Dactylitis ("sausage toe")

NewsBot · Oct 26, 2006

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Dactylitis, a term for different digit diseases.
Scand J Rheumatol. 2006 Sep-Oct;35(5):333-40
Olivieri I, Scarano E, Padula A, Giasi V, Priolo F

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronvarsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.
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Admin2 · Oct 26, 2006

Related thread:
Fat toe...????

NewsBot · Jan 15, 2009

Fast spin echo-T2-weighted sequences with fat saturation in toe dactylitis of spondyloarthritis.
Olivieri I, Scarano E, Padula A, D'Angelo S, Salvarani C, Cantini F, Niccoli L, Barozzi L.
Clin Rheumatol. 2008 Sep;27(9):1141-5.

We aimed to establish by using fast spin echo (FSE)-T2-weighted sequences with fat saturation if flexor tendon enthesitis is the primary lesion in spondyloarthritis (SpA) toe dactylitis. Consecutive patients showing toe dactylitis and meeting Amor criteria for the classification of SpA were enrolled. Dactylitic toes and their corresponding normal contralateral digits were studied by FSE-T2-weighted sequences with fat saturation. Twelve dactylitic toes belonging to ten SpA patients were studied. All dactylitic toes showed mild-to-moderate fluid collection in the synovial sheaths of flexor digitorum brevis and longus. Involvement of joint cavity was simultaneously seen in at least one joint of eight (66.6%) out of the 12 toes. A mild-to-severe peritendinous soft tissue edema was observed in all but one of the affected toes. In no dactylitic toe was bone edema observed either near the insertions of the flexor digitorum brevis and longus tendons or in other sites of the phalanges. No lesions were observed in the 12 contralateral clinically normal toes. In SpA toe dactylitis there is no evidence of enthesitis of the flexor digitorum brevis and longus tendons and joint capsules.
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NewsBot · Feb 22, 2012

Prevalence and clinical characteristics of dactylitis in spondylarthritis: a descriptive analysis of 275 patients.
Payet J, Gossec L, Paternotte S, Burki V, Durnez A, Elhai M, Fabréguet I, Koumakis E, Meyer M, Roure F, Dougados M.
Clin Exp Rheumatol. 2012 Feb 16.

OBJECTIVES:
Dactylitis is a common but little studied feature of spondylarthritis (SpA). Our objective was to assess the prevalence of dactylitis among a cohort of patients with spondylarthritis in a tertiary care centre and to describe the clinical characteristics of dactylitis.

METHODS:
This was a prospective single centre observational study carried out in 2010. The patients included had been diagnosed as having definite SpA based on Amo's criteria. Each patient was interviewed by a physician. The data collected included prevalence of dactylitis and its clinical characteristics, effectiveness of the different treatments, and association with severe manifestations of SpA, and analysed by descriptive analysis.

RESULTS:
275 consecutive SpA patients were assessed: mean age 43.2±13.5 years, mean disease duration 14.0±11.8 years, 169 (61.4%) were men. In all, 59 patients (21.5%) suffered from SpA-associated dactylitis. The localisation of dactylitis was toes in 46 patients (78.0%) and/or fingers in 25 patients (42.4%). The most frequent localisations were the second toe and the second finger. Dactylitis was the first symptom of SpA in 14 patients (5.1%), and 28.8% (n=17) of dactylitis appeared within the first 5 years of disease. Dactylitis was present in 35.1% (n=13) of patients with undifferenciated SpA and in 30.6% (n=15) of patients with psoriatic arthritis. It was significantly associated with history of peripheral arthritis or heel pain. In our population, there was no correlation between dactylitis and HLA B27 status or sex and it was not a marker of severity of disease.

CONCLUSIONS:
Dactylitis is a frequent manifestation in SpA (21.5%) particularly in peripheral disease and it may be the first manifestation of the disease with localisation being more frequent in the toes.
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NewsBot · Sep 22, 2015

Optimal management of dactylitis in patients with psoriatic arthritis
Toshiyuki Yamamoto
Open Access Rheumatology: Research and Reviews ? Volume 7 September 2015 Volume 2015:7 Pages 55—62

