Answer for BIR CoW 06 Oct 2024
Inflammatory arthritis-Right shoulder
Findings
Articular surface irregularities with juxta articular erosions involving capsular and lateral aspect of humeral head. PD/STIR hyperintensity with irregularities noted in glenoid with subchondral erosions noted. Enhancing Synovial thickening noted along antero inferior aspect of glenoid . PD hyperintensity noted around the biceps tendon with continuity of tendon could not be traced near labral attachment site. Minimal joint effusion. Mild distention of subacromial and sub deltoid bursa. Multiple enlarged axillary lymph nodes
Discussion
Patient known case of Rhumatoid arthritis for past 26 years on methotrexate and steroids. now presented with right shoulder pain for past 2 months present study shows Articular surface irregularities with juxta articular erosions involving capsular and lateral aspect of humeral head. PD/STIR hyperintensity with irregularities noted in glenoid with subchondral erosions noted. Enhancing Synovial thickening along antero inferior aspect of glenoid . PD hyperintensity around the biceps tendon with continuity of tendon could not be traced near labral attachment site. Minimal joint effusion. -features suggestive of inflammatory arthritis DISCUSSION: Rheumatoid arthritis (RA) is a chronic autoimmune multi-systemic inflammatory disease with predominant damage of synovial tissues. It affects around 0.5-1% of the adult population and occurs predominantly in females (2-3:1) between 45-65 years of age. DIAGNOSIS: - based on clinical, radiologic and serological findings. CLINICAL SYMPTOMS: - chronic and fluctuant. They consist principally of polyarthralgia, morning joint stiffness, and other extra-articular manifestations such as fever, fatigue and weight loss - Arthritis symptoms tend to appear first in smaller joints (hands and wrists) in a symmetric proximal distribution. With the progression of the disease, the symptoms spread to other joints such as the shoulder, which is affected in around 91% of patients with long-standing disease PATHOGENESIS: - RA is characterized by sinovial hyperplasia and pannus formation, fundamental elements in the pathogenesis of RA X-ray : - The typical findings are soft tissue swelling, symmetrical narrowing of the joint space, osteoporosis and marginal bone erosion due to the pannus . Osteolysis of the distal clavicle may be present. Computed tomography : - CT is not frequently used in the evaluation of peripheral disease, since the initial findings are soft-tissue changes and other techniques are superior in detecting them. Therefore, it is basically reserved for evaluation of spinal RA and peri-operative assessment. MRI : - MR has a greater sensitivity than radiographs to evaluate the inflammatory disease and can detect bone erosions years before conventional radiography . - Synovitis is the earliest finding in patients with RA. - MR allows direct visualization of the pannus, seen as soft tissue mass with low signal intensity on T1-weighted images, high signal on T2-weighted images, and enhancement after gadolinium administration . - MR can also detect bone marrow oedema and effusions, present in early phases of RA . In RA spontaneous tendon ruptures can also occur . - Rice bodies may be detected as multiple intra-articular small loose bodies consequence of a non-specific chronic synovial inflammation. They are iso-hypointense in T1, T2 and proton density-weighted images. They can be removed for symptomatic relief. MANAGEMENT : The life expectancy of patients with RA is reduced by 3 to 12 years, mainly because of cardiovascular diseases . The only treatment that has an effect on the course of the disease are the Disease-modifying antirheumatic drugs (DMARDs). Nonsteroidal antiinflamatory drugs and corticosteroids are also used
REFERENCE:
Vasanth LC, Pavlov H, Bykerk V. (2013) Imaging of rheumatoid arthritis. Rheum Dis Clin North Am 139(3):547-66. Sussmann AR, Cohen J, Nomikos GC, Schweitzer ME. (2012) Magnetic resonance imaging of shoulder arthropathies. Magn Reson Imaging Clin N Am 20(2):349-71. Shoulder rheumatoid arthritis DOI: 10.1594/EURORAD/CASE.14322 Sommer O, Kladosek A, Weiler V, Czembirek H, Boeck M, Stiskal M. Rheumatoid Arthritis: A Practical Guide to State-Of-The-Art Imaging, Image Interpretation, and Clinical Implications. Radiographics. 2005;25(2):381-98. doi:10.1148/rg.252045111 - Pubmed
