Pietro Pavlica

Proximal Bursitis in Active Polymyalgia Rheumatica

Polymyalgia rheumatica, a common disorder in elderly persons, is characterized by aches and morning stiffness in the neck, shoulders, and pelvic girdle [1-4]. A systemic inflammatory reaction (including fever, anorexia, weight loss, and high erythrocyte sedimentation rate) is usually associated with the condition. The cause of musculoskeletal symptoms in the proximal extremities is not completely understood. Evidence of joint synovitis has been revealed through scanning, arthroscopy, and synovial biopsy [5-8]. In a recent immunohistochemical study [8], researchers observed mild synovitis characterized by infiltration of macrophages and CD4 T cells. Diffuse and severe musculoskeletal discomfort of the proximal extremities can only be partially explained by this mild joint synovitis. In addition to involvement of the pelvic girdle, some patients have symptoms in the distal extremities that are caused by inflammation of the joints, inflammation of the tenosynovial membrane, or inflammation of both. Clinical evidence of peripheral synovitis was observed in 31% to 38% of patients who had polymyalgia rheumatica [2, 9]. In a recent study [10] conducted by the Mayo Clinic in 245 patients who had polymyalgia rheumatica, 19 patients (8%) had diffuse swelling and pitting edema in the distal extremities. The swelling and edema were similar to those observed in patients who had the remitting, seronegative, symmetrical synovitis with pitting edema syndrome (described by McCarty and colleagues in 1985 [11]). The authors of the study concluded that these clinical findings were most likely the result of vigorous tenosynovitis in the distal extremities and represent a symptom of polymyalgia rheumatica that had previously been poorly recognized. We recently observed a patient who satisfied diagnostic criteria of polymyalgia rheumatica and had bilateral diffuse swelling with pitting edema on the dorsum of the hand [12]. Magnetic resonance imaging (MRI) showed extensor tenosynovitis of the hand and synovitis of the glenohumeral joints together with marked inflammation of subacromial and subdeltoid bursae and tenosynovitis of the biceps in both shoulders. Impressed by the severe involvement of proximal periarticular synovial structures, we decided to use MRI to study the involvement of the shoulders and pelvic girdle in a series of consecutive patients who had symptoms of active polymyalgia rheumatica. Methods Consecutive patients who were seen at the Prato and Reggio Emilia rheumatology centers during a 6-month period and satisfied the Healey criteria for polymyalgia rheumatica [2] were considered suitable candidates for the study. Table 1 shows the demographic characteristics, clinical findings, and MRI results in the 13 case-patients. None of the case-patients had clinical or histologic evidence of giant cell arteritis. Bilateral MRI of the shoulders of the first three case-patients who entered the study revealed that the lesions were symmetrical and their severity was identical. We therefore decided to perform only monolateral MRI in the subsequent 10 case-patients. Three of the 8 case-patients in whom the hip girdle was involved also had pelvic scanning. Table 1. Demographic and Clinical Findings and Results of Magnetic Resonance Imaging of 13 Patients with Polymyalgia Rheumatica* Two control groups were considered. The first group consisted of nine control-patients who had elderly-onset rheumatoid arthritis (median age at onset, 71 years [range, 66 to 76 years]) and met the American Rheumatism Association 1987 modified criteria for rheumatoid arthritis [13]. The control-patients were seen at the Prato and Reggio Emilia rheumatology centers during the same 6-month period as the case-patients. The control-patients had early active disease (median disease duration, 3 months [range, 3 to 6 months]) and clinical evidence of shoulder involvement. The results of serologic examination were positive in three control-patients and negative in six control-patients. The median erythrocyte sedimentation rate at diagnosis was 65 mm/h (range, 56 to 88 mm/h). Bilateral MRI was done on two control-patients who had clinical involvement of both shoulders. Because only one shoulder was clinically involved in the other seven control-patients, monolateral MRI of only the affected shoulder was done. Second-line drug and corticosteroid therapies were not started until MRI had been completed. The second control group consisted of 10 age-matched healthy controls who did not have any clinical problems with their shoulders. The healthy controls were relatives of medical staff at both rheumatology centers. Monolateral MRI of the shoulder was done in all 10 healthy controls. Scanning of the shoulders of three case-patients was repeated after they began corticosteroid therapy (median, 2 months [range, 2 to 3 months]) and were in clinical remission. Scanning was done with a 0.5-T superconductive magnet system (MR Max