Psoriatic arthritis (PsA) is an inflammatory arthropathy associated with cutaneous psoriasis, which is currently classified as a seronegative spondyloarthropathy. The presence of cutaneous psoriasis is important for correct and early diagnosis of PsA, because the onset of cutaneous lesions usually precedes the appearance of joint manifestation. Thus, dermatologists are able to detect the condition at its inception. PsA has several unique characteristics such as enthesopathy, dactylitis, and abnormal bone remodeling. In particular, dactylitis occurs on the easily observed sites such as digits, and is thus a significant indicator of PsA. It is important to observe not only the fingers but also the toes, because dactylitis involves both digits of the hands and feet. Recently, new ideas regarding the involvement of the interleukin (IL)-23/Th17 axis have emerged, and the dramatic effects of targeting therapies have highlighted the physiological roles of key cytokines such as tumor necrosis factor-α, IL-17A, and IL-23 in psoriasis. As recent insights are shedding light on the pathogenesis of PsA, understanding of the pathogenesis of dactylitis and enthesitis are also progressing. In this article, current views on the optimal management of dactylitis are discussed.
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NewsBot · Oct 17, 2015

The Swedish Early Psoriatic Arthritis Registry 5-year Followup: Substantial Radiographic Progression Mainly in Men with High Disease Activity and Development of Dactylitis.
Geijer M et al
J Rheumatol. 2015 Oct 15. pii: jrheum.150165

OBJECTIVE:
To describe early radiographic findings in patients from the Swedish psoriatic arthritis (SwePsA) registry, progression of destruction, correlations with clinical disease variables, and predictors of destruction.
METHODS:
Hand and foot radiographs were available for 72 of 197 SwePsA patients followed for 5 years. Clinical data were collected according to the SwePsA protocol.
RESULTS:
Disease characteristics and clinical improvement were similar in men and women. Radiographic abnormalities were more pronounced in men. Total Wassenberg radiographic score at baseline was 0 in 45% of men and 51% of women. One man and one woman had a score > 10. At 5 years, total score was 0 in 14% of men and 40% of women (p = 0.018); 17% of men and 7% of women had scores > 10. Mean total scores for men and women had increased. Baseline erythrocyte sedimentation rate was associated with baseline total radiographic score. In men, swollen joint count was positively, and in women tender joint count negatively, correlated to total radiographic score. After 5 years, only male scores, mainly hand scores, significantly correlated with 28-joint Disease Activity Score and Disease Activity Index for Psoriatic Arthritis scores, swollen joint count, and dactylitis. Achieving remission or minimal disease activity after 5 years protected against structural damage, mainly in men.
CONCLUSION:
Radiographic progression in early PsA was generally slow but substantial. Male sex appears to be a risk factor for early radiographic damage while the presence of baseline radiographic damage and dactylitis developing during followup seem to predict further destruction. Hand and foot radiograph scoring cannot be substituted with clinical signs.
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NewsBot · Nov 15, 2016

Which Are the Ultrasound Lesions Underlying Dactylitis?
Adrien Nzeusseu Toukap et al
2016 ACR/ARHP Annual Meeting

Background/Purpose: Dactylitis (DACT) is defined as diffuse swelling of the digit and is included in the ASAS criteria for spondyloarthritis. It is a hallmark feature of psoriatic arthritis (PsA), occurring in 16-24% of cases. One of the main problems with the definition of dactylitis is the existence of a chronic non-tender form. The lack of tenderness suggests inactive disease, but subclinical inflammation may exist. Objective. To assess ultrasound (US) pathological lesions in dactylitic digits of patients suffering from PsA.

Methods: Consecutive PsA patients suffering from at least one DACT in feet or hand were included. The presence of DACT was diagnosed at clinical examination. At US examination, the entire DACT digit was scanned both on dorsal and palmar/plantar sides. The following ultrasound pathological lesions were scored: soft tissue thickness and edema, synovitis of MCP, PIP and DIP joints, inflammatory involvement of both flexor (tenosynovitis) and extensor (paratenonitis) tendons, nail bed vascularity, synovio-entheseal complex at DIP level, enthesitis of flexor tendon, intra-articular and extra-articular bone proliferation. Gray-scale (GS) and power-Doppler (PD) synovitis and tenosynovitis were assessed according to OMERACT scores (0-3). Nail bed vascularisation was scored 0 to 3. The other US lesions were scored 0 (absent) or 1 (present), both in GS and PD. The standard (HAQ) questionnaire, tender and swollen joint count, tenderness of DACT, global disease activity scored by physician and by patient were assessed in all patients.

