Srinivasan Harish

Rheumatoid Arthritis Is Associated With Increased Aortic Pulse-Wave Velocity, Which Is Reduced by Anti–Tumor Necrosis Factor-α Therapy

Background— Rheumatoid arthritis (RA) is associated with increased cardiovascular risk, which is not explained by traditional cardiovascular risk factors but may be due in part to increased aortic stiffness, an independent predictor of cardiovascular mortality. In the present study, our aim was to establish whether aortic stiffness is increased in RA and to investigate the relationship between inflammation and aortic stiffness. In addition, we tested the hypothesis that aortic stiffness could be reduced with anti–tumor necrosis factor-&agr; (TNF-&agr;) therapy. Methods and Results— Aortic pulse-wave velocity (PWV), augmentation index, and blood pressure were measured in 77 patients with RA and in 142 healthy individuals. Both acute and chronic inflammatory measures and disease activity were determined. The effect of anti-TNF-&agr; therapy on PWV and endothelial function was measured in 9 RA patients at 0, 4, and 12 weeks. Median (interquartile range) aortic PWV was significantly higher in subjects with RA than in control subjects (8.35 [7.14 to 10.24] versus 7.52 [6.56 to 9.18] m/s, respectively; P=0.005). In multiple regression analyses, aortic PWV correlated independently with age, mean arterial pressure, and log-transformed C-reactive protein (R2=0.701; P<0.0001). Aortic PWV was reduced significantly by anti-TNF-&agr; therapy (8.82±2.04 versus 7.94±1.86 versus 7.68±1.56 m/s at weeks 0, 4, and 12, respectively; P<0.001); concomitantly, endothelial function improved. Conclusions— RA is associated with increased aortic stiffness, which correlates with current but not historical measures of inflammation, suggesting that increased aortic stiffness may be reversible. Indeed, anti-TNF-&agr; therapy reduced aortic stiffness to a level comparable to that of healthy individuals. Therefore, effective control of inflammation may be of benefit in reducing cardiovascular risk in patients with RA.

Imaging features of spinal osteoid osteoma with emphasis on MRI findings

A retrospective evaluation of the imaging of 13 patients with a diagnosis of osteoid osteoma (OO) of the spine was undertaken. Available imaging included radiographs (n=10), computed tomography (CT) (n=13), bone scintigraphy (n=5) and magnetic resonance imaging (MRI) (n=13). MRI features evaluated were pattern of neural arch and vertebral body oedema and the presence of an identifiable nidus. MRI features were correlated with other available imaging. There were seven males and six females with an age range of 8–59 years. On radiographs, scoliosis was present in ten and a sclerotic pedicle in nine patients. Focal increased uptake on bone scintigraphy consistent with OO was seen in all five patients where scintigraphy was available. On CT, a nidus was identified in all patients and reactive sclerosis was seen in 12. MRI demonstrated the nidus in eight patients and unilateral neural arch oedema with anterior extension to involve the ipsilateral posterolateral vertebral body in 11. When MRI is performed in the evaluation of back pain, the presence of unilateral neural arch oedema extending to involve the posterolateral vertebral body raises the possibility of spinal OO and should prompt CT to confirm the presence of a nidus.

Myopericytoma in Kager's fat pad.

Myopericytoma is a recently described, rare, soft-tissue tumour with perivascular differentiation of myoid cells. We present a case of myopericytoma occurring around the ankle in a 68-year old man. The patient presented with a history of a lump around the ankle of 4 years’ duration. Clinical presentation, radiological features and histopathologic findings of this case are reported, and the relevant literature is reviewed.

Displaced fracture through the anterior atlantal synchondrosis

In the acute setting, accurate radiological interpretation of paediatric cervical spine trauma can be difficult due to a combination of normal variants and presence of multiple synchondroses. We present a rare case of a fracture through the anterior atlantal synchondrosis in a paediatric spine. A five-year-old boy, who fell backwards onto the top of his head while swinging across on a monkey bar frame, presented with neck pain, cervical muscle spasm and decreased right lateral rotation and extension of his neck. Computed tomography showed a displaced diastatic fracture through right anterior atlantal synchondrosis. There are only 12 cases of paediatric C1 fractures reported in the world literature. The importance of considering this diagnosis in the appropriate clinical setting, and the normal variants in the paediatric atlas that can cause diagnostic dilemma to the interpreting radiologist, are discussed in this case report.

