Unusual, but important, peri- and extra-articular manifestations of rheumatoid arthritis: a pictorial essay

Ultrasonography is a useful technique to detect soft tissue changes of rheumatoid arthritisnot only synovitis, but also tenosynovitis, bursitis, and enthesitis-even at a subclinical stage. However, radiologists tend to focus on synovitis in daily practice, and unusual peri- or extraarticular manifestations of rheumatoid arthritis are difficult to detect at the initial presentation. This pictorial essay describes a broad spectrum of ultrasonographic findings in tendons, bursae, ligaments, subcutaneous tissues, bones, and nerves to assist in the accurate diagnosis of rheumatoid arthritis.

Diffuse-Type Tenosynovial Giant Cell Tumor of the Tendon Sheath in Both Wrists

Diffuse-type tenosynovial giant cell tumor (D-TSGCT), previously known as pigmented villonodular synovitis, is a locally aggressive neoplasm that may arise from the synovium, bursa, or tendon sheath. D-TSGCT is usually monoarticular and can be classified into intra- and extra-articular forms, the latter of which is rarer. Here, we report a case of D-TSGCT in a 64-year-old female that involved the entire flexor and extensor tendon sheaths of both wrists. We describe the ultrasonography and MRI findings, as well as review the relevant literature.

Eosinophilic fasciitis: A case report with a brief literature review

Eosinophilic fasciitis (EF) is a scleroderma-like immune-allergic disorder of unknown etiology and pathogenesis. This rare disease is characterized by the progressive induration of the skin and soft tissue, and peripheral eosinophilia. Here, we report a case of EF. A 21-year-old female was referred due to edema in the upper and lower extremities for 1 month. Laboratory results were unremarkable except for severe eosinophilia. Parasite infestation, venous thrombosis, and cardiac and renal problems were excluded. Magnetic resonance imaging of both the lower extremities revealed symmetrical thickening and contrast enhancement of crural fascia with adjacent subcutaneous fat infiltration. A full-thickness biopsy at the lower extremity showed infiltration of the fascia by eosinophils, plasma cells, and lymphocytes with marked edema. Thus, this patient was confirmed to have EF and she was treated with systemic corticosteroids, resulting in a remarkable improvement in both edema and eosinophilia.

Ultrasound and MRI Findings of Giant Cell Fibroblastoma in the Abdominal Wall: Radiologic-Pathologic Correlations

Giant cell fibroblastoma (GCF) is a rare soft-tissue sarcoma of fibroblastic origin. To the best of our knowledge, only one brief description of the MRI findings of GCF exists in the pathologic literature. Herein, we report a case of histologically proven GCF in a 3-year-old boy who underwent ultrasonography and MRI of a superficial mass in the abdominal wall.

Spinal Extradural Meningioma: A Case Report and Review of the Literature

Spinal meningiomas account for 12% of all the meningiomas and are usually located in the intradural extramedullary space. In some cases, they are associated with some extradural extensions. However, purely extradural spinal meningiomas are rare. Additionally, it is difficult to make an accurate preoperative diagnosis. We report a case of pathologically confirmed atypical meningioma, presented as a posterior epidural mass on the thoracic spine. We review the case, clinical symptoms, radiologic findings and the histologic features.

A Case of Acute Osteomyelitis of the Femur Caused by Nalidixic-Acid-Resistant Salmonella enteritidis / 대한내과학회지

Infection with nontyphoidal Salmonella most often results in self-limited acute gastroenteritis. However, occasionally it causes bacteremia and localized infection requiring antibiotic treatment. A third-generation cephalosporin or fluoroquinolone is often the first choice of antibiotic. However, there has been an increase in nalidixic-acid-resistant nontyphoidal Salmonella with decreased fluoroquinolone susceptibility. Although there have been many cases reported of nontyphoidal Salmonella, no cases of nalidixic-acid-resistant nontyphoidal Salmonella have been reported in Korea. Here, we report on the case of a 61-year-old man with a diagnosis of acute osteomyelitis and periosteal abscess of the femur caused by nalidixic-acid-resistant Salmonella enteritidis. He was treated successfully with prolonged administration of a high-dose of ciprofloxacin and drainage of the abscess.

