Daniel Sá Ribeiro

Magnetic resonance imaging of Jaccoud's arthropathy in systemic lupus erythematosus.

OBJECTIVE To perform a detailed magnetic resonance imaging (MRI) analysis of the hands of patients with Jaccouds arthropathy (JA) secondary to systemic lupus erythematosus (SLE). METHODS The hand with more expressive deformities compatible with JA from a group of SLE patients was examined by 1.5-T MRI. The protocol included coronal, sagittal, and axial turbo-spin-echo images before and after the administration of contrast medium. The presence of synovitis, edema, erosion, cysts, and tenosynovitis in the carpometacarpal, metacarpophalangeal, and proximal interphalangeal joints were scored based on a modified Outcome Measures in Rheumatology recommendations. RESULTS Twenty SLE patients, (19 women and one man) with median age of 44.7 years (range: 20-76 years), median disease duration of 14.7 years (range: 5-26 years), and median arthritis duration of 13.7 years (range: 4-26 years) were studied. Of the 300 joints evaluated, 202 (67.3%) had some degree of synovitis. Sixteen out of 300 examined joints (5.3%) small areas of erosion were seen in 10 out of the 20 patients (50%). Subchondral bone edema was found in eight out of the 20 (40%) patients or a total of 18 joints (6%). A total of 200 compartments tendons were evaluated, and changes were found in 77 (38.5%) of them. In four out of the 20 patients, the MRI revealed bone cysts. CONCLUSIONS The MRI seems to be a non-invasive diagnostic tool in patients with JA secondary to SLE, and may contribute to understanding the mechanism involved in the development of this deformity.

Achados de imagem das alterações musculoesqueléticas associadas ao lúpus eritematoso sistêmico

Systemic lupus erythematosus is an autoimmune disease involving multiple organ systems. Musculoskeletal involvement is one of the most frequent presentations of the disease, affecting bones, joints, muscles, tendons and ligaments, either as a primary manifestation or secondary to the treatment of the disease. In the present article, the authors review and illustrate the joint disorders and the most common musculoskeletal abnormalities seen in this disorder.

Gout Initially Mimicking Rheumatoid Arthritis and Later Cervical Spine Involvement

Gout is clinically characterized by episodes of monoarthritis, but if not treated properly, it can lead to a chronic polyarthritis, which may eventually mimic rheumatoid arthritis (RA). We present the case of a 59-year-old man, with a history of symmetrical polyarthritis of the large and small joints with later development of subcutaneous nodules, which was initially misdiagnosed as RA, being treated with prednisone and methotrexate for a long period of time. He complained of occipital pain and paresthesia in his left upper limb, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an expansive formation in the cervical spine with compression of the medulla. He was admitted for spinal decompressive surgery and the biopsy specimen demonstrated a gouty tophus. Chronic gout can mimic RA and rarely involves the axial skeleton, and thus its correct diagnosis and the implementation of adequate therapy can halt the development of such damaging complications.

Imaging of Jaccoud’s arthropathy in systemic lupus erythematosus: not only hands but also knees and feet

We read with interest the review published by Pipili et al. [1]. Herein, we would like to illustrate another case of Jaccoud arthropathy (JA) involving multiple sites. A 41-year-old female was diagnosed with systemic lupus erythematosus (SLE) in 1985 based on the American College of Rheumatology criteria. Since the beginning, she had polyarthritis, nephrotic syndrome, leukopenia, lower C3 and C4, positive anti-ds DNA (1/80 by indirect immunofluorescence), and antinuclear antibodies (ANA) 1/320 in HEp-2 homogeneous pattern. She was initially treated with pulses of methylprednisolone (1 g) and cyclophosphamide (1 g) (monthly for 6 months and quarterly for a total of 2 years). There was a complete resolution of the proteinuria, but she remained with articular symptoms to which she was put on prednisone, hydroxychloroquine, and methotrexate. On physical examination in 1999, JA of hands had already been present characterized by ulnar deviation, swan neck, and ‘‘Z’’ thumb deformities. At that time, complementary investigation showed rightsided pleural effusion, mitral reflux on echocardiogram, and osteoporosis by densitometry. Despite the treatment, she complained of polyarthritis, and in 2005, reversible joint deformities were also observed in knees, toes, and knees. Magnetic resonance imaging (MRI) of the knees showed partial loss of articular alignment, medial meniscal rupture, synovial and tenosynovial hypertrophy. The MRI of the hands showed synovial and tenosynovial hypertrophy with few erosions in third and fourth metacarpal heads (Fig. 1). Abnormal subluxation of the first metatarsophalangeal with active synovial hypertrophy was seen in feet (Fig. 2). There are only a few descriptions in the literature of JA in sites other than hands [2, 3]. Hallux valgus, subluxation of the metatarsophalangeal joints, and widening of the forefoot are other signs of ‘‘lupus foot’’, a term defined by Morley et al. [4] to define the findings of foot deformities in SLE. Different from rheumatoid arthritis, in lupus foot, subluxations passively correctable are common place. Our patient also had signs of synovitis and early rupture of medial meniscal with loss of cartilage in the medial knee compartment. This could be associated with an intrinsic capsular laxity causing hypermobility and cartilage degeneration as previously suggested [5]. These findings may suggest that the frequency of JA in joints other than hands may be underestimated. This supports the idea that the utilization of newer image techniques such as MRI not only in the hands but also in other joints in patients with SLE could provide important information and, perhaps, predict those joints in risk for the development of JA.