Findings
Articular surface irregularities with juxta articular erosions involving capsular and lateral aspect of humeral head. PD/STIR hyperintensity with irregularities noted in glenoid with subchondral erosions noted. Enhancing Synovial thickening noted along antero inferior aspect of glenoid . PD hyperintensity noted around the biceps tendon with continuity of tendon could not be traced near labral attachment site. Minimal joint effusion. Mild distention of subacromial and sub deltoid bursa. Multiple enlarged axillary lymph nodes
Discussion
Patient known case of Rhumatoid arthritis for past 26 years on methotrexate and steroids. now presented with right shoulder pain for past 2 months present study shows Articular surface irregularities with juxta articular erosions involving capsular and lateral aspect of humeral head. PD/STIR hyperintensity with irregularities noted in glenoid with subchondral erosions noted. Enhancing Synovial thickening along antero inferior aspect of glenoid . PD hyperintensity around the biceps tendon with continuity of tendon could not be traced near labral attachment site. Minimal joint effusion. -features suggestive of inflammatory arthritis DISCUSSION: Rheumatoid arthritis (RA) is a chronic autoimmune multi-systemic inflammatory disease with predominant damage of synovial tissues. It affects around 0.5-1% of the adult population and occurs predominantly in females (2-3:1) between 45-65 years of age. DIAGNOSIS: - based on clinical, radiologic and serological findings. CLINICAL SYMPTOMS: - chronic and fluctuant. They consist principally of polyarthralgia, morning joint stiffness, and other extra-articular manifestations such as fever, fatigue and weight loss - Arthritis symptoms tend to appear first in smaller joints (hands and wrists) in a symmetric proximal distribution. With the progression of the disease, the symptoms spread to other joints such as the shoulder, which is affected in around 91% of patients with long-standing disease PATHOGENESIS: - RA is characterized by sinovial hyperplasia and pannus formation, fundamental elements in the pathogenesis of RA X-ray : - The typical findings are soft tissue swelling, symmetrical narrowing of the joint space, osteoporosis and marginal bone erosion due to the pannus . Osteolysis of the distal clavicle may be present. Computed tomography : - CT is not frequently used in the evaluation of peripheral disease, since the initial findings are soft-tissue changes and other techniques are superior in detecting them. Therefore, it is basically reserved for evaluation of spinal RA and peri-operative assessment. MRI : - MR has a greater sensitivity than radiographs to evaluate the inflammatory disease and can detect bone erosions years before conventional radiography . - Synovitis is the earliest finding in patients with RA. - MR allows direct visualization of the pannus, seen as soft tissue mass with low signal intensity on T1-weighted images, high signal on T2-weighted images, and enhancement after gadolinium administration . - MR can also detect bone marrow oedema and effusions, present in early phases of RA . In RA spontaneous tendon ruptures can also occur . - Rice bodies may be detected as multiple intra-articular small loose bodies consequence of a non-specific chronic synovial inflammation. They are iso-hypointense in T1, T2 and proton density-weighted images. They can be removed for symptomatic relief. MANAGEMENT : The life expectancy of patients with RA is reduced by 3 to 12 years, mainly because of cardiovascular diseases . The only treatment that has an effect on the course of the disease are the Disease-modifying antirheumatic drugs (DMARDs). Nonsteroidal antiinflamatory drugs and corticosteroids are also used
REFERENCE:
Vasanth LC, Pavlov H, Bykerk V. (2013) Imaging of rheumatoid arthritis. Rheum Dis Clin North Am 139(3):547-66. Sussmann AR, Cohen J, Nomikos GC, Schweitzer ME. (2012) Magnetic resonance imaging of shoulder arthropathies. Magn Reson Imaging Clin N Am 20(2):349-71. Shoulder rheumatoid arthritis DOI: 10.1594/EURORAD/CASE.14322 Sommer O, Kladosek A, Weiler V, Czembirek H, Boeck M, Stiskal M. Rheumatoid Arthritis: A Practical Guide to State-Of-The-Art Imaging, Image Interpretation, and Clinical Implications. Radiographics. 2005;25(2):381-98. doi:10.1148/rg.252045111 - Pubmed
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!