Flavia Costa

Acral Myxoinflammatory Fibroblastic Sarcoma Simulating Rheumatoid Bursitis – Diffusion-weighted Imaging

Joint Bone Spine - In Press.Proof corrected by the author Available online since mercredi 7 mars 2018

Usefulness of dynamic contrast-enhanced MRI in the evaluation of osteonecrosis of the proximal fragment in scaphoid fractures

Luiza Werneck1, Clarissa Canella2, Flavia Costa1, Alessandro Severo Alves de Melo3, Edson Marchiori4 1. Clínica de Diagnóstico Por Imagem (CDPI), Rio de Janeiro, RJ, Brazil. 2. Clínica de Diagnóstico Por Imagem (CDPI), Rio de Janeiro, RJ, e Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil. 3. Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil. 4. Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Correspondence: Dra. Clarissa Canella. Avenida das Américas, 4666, sala 325, Barra da Tijuca. Rio de Janeiro, RJ, Brazil, 22640-102. E-mail: clacanella@yahoo.com.br. Dear Editor, A 26-year-old man who had fractured his scaphoid four weeks previously presented with persistent wrist pain. Magnetic resonance imaging (MRI) showed a fracture line through the scaphoid waist (Figure 1). A gadolinium contrast-enhanced coronal T1-weighted sequence with fat saturation was acquired, as were time-signal intensity curves of the proximal and distal scaphoid poles. The complete absence of enhancement of the proximal pole of the scaphoid, together with the fact that the time-signal intensity curve was lower for the proximal pole than for the distal pole, denoted satisfactory perfusion of the proximal pole. The scaphoid is the most commonly fractured bone of the carpus, and healing is interrupted by nonunion in 5–15% of cases. Scaphoid fracture nonunion may progress to avascular necrosis of the scaphoid in cases of long-standing nonunion, after failed surgery, in certain fractures of the proximal third of the scaphoid, or when an occult fracture is not treated. The proximal pole of the scaphoid is prone to avascular necrosis due to the distal location of the main feeding vessels and the retrograde pattern of the intraosseous blood supply. Stress fracture of the scaphoid waist is believed to contribute to osteonecrosis of the scaphoid resulting from repetitive dorsiflexion of the wrist, the waist being the weakest point in the scaphoid. A number of recent studies conducted in Brazil have highlighted the importance of MRI in the evaluation of diseases affecting the musculoskeletal system. The use of a reliable noninvasive diagnostic tool to assess the viability of the proximal scaphoid pole is necessary to help surgeons plan the treatment of scaphoid nonunion, because there is currently no consensus regarding when conservative or surgical treatment is indicated. Recently, gadolinium contrast-enhanced MRI has been shown to be the most accurate modality for evaluating scaphoid viability. In fact, some authors have suggested that dynamic contrastenhanced MRI represents a valuable tool in assessing whether conservative or surgical treatment is indicated to achieve a good functional outcome . According to those authors, if dynamic contrast-enhanced MRI shows poor perfusion of the proximal pole of the scaphoid, primary surgical intervention would be indicated. Despite the fact that time-signal intensity curves of the proximal and distal scaphoid poles are actually widely used, there have been a few reports suggesting that the analysis of these curves does not provide additional predictive value over standard delayed enhancement MRI for acute scaphoid fracture.

Stress fracture and osteomyelitis in a patient with systemic lupus erythematosus

Isabela Lemos Murelli Rodrigues1 1. Conjunto Hospitalar do Mandaqui, São Paulo, SP, Brazil. Mailing address: Dra. Isabela Lemos Murelli Rodrigues. Conjunto Hospitalar do Mardaqui. Rua Voluntários da Pátria, 4110, Santana. São Paulo, SP, Brazil, 02401-400. E-mail: isalemos.m@gmail.com. diagnosis can promote the rapid extraction of a gallstone, mortality remains relatively high, especially among elderly patients and patients with comorbidities, because the extraction requires surgical intervention. Although Bouveret syndrome is a relatively rare disease, the diagnosis can be made on the basis of the imaging findings, thus allowing early endoscopic and surgical intervention.