“Mutilans-type” Jaccoud Arthropathy

Jaccoud arthropathy (JA) is a clinical complication most frequently seen in patients with systemic lupus erythematosus (SLE). It occurs at a prevalence of about 5%. JA is defined as the presence of reversible joint deformities, particularly in the hands, in the absence of articular erosions on plain radiographs1. A few small bone erosions may be identified by magnetic resonance imaging (MRI)2. …

Severe Jaccoud’s arthropathy in systemic lupus erythematosus

Jaccoud’s arthropathy (JA) is a clinical situation nowadays present mostly in systemic lupus erythematosus (SLE). It is characterized by the presence of joint deformities such as “swan neck,” ulnar deviation and “Z-thumb” resembling rheumatoid arthritis (RA) but that are passively correctable and without bone erosion on plain radiographs. From our cohort of SLE patients with JA, we selected a subgroup with a more severe form of this arthropathy and looked at their clinical and laboratory profile as well as studied the magnetic resonance imaging (MRI) findings or ultrasound (US) obtained from the hand with most evident deformities. Seven SLE patients with a severe form of JA were identified. All seven patients have “swan neck,” ulnar deviation and “Z-thumb” deformities. Two out of seven had “mutilans-type JA” and four had fixed deformities in the metacarpophalangeal (MCP) joints. The MRI of the hand with more evident deformity clinically performed in six cases and US performed in one case showed mild synovitis in five and moderate synovitis in two patients, mild flexor tenosynovitis in six and severe tenosynovitis in one. Only two small bone erosions were observed in the second and third MCP joints of one patient with moderate synovitis. Severe JA compromises the functional capacity of the joints and imposes the risk of misdiagnosis of RA. With the improvement of the survival rate of SLE and the lack of specific prophylactic or therapeutical measures for JA, it is reasonable to assume that more and more cases of severe JA are going to be identified.

Spondyloarthritis after bariatric surgery: is there a link?

Presently, bariatric surgery is considered the most effective treatment for reducing excess body weight and maintaining weight loss in severely obese. On the other hand, several early and late complications have been described after this procedure. This article reports two patients who developed a spondyloarthritis-like syndrome after bariatric surgery. Probable etiopathogenic mechanisms are discussed.

Ressonância magnética de alta resolução espacial para estudo arterial periférico com aquisição segmentar e contínua: Mobitrak

Our purpose is to present a new technique to evaluate arterial obstructions in the lower limbs by magnetic resonance using a single paramagnetic contrast agent double dose slowly administered using an infusion pump. The method is based on a software and hardware called Mobitrak available on the Philips high field magnetic resonance machines, which allows vascular evaluation of wide areas with continuous and segmentar high resolution acquisitions. An echo gradient sequence (FFE) was used, which allowed three simultaneous planning and had little overlapping on the intersections. This dynamic sequence is achieved in two phases, prior and during contrast injection, and allows signal subtraction of adjacent tissues and 3D reconstructions. The method has various advantages such as better visualization of the tibiofibular segments, study of the whole lower limb in a single patient visit, and reduction of the volume of contrast injected.