Results: Twenty-eight DACT from 17 consecutive patients (8 men and 9 women) suffering from PsA were examined by US. Mean age was 43.3±11.2 years. Nine patients presented with hand DACT and 8 patients with foot DACT. Ten patients had single DACT. Seven patients presented with multiple DACT: 3 simultaneous DACT in 4 patients and 2 simultaneous DACT in 3 patients. Seven patients were on non-biologic DMARD, 2 patients were on combined therapy with biologics, one patient was on biologic monotherapy and 7 patients were DMARD naïve. Soft tissue thickness was present in all DACT. Synovitis of at least one joint was present in all DACT (28/28). The MCP synovitis was present in 75% (21/28) of DACT, PIP synovitis in 60% (17/28) of DACT, and DIP synovitis in 43% (12/28) of DACT. Inflammatory involvement of tendons was observed in 75% (21/28) of DACT: more flexor than extensor tendons were involved. Enthesitis was present in 68% (19/28) of DACT. Nail bed hypervascularisation (PD grade 3) was present in 14% (4/28) of DACT. Bone proliferation was present in 46% of DACT (13/28). A significant association between tenderness and the presence of PD and/or edema in the soft tissue was observed (p<0.01). The frequency of synovitis, tenosynovitis and enthesitis did not differ significantly between tender and non-tender DACT.

Conclusion: We show that US pathological lesions in DACT are more heterogeneous than previously reported. In particular, DACT is characterized by simultaneous involvement of joints, tendons and soft tissue. A significant amount of joint, tendon and entheseal inflammation persists in non-tender DACT. Tenderness tends to be associated with the presence of edema and/or PD inside the soft tissue, but larger samples are required to confirm these results. The impact of current treatments on inflammation might differ according to joint, tendon or entheseal level involved in DACT.
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NewsBot · Jan 9, 2019

Pathophysiology, assessment and treatment of psoriatic dactylitis
Dennis McGonagle, Ai Lyn Tan, Abdulla Watad & Philip Helliwell
Nature Reviews Rheumatology (2019)

Dactylitis is diffuse swelling of the digits that is usually related to an underlying inflammatory or infiltrative disorder. Psoriatic arthritis (PsA) is the most common severe disease thought to cause dactylitis. Our understanding of the pathogenesis of PsA-related dactylitis comes from experimental animal models of PsA-like disease, as well as advances in imaging and other clinical studies. Clinical trials in PsA have increasingly included dactylitis as an important secondary outcome measure. These studies indicate that cytokines drive multi-locus microanatomical pan-digital pathology. Given the importance of pro-inflammatory cytokines, the pathogenesis of dactylitis is best understood as an initial aberrant innate immune response to biomechanical stress or injury, with subsequent adaptive immune mechanisms amplifying the dactylitis inflammatory response. Regarding the treatment of dactylitis, no studies have been conducted using dactylitis as the primary outcome measure, and the current knowledge comes from analysis of dactylitis as a secondary outcome measure.
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NewsBot · Mar 5, 2019

Symptomatic psoriatic dactylitis is associated with ultrasound determined extra-synovial inflammatory features and shorter disease duration
Nicolò GirolimettoLuisa CostaLuana MancarellaOlga AddimandaPaolo BottiglieriFrancesco SantelliRiccardo MeliconiRosario PelusoAntonio Del PuentePierluigi MacchioniCarlo SalvaraniDennis McGonagleRaffaele ScarpaFrancesco Caso
Clinical Rheumatology March 2019, Volume 38, Issue 3, pp 903–911

Objectives
To explore the link between ultrasonographic features of dactylitis in psoriatic arthritis (PsA) and symptoms, digital tenderness and duration of dactylitis.

Methods
Forty-eight cases of PsA dactylitis were investigated using high frequency ultrasound (US) both in grey scale (GS) and Power Doppler (PD), evaluating the presence and the degree of flexor tenosynovitis, peri-tendinous oedema, subcutaneous PD, extensor tendon involvement, GS synovitis and intra-articular PD signal (PDS) of the involved digits. Patients were compared according to the presence of local pain and digital tenderness, the duration of dactylitis and the concomitant treatment.

Results
The presence of pain/tenderness was positively associated with US GS flexor tenosynovitis of grade > 2 (p < 0.001), PD-flexor tenosynovitis (p < 0.001), peri-tendinous oedema (p < 0.001) and subcutaneous PDS (p < 0.001); moreover, it was negatively associated with GS synovitis (p < 0.001) and intra-articular PD (p < 0.001). The same positive and negative association with US findings were found comparing patients with duration of dactylitis shorter or longer than the median (24 weeks) (p < 0.001 for all comparisons).

Conclusions
Pain and digital tenderness are linked to dactylitis duration and earlier lesions are associated with extra synovial inflammatory changes. These findings suggest a hitherto unappreciated extra synovial basis for symptoms in PsA dactylitis.
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