The benefits of ultrasound in rheumatology highlighted at ISR Autumn Meeting

Using ultrasound in clinics “makes me a better rheumatologist”, according to Prof Emilio Filipucci, Consultant Rheumatologist at the Marche Polytechnic University in Italy. 

Speaking to the Medical Independent at the ISR meeting in Belfast, Prof Filipucci said that ultrasound can confirm a suspected diagnosis. 

“I’m still learning – it is an endless learning curve,” he said. “But to reach some sufficient level is not so difficult…. Especially with the ultrasound equipment that we have now.” 

“You don’t need to become an expert, but practice, practice, practice.” 

According to Prof Filipucci, ultrasound in rheumatology allows the sonographer to see more than just inflammation and damage in joints in rheumatoid arthritis. 

It also provides the ability to distinguish fluid and tissues, to detect active inflammation, and if the inflammation has reduced in follow-up examinations. It can also highlight swollen cartilage before it destroys the bone underneath it, he added. 

Prof Filipucci referenced a 2020 study, published in the Annals of the Rheumatic Diseases, which showed ultrasound scans of bone erosion in the feet can be a predictive indicator of rheumatoid arthritis. 

He also highlighted a 2011 study in Rheumatology that found ultrasound was more effective for detecting bone erosion than x-ray in rheumatoid arthritis patients. 

He added that ultrasound has also been beneficial at detecting crystal deposition diseases, such as gout and calcium pyrophosphate deposition (CPPD). A 2022 study in Rheumatology, which Prof Filipucci was involved in, demonstrated that ultrasound assessment of two bilateral joints shows “great accuracy” for diagnosing gout and CPPD. 

“If we scan the joints [of] the knee and the big toe we can make a diagnosis of gout, in most cases, that is very accurate,” he told delegates at the meeting. “If we scan the joints [of] the knee and the wrist, we can make a diagnosis of CPPD that is accurate in most of the cases.” 

Ultrasound also allows the sonographer to see enthesophytes, and thus, enthesitis, a symptom of psoriatic arthritis. 

Prof Filipucci added that ultrasound can help to find targets and avoid tendons in difficult to inject sites. 

However, he acknowledged the limitations of the tool. “The limitations basically can be summed up in these three items: The physics… the equipment… and the sonographer.” 

Ultrasound will not show a high-resolution image for an issue deeper into the tissue; for example, in patients with obesity, he said. 

He advised that rheumatologists should be open to switching to newer, more technologically advanced equipment, even if this requires new learning. 

He also pointed out that the human error of the sonographer can limit the effectiveness of ultrasound. 

Prof Filipucci also spoke to the ISR audience about the potential assistance of incorporating artificial intelligence into rheumatology. As part of a 2021 study in the Frontiers in Medicine journal, Prof Filipucci and colleagues showed that AI deep learning can provide feedback to the sonographer about the correct identification of scanned tissues. It can also aid in faster and standardised measurements.