Plus, GE Medical System, Milwaukee, Wisconsin) and a 17-cm extremity bore transmit-receive coil. A body coil was used to evaluate hip regions. Pulse sequences included coronal T1-weighted sequences (240-ms repetition time, 25-ms echo time, and four excitations), axial proton density sequences (2000-ms repetition time, 25-ms echo time, and two excitations), and T2-weighted sequences (2000-ms repetition time, 90-ms echo time, and two excitations). The coronal section was 5 mm thick, and the axial section was 7 mm thick; both had an intersection gap of 1 mm. The field of view was 20 cm; the matrix size was 160 cm 224 cm or 128 cm 192 cm. Scans were examined by a radiologist who was blinded to clinical findings and the diagnosis. The joint space, subacromial and subdeltoid bursae, and synovial sheaths of the long head of the biceps of the shoulder were evaluated for fluid collection. In addition, the joint space and the ileopectineal bursa in the hip region were evaluated. As shown in Figure 1, measurement of fluid accumulation was graded by using a semiquantitative scale (0 = no accumulation; 1 = sufficient accumulation to allow visualization of the articular shoulder structure, periarticular shoulder structure, or both; 2 = moderate accumulation; and 3 = sufficient quantity to stretch the walls of structures). Figure 1. Magnetic resonance images of patients with polymyalgia rheumatica. arrows arrows Statistical analysis was done by using the SPS program (SPS Inc., Chicago, Illinois). The Fisher exact test was used to compare the frequencies. Results All 13 case-patients (who had active polymyalgia rheumatica) showed bilateral fluid accumulation in the subacromial and subdeltoid bursae, thereby suggesting bursitis (Figure 1 and Table 1). Ten of the 13 case-patients had synovitis of the shoulder joint. Tenosynovitis of the long head of the biceps was found in 7 case-patients. No erosions were observed. Mild (grade 1) synovitis of the hip was seen in all three case-patients who had scans of the hip girdle. One of the three case-patients also had mild (grade 1) ileopectineal bursitis. Fluid accumulated in the subacromial and subdeltoid bursae of only two of the nine control-patients (that is, patients who had early symptoms of elderly-onset rheumatoid arthritis). Fluid accumulated in the joint space of five control-patients, and tenosynovitis of the long head of the biceps was observed in three control-patients. Joints were eroded in two control-patients. None of the 10 age-matched healthy controls showed evidence of fluid collection in joints, bursae, or sheaths of the long head of the biceps. Inflammation in the subacromial and subdeltoid bursae occurred significantly more frequently in case-patients than in control-patients (100% compared with 22%; P < 0.001). The frequencies of joint synovitis and tenosynovitis of the biceps did not significantly differ between case-patients and control-patients (77% compared with 55% and 54% compared with 33%, respectively). However, the frequency of both disorders was higher in the case-patients. Two of the three case-patients who had repeated MRI of the shoulder during treatment showed complete resolution of bursitis, tenosynovitis, and joint synovitis. The third case-patient showed only an improvement (from grade 3 to grade 2) of bursitis and joint synovitis. All three of these case-patients received a starting dosage of 12.5 mg of prednisone per day. When the second scan was obtained, the patients were asymptomatic, the erythrocyte sedimentation rate was normal (median, 18 mm/h [range, 15 to 20 mm/h]), and the median daily dosage of prednisone was 10 mg/d. Discussion All 13 case-patients showed evidence of subacromial and subdeltoid bursitis. This finding occurred significantly more frequently in the 13 case-patients than in the nine control-patients. The frequency of joint synovitis and bicipital tenosynovitis did not differ significantly between case-patients and control-patients. Joint erosions have never been observed in patients with polymyalgia rheumatica; in our study, however, erosions were seen in two control-patients (who had elderly-onset rheumatoid arthritis). According to MRI of normal shoulders [14], no pathologic findings were observed in the age-matched healthy controls. Our MRI study of pelvic girdles was limited because of the small number of study participants. However, one of the three patients had evidence of ileopectineal bursitis in addition to mild joint synovitis. No published studies have examined the results of MRI of the shoulders of patients with polymyalgia rheumatica. One ultrasonographic study [15] that examined hip and glenohumeral joints focused on an effusion of the two joints, which was found in 68% of the patients examined. A study [16] of MRI of the shoulder of patients who had rheumatoid arthritis did not report evidence of prominent bursitis or tenosynovitis. However, this study was not designed to investigate periarticular synovial structures. Possible limitations of

