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Dear Editor,

We would like to thank Falsetti and colleagues for their interest in our recent case report regarding subcalcaneal bursitis in very early rheumatoid arthritis (RA) pa- tients (1, 2), and we provide our response to their comments as follows.

n DEFINITION AND NOMENCLATURE

Although there is only limited literature- based evidence, there are several textbooks and pictorial reviews describing plantar bursitis as adventitial (adventitious) bursi- tis, as they pointed out in their letter (3, 4).

Therefore, we agree with their suggestion to use the term subcalcaneal adventitial bursitis.

n CAN SUBCALCANEAL ADVENTITIAL BURSITIS BE CONSIDERED AN EQUIVALENT FOR SYNOVITIS?

On ultrasound, an adventitial bursitis usu- ally appears as a poorly defined heteroge- neous region without vascularization (5).

In RA patients, however, adventitial bur- sitis often presents with power Doppler signals in the well-demarcated and thick- ened bursal wall. This observation makes us imagine that rheumatoid inflammation resembling synovitis has developed there, although an adventitial bursa essentially lacks a mesothelial lining and synovia.

Histological data are needed for further discussion.

n IS SUBCALCANEAL ADVENTITIAL BURSITIS SPECIFIC FOR RHEUMATOID ARTHRITIS?

We do not consider that subcalcaneal ad- ventitial bursitis itself is specific for RA.

However, we suppose that persistent in- flammation in soft tissues other than articu- lar synovium or tenosynovium can precede persistent synovitis at the onset of RA. We have previously reported cases of RA pa- tients with a high ACPA titer whose initial manifestation of RA was paratenonitis or tendinitis (6, 7). It is intriguing to specu- late that synovial membranes may not be necessary for the initiation of rheumatoid inflammation in the very earliest phase of the disease. Also from this point of view, a histopathological investigation of subcal- caneal adventitial bursitis that presented at the onset of RA is highly anticipated.

n REFERENCES

1. Suzuki T, Shirai H. Subcalcaneal bursitis as the initial manifestation of rheumatoid arthri- tis: ultrasonographic observation of two cases.

Reumatismo. 2020; 71: 230-4.

2. Falsetti P, Conticini E, Baldi C, et al. Observa- tions about subcalcaneal adventitial bursitis (heel fat pad inflammatory lesion) in rheuma- toid arthritis. Comment on article of Suzuki T.

and Shirai H. Reumatismo. 2020; 72: [in press].

3. Studler U, Mengiardi B, Bode B, et al. Fibro- sis and adventitious bursae in plantar fat pad of forefoot: MR imaging findings in asympto- matic volunteers and MR imaging-histologic comparison. Radiology. 2008; 246: 863-70.

4. Ruangchaijatuporn T, Gaetke-Udager K,

Reply to the comments by Falsetti et al.

T. Suzuki, H. Shirai

Division of Allergy and Rheumatology, Japanese Red Cross Medical Center, Tokyo, Japan

Corresponding author:

Takeshi Suzuki Division of Allergy and Rheumatology, Japanese Red Cross Medical Center, Tokyo, 150-8935, Japan E-mail: takecsuzu@gmail.com 184 Reumatismo 3/2020

Reumatismo, 2020; 72 (3): 184-185

LETTER TO THE EDITOR

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Reumatismo 3/2020 185 Reply to the comments by Falsetti et al.

LETTER

TO THE EDITOR

Jacobson JA, et al. Ultrasound evaluation of bursae: anatomy and pathological appearanc- es. Skeletal Radiol. 2017; 46: 445-62.

5. Filippini C, Teh J. Ultrasound features of sole of foot pathology: a review. J Ultrason. 2019;

19: 145-51.

6. Suzuki T, Ishihara K. Achilles paratendoni- tis as the initial manifestation of rheuma-

toid arthritis. Mod Rheumatol. 2011; 21:

219-22.

7. Suzuki T, Okamoto A. Marked multiple tendinitis at the onset of rheumatoid arthritis in a patient with heterozygous familial hy- percholesterolemia: ultrasonographic obser- vation. Case Rep Rheumatol. 2014; 2014:

486348.

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