Differential diagnosis of rheumatoid and psoriatic arthritis at an early stage in the small hand and foot joints using magnetic resonance imaging.

The 2 major and clinically most important primary inflammatory rheumatic diseases which affect small hand and feet joints are rheumatoid arthritis (RA) and psoriatic arthritis (PsA). The most important initial histopathological feature of RA is synovitis followed by chronic proliferative granulomatous pannus-tissue, which is associated with cartilage and bone destruction. Early inflammatory changes in RA also develop synchronously within the subchondral bone marrow. Enthesitis is the hallmark of SNSA, and is often seen as one of the first radiological manifestations of the diseases. As a rule inflammation within the synovial joints, histologically similar to RA, is not so pronounced. Consequently destructive changes within the synovial joints are much less with the exception of PsA in which pronounced bone destruction may develop (arthritis mutilans). Considerable overlapping in clinical and morphological manifestation of RA and PsA may be present. For evaluation of hand and feet joints and surrounding soft tissue structures in RA and PsA different imaging modalities are used, which include projection radiography, ultrasonography (US), radionuclide techniques and magnetic resonance imaging (MRI). MRI has become the imaging modality of choice for evaluation of arthritis, when conventional radiography is not conclusive.

[Methods of imaging and bone densitometry in osteoporosis of patients with inflammatory rheumatoid diseases]. / Methoden der Bildgebung und der Knochendichtemessung bei der Osteoporose im Rahmen entzündlich- rheumatischer Erkrankungen.

Besides clinical history and clinical findings conventional X-ray is important in the evaluation of osteoporosis as the third diagnostic tool. Its purpose is mainly excluding other diseases and proof of fractures as well as their follow up. Also X-ray is able to demonstrate complications of osteoporosis such as insuffiency fractures and effects of therapy as for example fluorosis. For very early diagnosis bone densitometry is used. Today the improved methods deliver fracture prediction percentages of high value. As a planar measurement method DXA of the spine and of the femoral neck can be used. Volumetric tools, which can measure trabecular bone, without overlying cortical bone, are computed tomography of the spine and of the distal radius. Quantitative ultrasound is an interesting approach, but which does not really measure bone densitometry and which is net yet suited for clinical follow up. Quantitative Magnetic Resonance is far from routine clinical application.

[Differential diagnosis of rheumatic diseases]. / Differenzialdiagnose rheumatischer Erkrankungen.

UNLABELLED: QUESTION TO ANSWER: Which imaging modalities are appropriate for the Differential diagnosis of Rheumatic diseases. METHODS AND RESULTS: MRI has far most the highest sensitivity and is unequaled in its brilliant presentation of anatomy and pathology. But it is sometimes forgotten, that this is at least in part the result of carefully selected sequences, dedicated to the expected result. CONCLUSION: Plain X-ray offers high specificity in the differential diagnoses of rheumatic diseases, it is well standardised and it is a device, to use independent from any suspected findings.

[Imaging techniques in rheumatology: conventional radiography in rheumatoid arthritis]. / Bildgebende Verfahren in der Rheumatologie: Konventionelle Röntgendiagnostik bei der rheumatoiden Arthritis.

Conventional radiography is still regarded the gold standard for imaging techniques in rheumatoid arthritis (RA). It is a very important tool for the diagnosis, the differential diagnosis, and the evaluation of the course and prognosis of the disease. Special advantages of conventional radiography are the worldwide availability and experience with the method over decades and the relatively low costs. Moreover, x-rays can be stored and re-evaluated over long periods of time. Joint damage caused by RA can be quantified by means of scoring methods. The amount of destruction correlates well with functional disability over time. The inhibition of damage progression seen on radiographs is the most important characteristic of a DMARD. Typical radiographic changes are part of the ACR classification criteria of RA. Technically, bone structure can be demonstrated with a high local resolution better than with all other imaging techniques, whereas only indirect conclusions can be drawn concerning soft tissue and cartilage lesions. This review includes recommendations given by the "Commission on Imaging Techniques" of the German Society of Rheumatology regarding technical and personal preconditions, costs, indication as well as practical performance of radiography in RA. In addition, radiographic changes that can be expected in RA including destruction and repair are discussed briefly.

[Osteomyelitis--imaging methods and their value]. / Osteomyelitis--Bildgebende Verfahren und ihre Wertigkeit.

Various imaging modalities are used in diagnosis of acute and chronic infectious endogenous osteomyelitis and exogenous ostitis. The pathophysiological changes of osteomyelitis/ostitis in the bone and surrounding soft tissue are known. Findings in plain film radiography show these changes only in relatively advanced stages of disease. Hence, plain film radiographs are useful as a basic imaging modality by excluding other differentials and as a follow-up modality under therapy. Ultrasound-using advanced technology--offers diagnostic help in acute osteomyelitis, especially in infants. The various techniques of nuclear medicine show much higher sensitivity for detecting osteomyelitis than plain film radiography, but do not permit good separation for bone involvement and infectious changes in the surrounding soft tissue. While computed tomography offers the ability to display bone and soft tissue separately, it has been widely replaced by magnetic resonance imaging using fat-suppressed sequences and paramagnetic contrast media which show the spread of the infectious changes with higher sensitivity and accuracy.

Insufficiency and stress fractures of the long bones occurring in patients with rheumatoid arthritis and other inflammatory diseases, with a contribution on the possibilities of computed tomography.