Blunt Abdominal Trauma: Emergency Contrast-Enhanced Sonography for Detection of Solid Organ Injuries

OBJECTIVE The objective of our study was to prospectively compare the diagnostic value of sonography and contrast-enhanced sonography with CT for the detection of solid organ injuries in blunt abdominal trauma patients. SUBJECTS AND METHODS Sonography, contrast-enhanced sonography, and CT were performed to assess possible abdominal organ injuries in 69 nonconsecutive hemodynamically stable patients with blunt abdominal trauma and a strong clinical suspicion of abdominal lesions. Sonography and contrast-enhanced sonography findings were compared with CT findings, the reference standard technique. RESULTS Thirty-two patients had 35 abdominal injuries on CT (10 kidney or adrenal lesions, seven liver lesions, 17 spleen lesions, and one retroperitoneal hematoma). Sixteen lesions were detected on sonography, and 32 were seen on contrast-enhanced sonography. The sensitivity and specificity of sonography were 45.7% and 91.8%, respectively, and the positive and negative predictive values were 84.2% and 64.1%, respectively. Contrast-enhanced sonography had a sensitivity of 91.4%, a specificity of 100%, and positive and negative predictive values of 100% and 92.5%, respectively. CONCLUSION Contrast-enhanced sonography was found to be more sensitive than sonography and almost as sensitive as CT in the detection of traumatic abdominal solid organ injuries. It can therefore be proposed as a useful tool in the assessment of blunt abdominal trauma.

Imaging of the acute scrotum

Abstract The scrotum is a superficial structure and clinical examination is frequently not enough for making a specific diagnosis. In acute scrotal pain US can confirm the presumptive clinical diagnosis and provide additional relevant information. In testicular torsion, color-Doppler imaging has a central role since it has become possible to identify it at early stage by showing absence of perfusion in the affected testis before any gray-scale abnormality. Scintigraphy remains a satisfactory alternative in evaluating testicular torsion and should be used when color Doppler is inadequate, raising doubts about the suspected torsion. Diagnosis of torsion of testicular appendages is particularly difficult. Ischemic infarction shows a characteristic pattern at gray-scale and color-Doppler imaging, whereas hemorrhagic ischemia may require MRI. Inflammatory diseases of the scrotum can be easily investigated by echo color Doppler and conventional radiography, and CT can be particularly useful in the detection of gas bubbles. In scrotal trauma, scrotal hematoma, hematocele, intratesticular hematoma, and testicular rupture can be identified using gray-scale US with very good reliability. Magnetic resonance imaging is indicated when a small tear of tunica albuginea is suspected but not visualized on US.

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome: a prospective follow up and magnetic resonance imaging study

OBJECTIVE To determine the clinical characteristics of patients with “pure” remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) syndrome, and to investigate its relation with polymyalgia rheumatica (PMR). Magnetic resonance imaging (MRI) was used to describe the anatomical structures affected by inflammation in pure RS3PE syndrome. METHODS A prospective follow up study of 23 consecutive patients with pure RS3PE syndrome and 177 consecutive patients with PMR diagnosed over a five year period in two Italian secondary referral centres of rheumatology. Hands or feet MRI, or both, was performed at diagnosis in 7 of 23 patients. RESULTS At inspection evidence of hand and/or foot tenosynovitis was present in all the 23 patients with pure RS3PE syndrome. Twenty one (12%) patients with PMR associated distal extremity swelling with pitting oedema. No significant differences in the sex, age at onset of disease, acute phase reactant values at diagnosis, frequency of peripheral synovitis and carpal tunnel syndrome and frequency of HLA-B7 antigen were present between patients with pure RS3PE and PMR. In both conditions no patient under 50 was observed, the disease frequency increased significantly with age and the highest frequency was present in the age group 70–79 years. Clinical symptoms for both conditions responded promptly to corticosteroids and no patient developed rheumatoid arthritis during the follow up. However, the patients with pure RS3PE syndrome were characterised by shorter duration of treatment, lower cumulative corticosteroid dose and lower frequency of systemic signs/symptoms and relapse/recurrence. Hands and feet MRI showed evidence of tenosynovitis in five patients and joint synovitis in three patients. CONCLUSION The similarities of demographic, clinical, and MRI findings between RS3PE syndrome and PMR and the concurrence of the two syndromes suggest that these conditions may be part of the same disease and that the diagnostic labels of PMR and RS3PE syndrome may not indicate a real difference. The presence of distal oedema seems to indicate a better prognosis.