A Case of Vertebral Osteomyelitis and Spinal Epidural Abscess Caused by Haemophilus aphrophilus / 대한내과학회지

Haemophilus aphrophilus is an aerobic, gram-negative oropharyngeal bacterium, commonly isolated from cases of HACEK endocarditis. In addition, H. aphrophilus has also been shown to cause invasive bone and joint infections. Although multiple cases of H. aphrophilus endocarditis have been described, no cases of invasive bone and joint infections caused by H. aphrophilus have been reported in Korea. Here we report the case of a 69-year old woman with a diagnosis of vertebral osteomyelitis and spinal epidural abscess with compressive myelopathy caused by H. aphrophilus, in which there was no objective evidence of infective endocarditis. She was successfully treated with intravenous administration of cefotaxime and drainage of the epidural abscess by laminectomy of the T3-7 vertebrae.

A Case of Small Bowel Fistulas Caused by Multiple Magnet Ingestion: Usefulness of Ultrasonography

Foreign body ingestion is a common problem in the pediatric population and the majority of such cases occur between the ages of six months and three years. Most objects pass uneventfully through the gastrointestinal tract; however, ingestion of multiple magnets can cause serious gastrointestinal complications through interaction with each other across the bowel wall. In these situations, radiologic evaluation is imperative for proper treatment. This is a case report on ingestion of 32 magnets in a 10-year-old boy. We diagnosed a small bowel fistula caused by ingestion of multiple magnets using sonography, which showed hyperechoic magnetic foreign bodies attached together penetrating the thickened neighbouring jejunum.

Solitary Epidural Lipoma with Ipsilateral Facet Arthritis Causing Lumbar Radiculopathy

A 55-year-old obese man (body mass index, 31.6 kg/m2) presented radiating pain and motor weakness in the left leg. Magnetic resonance imaging showed an epidural mass posterior to the L5 vertebral body, which was isosignal to subcutaneous fat and it asymmetrically compressed the left side of the cauda equina and the exiting left L5 nerve root on the axial T1 weighted images. Severe arthritis of the left facet joint and edema of the bone marrow regarding the left pedicle were also found. As far as we know, there have been no reports concerning a solitary epidural lipoma combined with ipsilateral facet arthorsis causing lumbar radiculopathy. Solitary epidural lipoma with ipsilateral facet arthritis causing lumbar radiculopathy was removed after the failure of conservative treatment. After decompression, the neurologic deficit was relieved. At a 2 year follow-up, motor weakness had completely recovered and the patient was satisfied with the result. We recommend that a solitary epidural lipoma causing neurologic deficit should be excised at the time of diagnosis.

Imaging of Arthritis / 대한내과학회지

Imaging study of joint is important to differentiate various kinds of arthritis, and to evaluate the treatment response of the arthritis. Radiograph is the basic and first line imaging study of the joint, but there are overlapped imaging findings between arthritis. The objective of this review is to present a simplified approach to radiographic evaluation of arthritis and to help in making adequate decision to choose a further imaging study among ultrasonography, CT and MRI.

Coronary to Bronchial Artery Fistula Causing Massive Hemoptysis in Patients with Longstanding Pulmonary Tuberculosis

We report on three cases of longstanding pulmonary tuberculosis patients with coronary to bronchial artery fistula (CBF) who presented with recurrent massive hemoptysis. The first and second patients died because of decreased functional pulmonary volume plus massive hemoptysis and cannulation failure of CBF due to hypovolemic vasospasm, respectively. When recurrent hemoptysis occurs despite successful embolization treatment, CBF should be considered as a potential bleeding source. Moreover, a coronary angiography should be performed, especially in patients with longstanding cardiopulmonary disease such as pulmonary tuberculosis.

Lateralization of Hypoglycemic Encephalopathy: Evidence of a Mechanism of Selective Vulnerability

BACKGROUND: One of the characteristics of hypoglycemic encephalopathy (HE) is selective vulnerability of different brain regions. CASE REPORT: We observed a patient with unilateral HE affecting the right internal capsule and the subcortical white matter. The patient had a preexisting stroke in the opposite hemisphere. The hemisphere that was affected by HE exhibited greater regional blood flow (single positron-emission tomography) and higher fractional anisotropy (diffusion-tensor imaging) than the unaffected hemisphere. CONCLUSIONS: This case suggests that the degree of metabolism required to maintain the function of brain structures and neuronal integrity is an important factor determining the selective vulnerability in HE.

