Chronic hepatitis B virus (HBV) infection may be reactivated by immunosuppressive drugs in patients with autoimmune inflammatory rheumatic diseases. This study evaluates HBV serum markers’ prevalence in rheumatic outpatients belonging to Spondyloarthritis, Chronic Arthritis and Connective Tissue Disease diagnostic groups in Italy. The study enrolled 302 subjects, sex ratio (M/F) 0.6, mean age ± standard deviation 57 ± 15 years, 167 (55%) of whom were candidates for immunosuppressive therapy. The Spondyloarthritis group included 146 subjects, Chronic Arthritis 75 and Connective Tissue Disease 83 (two patients had two rheumatic diseases; thus, the sum is 304 instead of 302). Ten subjects (3%) reported previous anti-HBV vaccination and tested positive for anti-HBs alone with a titer still protective (>10 IU/mL). Among the remaining 292 subjects, the prevalence of positivity for HBsAg, isolated anti-HBc, anti-HBc/anti-HBs, and any HBV marker was 2%, 4%, 18%, and 24%, respectively. A total of 26/302 (9%) patients with γ-globulin levels ≤0.7 g/dL were more frequently (p = 0.03455) prescribed immunosuppressive therapy, suggesting a more severe rheumatic disease. A not negligible percentage of rheumatic patients in Italy are at potential risk of HBV reactivation related to immunosuppressive therapy. Before starting treatment, subjects should be tested for HBV markers. Those resulting positive should receive treatment or prophylaxis with Nucleos (t) ides analogue (NUCs) at high barrier of resistance, or pre-emptive therapy, according to the pattern of positive markers. HB vaccination is recommended for those who were never exposed to the virus.

Introduction: Dactylitis is a hallmark of psoriatic arthritis (PsA). While its assessment is clinical, recently musculoskeletal ultrasonography (MSUS) has been applied to its monitoring. However, the evidence on MSUS application for toe dactylitis is limited. The aim of this study is to characterize the ultrasonographic features of toe dactylitis in PsA. Method: Patients with PsA and painful toe dactylitis were retrospectively identified from clinical records. Demographic and clinical variables were analyzed. Ultrasound images of the affected toe, allowing the assessment of grey scale (GS) and power Doppler (PD) were collected, to evaluate tenosynovitis, soft tissue oedema (STO), synovitis of metatarsophalangeal (MTP), proximal and distal interphalangeal (PIP, DIP) joints (all graded 0–3), and peritendonitis (PTI) at the MTP and PIP (graded 0–1). Clinical and ultrasonographic features were analyzed through descriptive statistics. Results: The study included 26 patients (30 toes) of which 9 (34.5%) females, with mean (sd) age of 46.8 (11.73). All but one patient had an oligoarticular phenotype. Tenosynovitis was the most frequent lesion, with GS abnormalities in 27/30 toes (90%) and PD in 25/30 (83.3%). STO was common (GS in 28/30 (93.33%) toes and PD in 20/30 (66.66%)). Synovitis was less common (63.33%, 46.66% and 33.33% of MTPs, PIPs and DIPs, respectively), while PTI was uncommon, with no patient presenting with PD. Conclusions: Ultrasound showed different elementary lesions in toe dactylitis confirming the complexity of this manifestation also at foot. These findings represent a first step toward the development of further imaging studies assessing toe dactylitis in PsA. Key Points• Tenosynovitis and soft tissue oedema were the most common ultrasonographic elementary lesion in acute toe dactylitis in psoriatic arthritis.• Synovitis was less frequent and peritendonitis was very uncommon.• Musculoskeletal ultrasound confirms the presence of multiple lesions in painful toe dactylitis, confirming the complexity of this manifestation.