Blunt Abdominal Trauma: Diagnostic Performance of Contrast-enhanced US in Children—Initial Experience

PURPOSE To prospectively compare the sensitivity and specificity of ultrasonography (US) with those of contrast material-enhanced US in the depiction of solid organ injuries in children with blunt abdominal trauma, with contrast-enhanced computed tomography (CT) as the reference standard. MATERIALS AND METHODS The study protocol was approved by the ethics board, and written informed consent was obtained from parents. US, contrast-enhanced US, and contrast-enhanced CT were performed in 27 consecutive children (19 boys, eight girls; mean age, 8.9 years +/- 2.8 [standard deviation]) with blunt abdominal trauma to determine if solid abdominal organ injuries were present. Sensitivity, specificity, agreement, accuracy, number of lesions correctly identified, and positive and negative predictive values were determined for US and contrast-enhanced US, as compared with contrast-enhanced CT. RESULTS In 15 patients, contrast-enhanced CT findings were negative. Contrast-enhanced CT depicted 14 solid organ injuries in 12 patients. Lesions were in the spleen (n = 7), liver (n = 4), right kidney (n = 1), right adrenal gland (n = 1), and pancreas (n = 1). Contrast-enhanced US depicted 13 of the 14 lesions in 12 patients with positive contrast-enhanced CT findings and no lesions in the patients with negative contrast-enhanced CT findings. Unenhanced US depicted free fluid in two of 15 patients with negative contrast-enhanced CT findings and free fluid, parenchymal lesions, or both in eight of 12 patients with positive contrast-enhanced CT findings. Overall, the diagnostic performance of contrast-enhanced US was better than that of US, as sensitivity, specificity, and positive and negative predictive values were 92.2%, 100%, 100%, and 93.8%, respectively. CONCLUSION Contrast-enhanced US was almost as accurate as contrast-enhanced CT in depicting solid organ injuries in children.

Imaging of male urethra.

Abstract. The male urethral imaging and pathology is not widespread in the radiology literature because this part of the urinary tract is easily studied by urologists with clinical or endoscopic examinations. Ultrasonography and MR imaging are increasingly being used in association with voiding cystourethrography and retrograde urethrography. The posterior urethra is being studied with voiding cystourethrography or voiding sonography which allows the detection of bladder neck pathology, post-surgical stenosis, and neoplasms. The functional aspects of the bladder neck and posterior urethra can be monitored continuously in patients with neuromuscular dysfunction of the bladder. The anterior urethral anatomy and pathology is commonly explored by retrograde urethrography, but recently sonourethrography and MR imaging have been proposed, distending the lumen with simple saline solution instead of iodinated contrast media. They are being used to study the urethral mucosa and the periurethral spongy tissue which can be involved in the urethral pathologies such as strictures, diverticula, trauma, and tumors. Imaging has an important role to play in the study of the diseases of the male urethra since it can detect pathology not visible on urethroscopy. The new imaging techniques in this area, such as sonography and MR, can provide adjunct information that cannot be obtained with other modalities.

Role of contrast enhanced ultrasound in acute scrotal diseases

ObjectiveTo evaluate the efficacy of contrast-enhanced ultrasound (CEUS) in patients with acute scrotal pain not defined at ultrasound (US) with colour Doppler .MethodsCEUS was carried out in 50 patients with acute scrotal pain or scrotal trauma showing testicular lesion of undefined nature at US. The accuracy of US and CEUS findings versus definitive diagnosis (surgery or follow-up) was calculated.ResultsTwenty-three patients had a final diagnosis of testicular tumour, three abscess, eight focal infarction, seven trauma, three testicular torsion, one haematoma. Five patients were negative. Thirty-five patients were operated (23 testicular tumours, six trauma, three testicular torsion, one abscess, one focal infarction, and one haematoma) and 15 underwent medical treatment or were discharged. US provided a definitive diagnosis in 34/50 as compared to the 48/50 patients diagnosed at CEUS. Sensitivity and specificity were 76% and 45% for US and 96% and 100% for CEUS respectively.ConclusionsCEUS was more accurate in the final diagnosis compared to US, potentially reducing the need for further imaging. In particular CEUS can be proposed in emergency in cases where US diagnosis remains inconclusive, namely in infarction, and trauma, when testicular torsion cannot be ruled out, and in identifying testicular mass.