Arthroscopic Treatment of Septic Arthritis of Acromioclavicular Joint

Septic arthritis requires an early diagnosis and proper treatment to prevent the destruction of articular cartilage and joint contracture. This paper presents a rare case of septic arthritis of the acromioclavicular joint that was treated with arthroscopic debridement and resection of the distal clavicle.

Percutaneous Excision of a Benign Breast Mass Using Ultrasound-guided, Vacuum-assisted Core Biopsy: A Review of 197 Cases with Long Term Follow-up

PURPOSE: To assess long term results of excising benign masses using ultrasound (US)-guided, vacuum-assisted core biopsy (Mammotome). MATERIALS AND METHODS: We enrolled 163 patients (197 masses) receiving USguided excision using vacuum-assisted core biopsy and follow-up sonography in this retrospective study. The masses were category 3 as determined by ultrasound imaging according to the Breast Imaging Reporting and Data System (BI-RADS) (n=145) or pathologically confirmed as benign masses by a previous core-needle biopsy although category 4a and 4b (n = 52). Pathology, the presence of hematoma and residual tissue, as well as scar formation were assessed. RESULTS: We diagnosed 190 (96.5%) benign masses, 4 (2.0%) malignant masses, and 3 (1.5%) high-risk lesions. Most (176 masses, 91.2%) were excised completely as demonstrated by the follow-up ultrasound examination. Scar changes were minimal (68.7%) or moderate (31.3%), with regression in 53%. CONCLUSION: US-guided excision using vacuum-assisted core biopsy is effective for the removal of benign breast masses. The majority of scars are minimal, with good cosmetic effect. However, subsequent excision should be done for malignant masses or phyllodes tumor because radiologic absence does not guarantee complete removal.

Surgical Treatment of Brucellar Spondylodiscitis with Epidural Abscess: A Case Report / 대한척추외과학회지

Brucellosis is a well known systemic, zoonotic disease that can affect many organs. We report a rare case of spondylodiscitis with an epidural abscess caused by brucellosis. The patient was treated surgically for severe pain and concomitant devastating neurological deficit. A diagnosis of spondylodiscitis or an epidural abscess due to brucellosis must be considered when acute back pain, radiating pain and febrile episodes occur, particularly in people in a high risk group.

Color Doppler Ultrasonographic Findings of Vascular Leiomyoma: Pathologic Correlation

PURPOSE: To evaluate the distribution of color flow signals on color Doppler ultrasonography of vascular leiomyomas and to correlate them with pathologic findings. MATERIALS AND METHODS: We retrospectively analyzed color Doppler ultrasonographic images and pathologic slides of six vascular leiomyomas. We classified the patterns of distribution of color flow signals into localized compact cluster types and non-cluster types, and the pathologic findings into three subtypes: solid, venous and cavernous. RESULTS: All cases showed well-defined homogenous hypoechoic subcutaneous masses on gray-scale ultrasonography. Three cases showed localized compact cluster types on color Doppler ultrasonography, one in each subtype (solid, venous and cavernous). For the three non-cluster types, again there was on in each subtype. In addition, on pathologic analysis the zone of the localized compact cluster of color flow signals coincided with a cluster of larger, vascular caliber masses. CONCLUSIONS: Localized compact clusters of color flow signals on color Doppler ultrasonography were seen in 50% of our cases and correlated with a cluster of larger vascular caliber in the mass. But the pattern of distribution of color flows didn't show a correlation with pathologic type.