Bullous pemphigoid (BP) is an autoimmune blistering skin disease, mainly observed in the elderly. Infections have been suggested as possible disease triggers. However, infections may even heavily influence the disease clinical course and mortality. A 75-year-old woman was admitted to hospital for severe erythematosus blistering disease, accompanied by hyper-eosinophilia and hyper-IgE. The culture of bullous fluid was positive for Enterococcus faecalis, the blood culture was positive for Staphylococcus aureus, and the urine culture was positive for Proteus mirabilis and Escherichia coli. Moreover, circulating anti-BP180 IgG was present and the histopathological/ultrastructural examination of a lesional skin biopsy was compatible with BP. High eosinophil levels (up to 3170/µL) were found throughout the clinical course, while values below 1000/µL were associated with clinical improvement. The total IgE was 1273 IU/mL, and specific anti-G/V-penicillin/ampicillin IgE antibodies were positive. The patient had a complete clinical recovery in two months with methyl-prednisolone (40 then 20 mg/day) and low-dose azathioprine (50 mg/day) as a steroid-sparing agent. The steroid treatment was tapered until interruption during a one-year period and intravenous immunoglobulins have been administered for three years in order for azathioprine to also be interrupted. The patient stopped any treatment five years ago and, in this period, has always been in good health. In this case, the contemporaneous onset of different bacterial infections and BP is suggestive of bacterial infections acting as BP trigger(s), with allergic and autoimmune pathways contributing to the disease pathogenesis.

Objective. To develop and test an algorithm with the aim of optimizing the implementation of ultrasound in the diagnostic workflow in clinical practice. Methods. Through a consensus among the Musculoskeletal Ultrasound (MSUS) Study Group of the Italian Society for Rheumatology, we identified clinical and laboratory variables to be included in 1000minds surveys to develop an algorithm driving clinical diagnostic suspicion. The algorithm would identify potential differential diagnoses where MSUS protocols targeted for specific diseases (rheumatoid arthritis, psoriatic arthritis, gout, calcium pyrophosphate deposition disease, polymyalgia rheumatica, and osteoarthritis) could be applied. The joint sites and elementary lesions for each disease were selected based on a previously performed systematic literature review (SLR) and consensus. Finally, we conducted a pilot study on patients with new-onset arthritis to assess the performance of the algorithm, comparing the algorithm-based diagnosis with the final clinical diagnosis. Results. Based on the consensus and the surveys, age, the number of involved joints, anti-citrullinated protein antibody, rheumatoid factor, C-reactive protein, and erythrocyte sedimentation rate were included in the algorithm. The pilot study included 59 patients: median (interquartile range) age 62.2 (54.1-72.6) years, 78% female. The agreement between the diagnosis selected by the algorithm and the final diagnosis by the rheumatologist was 88.1%. The elementary lesions and joint sites included in the different MSUS protocols were selected based on the best diagnostic accuracy, as shown by the SLR and defined by the working group. Conclusions. The developed algorithm was accurate in identifying the correct diagnosis. Thus, it could reliably drive the decision on the MSUS assessment to perform. The RADIAL study will further investigate the feasibility and added value of MSUS in the diagnostic workflow according to this newly developed clinical suspicion-driven algorithm.

Objectives: To develop a practical consensus for standardizing communication between rheumatologists and radiologists regarding magnetic resonance imaging (MRI) of the sacroiliac joints and spine in the diagnosis and management of axial spondyloarthritis (axSpA). Methods: A task force comprising six rheumatologists and five musculoskeletal radiologists with expertise in axSpA imaging reviewed the Assessment of SpondyloArthritis International Society (ASAS) framework to draft initial recommendations and define project goals. A broader expert panel (21 rheumatologists, 19 radiologists) then participated in a voting process to refine and validate these recommendations. Final endorsement was sought from the steering committees of the Italian Society of Medical and Interventional Radiology (SIRM) and the Italian Society of Rheumatology (SIR) using a modified Delphi method. Results: Thirty-one recommendations were validated, organized into eight domains. Domain 1 outlines five overarching principles. Domain 2 comprises recommendations on clinical features, symptoms, and risk factors. Additional domains address MRI technical parameters, including image quality and sequencing (Domain 3), and standardized reporting criteria. For the sacroiliac joints (Domains 4 and 5), five signs of inflammation and six of structural damage are defined. For the spine (Domains 6 and 7), five inflammatory and four structural features are specified. Domain 8 provides guidance on report conclusions. The recommendations were endorsed by SIRM/SIR with 88.5% approval. Conclusion: This consensus offers structured guidance for MRI requesting and reporting in axSpA, fostering clear communication between radiologists and rheumatologists. The standardized approach aims to improve diagnostic accuracy and patient outcomes.