Contrast-enhanced ultrasonography in blunt abdominal trauma: considerations after 5 years of experience

PurposeThe aim of the study was to evaluate the diagnostic capability of contrast-enhanced ultrasonography (CEUS) in a large series of patients with blunt abdominal trauma.Materials and methodsWe studied 133 haemodynamically stable patients with blunt abdominal trauma. Patients were assessed by ultrasonography (US), CEUS and multislice computed tomography (MSCT) with and without administration of a contrast agent. The study was approved by our hospital ethics committee (clinical study no. 1/2004/O).ResultsIn the 133 selected patients, CT identified 84 lesions; namely, 48 splenic, 21 hepatic, 13 renal or adrenal and two pancreatic. US identified free fluid or parenchymal alterations in 59/84 patients with positive CT and free fluid in 20/49 patients with negative CT. CEUS detected 81/84 traumatic lesions identified on CT and ruled out traumatic lesions in 48/49 patients with negative CT. The sensitivity, specificity and positive and negative predictive values of US were 70.2%, 59.2%, 74.7% and 53.7%, respectively, whereas those of CEUS were 96.4%, 98%, 98.8% and 94.1%, respectively.ConclusionsOur study showed that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. The technique is able to detect active bleeding and vascular lesions, avoids exposure to ionising radiation and is useful for monitoring patients undergoing conservative treatment.RiassuntoObiettivoScopo di questo lavoro è stato valutare le possibilità diagnostiche dell’ecografia con mezzo di contrasto (CEUS) in un’ampia serie di pazienti con trauma chiuso dell’addome.Materiali e metodiSono stati studiati 133 pazienti con trauma addominale chiuso, emodinamicamente stabili. I pazienti sono stati valutati con ecografia (US), CEUS e tomografia computerizzata (TC) multistrato senza e con mezzo di contrasto (MdC). Lo studio è stato approvato dal comitato etico dell’Ospedale (studio clinico no1/2004/O).RisultatiNei 133 pazienti la TC ha identificato 84 lesioni, 48 spleniche, 21 epatiche, 13 renali o surrenaliche e 2 pancreatiche. L’US ha identificato versamento libero o alterazioni parenchimali in 59/84 pazienti positivi alla TC e versamento libero in 20/49 pazienti negativi alla TC. La CEUS ha riconosciuto 81/84 lesioni traumatiche identificate dalla TC e ha escluso lesioni traumatiche in 48/49 pazienti negativi alla TC. Sensibilità, specificità, valore predittivo positivo e negativo per l’US sono stati rispettivamente 70,2%, 59,2%, 74,7% e 53,7%; per la CEUS sono stati 96,4%, 98%, 98,8% e 94,1%.ConclusioniLo studio ha dimostrato che la CEUS è uno strumento accurato nella valutazione delle lesioni traumatiche degli organi solidi addominali. La metodica riconosce il sanguinamento attivo e le lesioni vascolari, evita l’esposizione a radiazioni ionizzanti ed è utile nel monitoraggio dei pazienti con trattamento conservativo.

Remitting distal lower extremity swelling with pitting oedema in acute sarcoidosis

Remitting distal extremity swelling with pitting oedema is a clinical manifestation that may be observed in different rheumatic conditions such as RS3PE syndrome,1 polymyalgia rheumatica,2 late onset undifferentiated spondyloarthropathy,3 ankylosing spondylitis,4 psoriatic arthritis,5 and more rarely in other rheumatic disease.5 In RS3PE the swelling with pitting oedema predominantly involves the upper extremities symmetrically.1 This clinical finding may occur unilaterally in polymyalgia rheumatica and upper and lower limbs may be equally affected,2 whereas in seronegative spondyloarthropathies it has been described more frequently in lower extremities with asymmetric involvement.3 4 The oedema is characterised by a rapid response to small doses of corticosteroids. The pathogenesis of swelling with pitting oedema has not been completely defined, but the distribution along the tenosynovial membranes suggests that it probably results from tenosynovitis.5 Sarcoidosis is a …

Renal ultrasonography in critically ill patients.

Acute renal failure is a sudden and sustained decrease in the glomerular filtration rate associated with a loss of excretory function and the accumulation of metabolic waste products and water. It leads to an increase in serum urea and creatinine, usually with a decrease in urine output. Although routine surveillance of patients by means of laboratory examinations has been well defined, very little is known about renal imaging. Modern technology has provided a large number of sophisticated monitoring systems. Ultrasonography with color-Doppler study of the kidneys may be indicated as a possible monitor of renal perfusion. Ultrasonography is often used as the initial imaging procedure in the examination of patients with renal failure. Aside from excluding hydronephrosis, it is well recognized in characterizing the type of renal disease, especially in an acute setting. This article describes the use of ultrasound to achieve the proper diagnosis of acute renal diseases and to enable the appropriate and early assessment of these patients in intensive care units.