The Value of Sonographic Evaluation of the Appendix in Patient with Pelvic Inflammatory Disease: Correlation with CT, clinical, and Pathological Findings

PURPOSE: To assess the sonographic evaluation of the appendix in patients with pelvic inflammatory disease (PID) using CT, clinical, and pathological comparisons. MATERIALS AND METHODS: During a three-year period, 51 patients with PID underwent appendix US and abdomino-pelvic CT. The findings of appendix on US were classified into three categories (normal appendix, normal appendix with inflamed periappendiceal fat, and acute appendicitis). Based on the CT analysis, the condition of the appendix was classified into five categories, namely ('normal, 'probably normal', 'equivocal CT findings for diagnosis of appendicitis', 'probable appendicitis', 'definite appendicitis'). The CT and US results were then correlate with clinical and pathological findings. RESULTS: Of 21 patients with definite or probable appendicitis as shown by CT analysis, US demonstrated normal appendix in 10 patients (48%), normal appendix with inflamed periappendiceal fat in 10 patients (48%), and primary appendicitis in the remaining patient (4%). Of 25 patients with normal or probably normal appendix as shown by CT analysis, US demonstrated normal appendix in 24 patients (96%), and primary appendicitis in the remaining patient (4%). The two patients with primary appendicitis, as shown by US, underwent appendectomy and pathological studies revealed primary appendicitis. CONCLUSION: A sonographic evaluation of the appendix in patients with PID improved the diagnostic accuracy for primary appendicitis.

Percutaneous Needle Aspiration Biopsy (PCNA) of Pulmonary Lesions: Evaluation of a Reaspiration or a Rebiopsy (second PCNA)

PURPOSE: To evaluate the effectiveness of the reaspiration or rebiopsy of pulmonary lesions (second PCNA) in cases where the pathologic results are inconclusive upon initial percutaneous needle aspiration biopsy (PCNA). MATERIALS AND METHODS: A total of 364 PCNA cases (350 initial PCNA, 14 second PCNA) were performed under CT or fluoroscopy guidance for all the 350 patients enrolled. The procedure was performed by either using an automated biopsy gun with a 20-G needle (298 cases) or a 20-G aspiration needle (66 cases). The pathologic agreement rates between the initial and second PCNA, as well as the causes for a second PCNA, were evaluated. Finally the type and rate of complication were also evaluated. RESULTS: The second PCNA rate was 4.0% (14/350). The causes for a second PCNA, following the initial PCNA included unexpected pathologic results (n = 7) and inconclusive pathologic results (n = 7). Of the seven cases which had unexpected pathologic results from their initial PCNAs, five had similar pathologic results after a second PCNA. Also, of the seven cases of inconclusive pathologic results, such as atypical cells, the scanty cellularity or necrosis upon an initial PCNA, six cases revealed a malignancy on a second PCNA. The overall complication rate, including both the initial and second PCNAs was 14.0% (51/364). CONCLUSION: A second PCNA was performed to help resolve the exact diagnosis for a pulmonary lesion in cases of inconclusive pathologic results upon an initial PCNA.

Killian-Jamieson Diverticulum Mimicking a Thyroid Nodule on Ultrasonography: A Case Report

Thyroid ultrasonography is widely used for diagnosis and cytologic evaluation of thyroid nodules. We encountered a case of Killian-Jamieson diverticulum, which was differentiated from a thyroid nodule using ultrasonography.

Comparison of Arthroscopy and Routine MRI About Cartilage Lesion in Knee Joint

PURPOSE: The cartilage lesions of routine MRI (no cartilage-specific image sequences) compared with those of arthroscopy for detecting how much we can predict. MATERIALS AND METHODS: We made a retrospective study of 53 patients with cartilage lesions of medial femoral condyle in the knee arthroscopy from Nov. 2003 to Jan. 2006. We analyzed the extent of agreement in cartilage lesions between arthroscopy and routine MRI using modified Outerbridge classification. RESULTS: All patients were categorized by modified Outerbridge Grade I~IV. In arthroscopy, 3, 4, 24, 22 cases were reported in each category: on routine MRI, 3, 10, 12, 23 cases were reported in each category and there were 5 normal cases. The sensitivity of cartilage lesions on MRI was high (90.6%), however, the agreement of those was low (K=0.24). We found 24 cases (45.2%) that MRI levels and arthroscopy levels were matched. We found 29 cases (54.7%) that those two levels were not matched. CONCLUSION: It is important to make a close inspection of chondral surfaces even in routine MRI. And cartilage lesions in routine MRI should be considered as those of higher grade in arthroscopy.