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Dr. Rothschild replies To the Editor: The crux of the question raised by Dr. Juan-Mas and Dr. Carmona is the definition of rheumatoid arthritis (RA). While fulfillment of the American College of Rheumatology (ACR) criteria and lack of sacroiliitis may be sufficient for entry of patients into drug studies, it is not adequate for distinguishing RA from spondyloarthropathy (SpA). Even individuals with psoriasis frequently fulfill the ACR criteria, especially with the deletion of the original "exceptions" category1,2. Demonstrated (exclusive of the sacroiliac joint) distinguishing skeletal features of SpA include subchondral localization of erosions, para-erosional new bone formation, preservation of residual para-erosional trabeculae, enthesial calcification, zygapophyseal joint fusion and erosions, costovertebral joint fusion and erosions, syndesmophytes, erosion of anterior-superior and anterior-inferior vertebral margins, often more limited distribution (fewer joints than in RA, even in those with polyarticular disease), and presence of characteristic patterns (including arthritis mutilans, all joints on a single digit, and distal interphalangeal joint predominant)3-10. The most likely consideration is problems in recognition of the polyarticular presentation of SpA4,5. While diagnosis of SpA is facilitated in the presence of sacroiliac joint erosion or fusion, that is only found in less than half of individuals with SpA3-5,8. Recognition of SpA in the latter group and distinguishing it from other erosive disorders, such as RA, is the challenge, I suspect, in EMECAR cases. Juan-Mas and Carmona report that their clinical experience mimics mine. It is the drug study patients that require clarification. A "broad definition" of RA may relate to the "lumper-splitter" issue8,9. I certainly would appreciate an opportunity to examine the radiographs and case histories in the EMECAR and BIOBADASER studies with Juan-Mas and Carmona, as only through such collaborative efforts can this question be clarified. BRUCE M. ROTHSCHILD, MD, Northeastern Ohio Universities College of Medicine, Arthritis Center of Northeast Ohio, 5500 Market, Youngstown, Ohio 44512, USA. E-mail: bmr@neoucom.edu REFERENCES 1. Rothschild BM, Martin L. Paleopathology: Disease in the fossil record. London: CRC Press; 1993. 2. Rothschild BM. Not the Lucy, not the one. Clin Exp Rheumatol 2002;20:741-3. 3. Rothschild BM. Two faces of "rheumatoid arthritis": Type A versus type B disease. J Clin Rheumatol 1997;3:334-8. 4. Kelley WN, Harris ED Jr, Ruddy S, Sledge CB. Textbook of rheumatology. 2nd ed. Philadelphia: Saunders; l985:915-55. 5. Resnick D. Diagnosis of bone and joint disorders. Philadelphia: Saunders; 2002. 6. Rothschild BM, Woods RJ. Character of pre-Columbian North American spondyloarthropathy. J Rheumatol 1992;19:1229-35. 7. Rothschild BM, Rothschild C. Nineteenth century spondyloarthropathy independent of socioeconomic status: Lack of skeletal collection bias. J Rheumatol 1993;20:314-9. 8. Rothschild BM, Woods RJ. Spondyloarthropathy: Erosive arthritis in representative defleshed bones. Am J Phys Anthropol 1991;85:125-34. 9. Rothschild BM, Woods RJ. Implications of osseous changes for diagnosis of spondyloarthropathy. J Orthop Rheumatol 1992;5:155-62. 10. Koopman WJ. Arthritis and allied conditions. 2nd ed. Baltimore: Williams & Wilkins; 1997. |