Advanced MRI Techniques of Soft Tissue Tumors

Magnetic resonance imaging (MRI) is the method of choice for the preoperative and posttreatment staging of musculoskeletal tumors. In addition, MR imaging offers several advantages when compared with other methods in the evaluation and staging of soft tissue tumors considering high resolution, tissue contrast, and multiplanar capability.

Actinomycetoma of the Foot

body specificity and have opposing inflammatory and regulatory roles in a murine model of lupus. Immunity 2006;25:417–28. 38. Clancy RM, Alvarez D, Komissarova E, Barrat FJ, Swartz J, Buyon JP. Ro60-associated single-stranded RNA links inflammation with fetal cardiac fibrosis via ligation of TLRs: a novel pathway to autoimmune-associated heart block. J Immunol 2010; 184:2148–55. 39. Prinz N, Clemens N, Strand D, Putz I, Lorenz M, Daiber A, et al. Antiphospholipid antibodies induce translocation of TLR7 and TLR8 to the endosome in human monocytes and plasmacytoid dendritic cells. Blood 2011;118:2322–32.

Infectious Tenosynovitis in a Patient with Dermatopolymyositis and Vasculitis

Flexor tendon sheath infection calls for appropriate antimicrobial and surgical therapy to overcome complications such as deep abscesses, septic arthritis, and osteomyelitis. A 33-year-old woman with dermatopolymyositis and vasculitis for 1 year was diagnosed by typical rash (heliotrope rash, Gottron’s sign), symmetric proximal muscle weakness, elevated serum skeletal muscle enzymes, electromyographic abnormalities, and interstitial lung disease. She started intravenous (IV) methylprednisolone …

Sacroiliitis in Behçet syndrome.

33-year-old woman presented with inflammatory low back pain for 1 year, recurrent painful oral aphthous, and genital ulcers for 6 months with remaining tissue scarring, extensive pseudofolliculitis on the upper and lower limbs, fever, weight loss, and bilateral anterior uveitis. Seven months later, the pa- tient presented bilateral panuveitis. She had no abdominal pain, diarrhea, anemia, or other symptoms that suggested inflam- matory intestinal disease. Human leukocyte antigen B27 and antinuclear antibody tests were negative. The patient was diag- nosed with Behcet disease according to the International Study Group criteria. 1 Most symptoms were resolved with corticoste- roid eye drops, oral corticosteroids, colchicine, and methotrexate, but the low back pain alleviated only with nonsteroidal anti- inflammatory drugs. After 4 years of follow-up, there is no back pain or skin or eye disease on this treatment. Radiography has not been performed again. Radiography of the sacroiliac joints did not show abnor- malities. After gadolinium administration, coronal T1-weighted magnetic resonance imaging of the sacroiliac joints demonstrated left joint space enhancement indicative of synovitis (Figure, arrows). Edema of the sacral surface of the adjacent sacroiliac joint (Figure, open arrow) and sclerosis of the iliac surface (Figure, asterisk) were also observed, indicating sacroiliitis. Behcet disease, a systemic vasculitis of unknown etiology, is characterized by relapsing episodes of oral and genital ulcers, skin lesions, and ophthalmological disease. It can also affect the vascular, gastrointestinal, and neurological systems. 1Y4 Rheu- matic manifestations have been described in 45% of patients with Behcet syndrome, ranking second after skin and mucosal mani- festations. Inflammatory arthralgia is the most common mani- festation (81% of cases), and sacroiliitis is uncommon (7.5% of cases). 1Y5 Some authors have described a high prevalence of sacroiliitis in patients with Behcet disease, but others have found no association between these conditions. 5 The main reason for these differing results could be a high degree of interobserver variation in interpreting radiographs of the sacroiliac joints. In our case, sacroiliitis was demonstrated by magnetic resonance imaging, the most sensitive method for the detection and early diagnosis of this condition. Joint involvement can be an early manifestation of Behcet syndrome, potentially causing significant