THU0617 WRIST ULTRASOUND (US) PATHOLOGY IN EARLY RHEUMATOID ARTHRITIS (RA); OBSERVATIONS FROM AN EARLY INFLAMMATORY ARTHRITIS (EIA) DIAGNOSTIC SERVICE
Authors: Rizwan Rajak, Momina Zaman, Tim Jones, Fazal Sheikh, Mohammed Sharif
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> To ensure a timely diagnosis of RA, diagnostic US is increasingly being utilized to detect subclinical pathology in order to implement treatment plans rapidly. There are several 'optimal' synovitis scoring protocols in the literature but a consensus regarding a definitive system still eludes us. There are few studies that have focussed specifically on wrist US pathology in early RA. Hence, we assessed what the common wrist US pathologies are in patients diagnosed with early RA. <h3>Objectives:</h3> To identify the patterns of wrist US abnormalities seen in patients diagnosed with early RA from our EIA service in a large urban London hospital. <h3>Methods:</h3> Retrospective service review of patients seen in the EIA US diagnostic service at Croydon Health Services in South London. Patients diagnosed with RA (EULAR/ACR 2010 criteria) with wrist US synovitis/tenosynovitis (EULAR-OMERACT definitions) between Jan2017-Dec2018 were included. The US protocol in the EIA diagnostic service includes lateral and dorsal (long axis &amp; short axis views) of the ulnarcarpal(UCJ) &amp; radiocarpal(RCJ) joints with views covering the radioulnar joints &amp; ulnar-styloids and views of the extensor &amp; flexor tendons. Images and reports were reviewed and correlations with rheumatoid factor(RhF), anti-CCP antibodies(CCP), CRP &amp; ESR were also assessed. <h3>Results:</h3> 86 patients with RA (meeting EULAR-ACR criteria) were found to have wrist pathologies on US. The commonest finding (36%) was moderate (grade 2) greyscale(GSUS) synovitis in the UCJ with almost all having moderate (grade 2) power Doppler(PDUS) synovitis (32%). Only a few (5/86) had more severe pathology with GSUS/PDUS (grade 3). 22%(19/86) had milder changes GSUS grade 1 with three quarters of these patients having concomitant PDUS signal. Just under 10% had RCJ US synovitis and 3 cases had radioulnar joint synovitis. Only 6% of the cohort had whole wrist joint involvement. Erosions were very uncommon (2/86). In total just under 25%(21/86) had tendon disease with roughly 70% affecting 1 tendon compartment and the others affecting 2 or more. Of those with tendon pathology, the two most commonly affected tendons were the 2<sup>nd</sup> [48%(10/21)] and 4<sup>th</sup> [38%(8/21)] extensor compartments. Extensor tenosynovitis was more common than flexor(26 v 4 cases). US synovitis 'only' was seen in 76%, US tendon disease 'only' in 7% and concomitant pathology in 17%. Correlation with inflammatory markers was not seen with only 3 patients presenting with significantly elevated CRP (&gt;15) and ESR (&gt;20). Though CCP was more commonly seen compared to RhF(32% vs 17%), just over half did not have positive antibodies. <h3>Conclusion:</h3> Our observational study found that in early RA, mild-to-moderate GSUS and PDUS in the UCJ is the commonest wrist US pathology with tenosynovitis of the 2<sup>nd</sup> and 4<sup>th</sup> extensor compartments. Severe disease and erosions were very uncommon. The pattern of these US wrist pathologies are likely to reflect the initial disease course of these patients that present to our EIA service (i.e. early RA patients). Furthermore, biochemical markers do not seem to be useful in these patients and serology may not be present in over 50%. Therefore, clinicians who are running EIA diagnostic services with US should be expectant of milder-to-moderate US findings when diagnosing early RA and not be misled by the absence of more severe findings. Our understanding of US pathologies in the RA disease course therefore needs to be more nuanced and further work in other specific joint areas may help to elaborate what US pathology is most common in early RA. <h3>Disclosure of Interests:</h3> None declared