associated with a poorer quality of life, worse function, and a higher likelihood of ongoing active disease after the initial treatment. Because the current guidelines for the management of ERA is not considered separately from other categories of JIA, there is a need for treatment guidelines specific to ERA to improve the overall disease outcomes.

Keyword

Juvenile arthritis; Enthesitis-related arthritis; Pathogenesis; Therapeutics; Prognosis

MeSH Terms

Antibodies, Antinuclear
Antirheumatic Agents
Arthritis*
Arthritis, Juvenile
Asian Continental Ancestry Group
Cytokines
Humans
Joints
Leukocytes
Lower Extremity
Necrosis
Prognosis
Quality of Life
Rheumatoid Factor
Sacroiliac Joint
Spine
Spondylitis, Ankylosing
Antibodies, Antinuclear
Antirheumatic Agents
Cytokines
Rheumatoid Factor

Figure

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  Figure 1. Modified Schober's test. With patient standing up-right, two points are marked on the back 5 cm below and 10 cm above the horizontal line joining the dimples of Venus which is used as a mark for the lumbosacral junction. On maximal forward flexion, keeping the knees straight, an increase of the distance between the top and bottom points reflects lumbosacral spinal mobility and is considered normal if more than 5 cm.

• 

  Figure 2. Anteroposterior view of the pelvis shows joint space narrowing, bone erosions, and reactive sclerosis in the sacroiliac joints.

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  Figure 3. Corner lesion in 15 year old male with en-thesitis-related arthritis. Plain radiograph (A) and T1-weighted magnetic resonance imaging (B) of spine show increased signal at the anterior aspect of the superior endplate of L2 (arrows).

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  Figure 4. Achilles tendon enthesitis in a 14 year old boy. (A) Longitudinal grayscale ultrasound image demonstrates increased thickness of Achilles tendon (arrowheads) with hypo-echogenicity and loss of fibrillar pattern in deep layer. (B) Power Doppler images demonstrates increased signals within the tendon consistent with hyperemia.

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  Figure 5. Coronal T1-weighted magnetic resonance imaging of pelvis in 15 year old male with enthesitis-related arthritis. There is active sacroiliitis with bone marrow edema (arrows) on both iliac and sacral sides of the sacroiliac joints.

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  Figure 6. Flow of treatments for patients with enthesitis-related arthritis. NSAIDs: non-steroidal anti-inflammatory drugs, IA: intraarticular, SSZ: sulfasalazine, MTX: methotrexate, TNF: tumor necrosis factor.

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