Case 1. A young female with erosive arthritis and SLE A Caucasian female patient was diagnosed with systemic lupus erythematosus (SLE) at the age of 18 years due to malar rash, arthralgias, alopecia, oral ulcers and, positive anti-double-stranded DNA (anti-dsDNA). In 2008 she had a severe flare characterized by alopecia and hyperglobulinemia. She received plasma exchanges and later cycles of rituximab for 2 years. Follow-up was missed for several years. In 2015 she moved to Barcelona and visited our centre. In February 2015 she had a polyarticular flare that was treated with intermediate doses of steroids and methotrexate (MTX) up to 20 mg SC per week. In May 2016, she had a new polyarticular flare, and MTX was increased to 25 mg SC per week. In November 2016 she persisted with articular flares, therefore IV belimumab was started with good clinical response over 3 years. In March 2019, she presented a new flare. On physical examination, she had Cushingoid features, synovitis in both wrists with flexor tenosynovitis in the left wrist. She had severe limitations to flex extension in both wrists. X-rays of the wrists revealed loss of joint space and carpal bone erosions. Local infiltration in both wrists was made, but she persisted active. Treatment of erosive disease in SLE will be discussed in detail.

Case 2. Role of the imaging in lupus A 34-year-old Caucasian patient was diagnosed with SLE in 2020 after presenting with inflammatory arthritis, Raynaud’s phenomenon, chilblain lupus, and oral ulcers. She started treatment with hydroxychloroquine 200 mg/day plus prednisone 5 mg/day. Two months later she complained of joint pain, but no swollen joints were seen on physical examination. We performed a hand ultrasound assessment. Longitudinal examination at the level of the proximal interphalangeal joint indicates the presence of a discrete component of synovial effusion, irregularity, and prominence of the articular component of the distal epiphysis of the proximal phalanx. The Power Doppler evaluation showed a moderate increase in vascular uptake at the joint level of synovial capsular distention and periarticular soft tissues in the distal epiphysis of the proximal phalanx. Findings were suggestive of active synovitis with associated joint remodelling and active inflammatory and neovascular signs of the periarticular soft tissues. Treatment was changed. She started MTX treatment 15 mg/week initially oral and then SC. Eight weeks later she persisted with articular pain in MCP and proximal inter-phalangeal joints in both hands, but no evidence of synovitis was seen on clinical examination. She underwent magnetic resonance imaging of the hands and wrist - coronal STIR sequence. Mild synovitis was present in the second, third, and fourth metacarpophalangeal joints and the distal radioulnar joint, there was no structural or inflammatory bone damage.

Learning Objectives

• Discuss the treatment approach for patients with SLE and erosive arthritis (rhupus)

• Discuss the role of imaging in SLE and treatment approaches in patients with articular involvement