Image-guided percutaneous biopsy of intramedullary lytic bone lesions: utility of aspirated blood clots

The diagnostic value of aspirating blood clots while performing percutaneous biopsy of intramedullary lytic bone lesions was assessed. This was a retrospective analysis of 400 patients with intramedullary lytic bone lesions who underwent image-guided needle biopsy. The nature of the specimens obtained was noted from the histopathology records. In 83 (20.8%) of the 400 patients, the specimen obtained was either blood clot only or essentially blood clot with only tiny fragments of bone or soft tissue. Lesional tissue was present on needle biopsy specimens in 65 (78.3%) of the 83 cases, while in 18 (21.7%) cases no lesional tissue was obtained. In 24 of the 83 cases, there was no surgical histological diagnosis available. Inthe 59 cases where surgical histological diagnosis was available for comparison, the diagnostic accuracy for needle biopsy was 73%. Percutaneous biopsy provided the diagnosis allowing appropriate further management in 62 cases, for an overall diagnostic yield of 75%. The results of our study show a sufficiently good diagnostic value in obtaining blood clots as to necessitate routine attempts at obtaining such material while performing percutaneous biopsy of intramedullary lytic bone lesions.

Symptomatic resolution of spinal osteoid osteoma with conservative management: imaging correlation

A 10-year-old girl presented with a history of painful scoliosis. Imaging performed, including computed tomography (CT) and magnetic resonance imaging (MRI), demonstrated a lesion with radiological features consistent with an osteoid osteoma (OO) of the 6th thoracic vertebra. The patient was treated conservatively with non-steroidal anti-inflammatory drugs (NSAIDs). Over eight months of clinical and radiological surveillance, she became entirely asymptomatic and demonstrated complete resolution of the scoliotic curve. The CT and MRI features of the osteoid osteoma during the period of surveillance are presented and are correlated with the corresponding clinical features.

Giant atypical ossifying fibromyxoid tumour of the calf

We present a case of giant atypical ossifying fibromyxoid tumour (OFMT) of soft tissue, occurring in the calf, in a 77-year-old woman. The patient presented with a history of bleeding ulcer over a calf lump that had been present for over 4 years. Clinical presentation, radiological features and histopathologic findings are described, and the relevant literature is reviewed.

Soft tissue masses with “cyst-like” appearance on MR imaging: distinction of benign and malignant lesions

The purpose of this study was to assess the reliability of MR imaging features in distinguishing between benign and malignant soft tissue masses that have a “cyst-like” appearance (hypointense to muscle on T1-weighted and hyperintense on T2-weighted or fluid-sensitive MR sequences). MR imaging features of 40 patients with histologically proven soft tissue masses (27 benign and 13 malignant lesions) that were hypointense to muscle on T1-weighted and hyperintense on T2-weighted or fluid-sensitive MR sequences were analysed to see if a distinction could be made between benign and malignant lesions. There were 23 females and 17 males (mean age, 56xa0years; age range, 23–82xa0years). MR imaging features analysed for statistical significance included lesion size, lesion homogeneity, presence of lobulation, depth in relation to fascia and border definition. Clinical assessment included the age and sex of the patient and location of the lesion. Statistically significant MR imaging features favouring a diagnosis of a malignant lesion included larger average dimension of the mass (P≤0.004), larger greatest dimension of the mass (P≤0.028) and heterogeneity of the lesion on T1-weighted sequences (P=0.017). The most statistically significant predictor of malignancy was the larger average dimension of the mass.

Synovial chondromatosis of the foot presenting with Lisfranc dislocation

Primary synovial chondromatosis is rare in the foot. We report a case of synovial chondromatosis affecting multiple sites of the foot and causing bone erosions in a 44-year-old woman. Radiographs demonstrated erosions of multiple metatarsals including the tarsometatarsal joints, resulting in Lisfranc tarsometatarsal dislocation. Magnetic resonance imaging showed the widespread synovial proliferation and soft tissue masses affecting the foot and helped in arriving at a differential diagnosis and plan for needle biopsy. Diagnosis was made initially by needle biopsy under computed tomography guidance and was subsequently confirmed by histopathological assessment of the surgically excised synovial masses. To our knowledge, multifocal synovial chondromatosis causing Lisfranc dislocation in the foot has not been reported previously.

Pseudotumoral appearance of a ruptured epidermal cyst in the foot

We present a case of keratin granuloma due to a ruptured epidermal cyst, occurring in the foot, in a 52-year-old woman. The patient presented with a history of a slow-growing lump in the web space of the foot that had been present for over a year. Imaging appearances suggested a soft tissue neoplasm. Clinical presentation, radiological features and histopathological findings are described, and the relevant literature is reviewed.