In patients with long standing rheumatoid arthritis and other rheumatoid disorders, stress fractures and insufficiency fractures are not uncommon. The cause may be osteoporosis due to rheumatoid arthritis, corticosteroid therapy, joint stiffness, and deformity of the joints caused by the inflammatory process. Also, unaccustomed exercise after reconstructive joint surgery may be a cause of fractures in these patients. Fractures can be documented on conventional X-ray-pictures and tomograms. Computed tomography can show the medullary extent of these fractures and gives, in several cases, additional information showing the combination of insufficiency fractures with fragmentations of parts of the involved bone. Reconstructive surgery with total joint replacement may be another cause of the development of these fractures. This unaccustomed increase in ambulation may lead to stress fractures in other joints of the same extremity or of contralateral extremity. Pain beginning in joint of the lower extremity in a patient with chronic rheumatoid arthritis should, besides arthritis, raise the possibility of a stress fracture. Also with cases of angular deformity of a joint and unaccustomed exercise after reconstructive surgery patients stress fractures may be seen and can be established by Plainfilm, Computed Tomography scintimetric bone scanning and MRI.

[Roentgen diagnosis and computerized tomography in inflammatory rheumatic diseases. Methods with a future?]. / Röntgendiagnostik und Computertomographie bei entzündlich-rheumatischen Erkrankungen. Methoden mit Zukunft?

Plain-film radiography is an important and basic element in the assessment of inflammatory rheumatic diseases. Its various uses include assessment of inflammatory osseous destruction and the activity of inflammatory changes. Furthermore, the inflammatory collateral phenomena can indicate an acute clinical phase, and the articular soft tissue swelling and tenosynovitis are shown directly and indirectly very clearly. On the other hand, high-resolution computed tomography is very capable of showing cortical structures of bone complementary to MR. In some special clinical questions and anatomical regions, especially the axial skeleton, it delivers information of high specifity, partly for definitive diagnosis and partly for planning surgical procedures. The assessment of changes in the sacroiliac joints, sternoclavicular joints and craniocervical junction are domains of computed tomography.

[Paroxysmal non-hereditary angioedema]. / Paroxysmales nicht-hereditäres Angioödem.

Recurrent hypovolaemic shock had been occurring over the last five and four years, respectively, in a 53-year-old woman and a 46-year-old man who had previously been healthy. The attacks were characterized by a tension feeling and sometimes oedema in the limbs, as well as increased thirst. Within a few hours sweating, tachycardia, orthostatic complaints and shock would occur. The woman's systolic blood pressure would fall to 70 mm Hg and the pulse rate rise to 150/min. The man's blood pressure was not measurable by sphygmomanometer during his first attack. Haematocrit rose to 61 and 71.5%, haemoglobin concentration to 20.7 and 21.3 g/dl, respectively. On administration of plasma expanders all abnormal clinical and biochemical changes quickly disappeared, only to recur within weeks or months. The cause of the condition is an increased permeability of the tissue capillaries, while renal, pulmonary and cerebral vessels apparently are unaffected. During ketotifen and tebonin (gingko biloba extract) administration to the man, he required no further hospitalization for nine months, after which he had three severe attacks. The woman had a severe attack of hypovolaemic shock one month on this treatment. The prognosis of capillary leak syndrome is bad.

[Manifestation of rheumatic diseases of the lung. Roentgenologic changes]. / Manifestation rheumatischer Erkrankungen an der Lunge. Röntgenologische Veränderungen.

This paper first tries to relate the four types of immuno-pathologic reactions to certain basis-reactions of the lung. Subsequently, radiologic patterns will be correlated to these basis-reactions and will be further related to certain rheumatic diseases. It is shown that these basis-reactions cannot be clinically and radiologically distinguished from one another in all cases, and that in most cases there are combinations of several types of reaction to be found. The radiological patterns in the most important rheumatic diseases are demonstrated in an immunological arrangement. The possibilities of conventional radiological techniques and modern imaging techniques are described.

[Clinical study comparing the effectiveness and tolerance of 2 current and one new glibenclamide formulation]. / Klinische Studie zum Vergleich der Wirksamkeit und Verträglichkeit zwischen einer herkömmlichen und einer neuen Glibenclamidformulierung.

In a clinical study efficacy and tolerance of Neogluconin (2.5 mg) a new galenical form of glibenclamide were compared with a conventional preparation (Euglucon 5). Neogluconin showed an improved absorption and comparable blood sugar levels at a dosage reduced by 25%. 25 outpatients suffering from Type II diabetes in a well balanced metabolic state and previously under Euglucon therapy for at least one year were changed to the new product. After 2 months of Neogluconin therapy blood sugar profiles, HbA1, C-peptide and cholesterin levels were unchanged in comparison to values determined during the previous Euglucon treatment. This confirms that Neogluconin produces a comparable favorable blood glucose lowering effect despite a 25% reduction in dosage.

[X-ray morphology and pathologic anatomy of osteoblastoma]. / Zur Röntgenmorphologie und pathologischen Anatomie des Osteoblastoms.

Between 1974 and 1984, 24 patients with osteoblastomas were entered in the bone tumour registry of the Gerhard Domagk Institute of Pathology and Institute for Clinical Radiology of Westphalia. These cases are evaluated. Osteoblastoma is a benign primary bone tumour with a peak incidence between ten and 20 years and a sex ratio of 18 males to 4 females in our series. The site of predilection is the spine (59%) with long bones in second place (32%). The tumor is mostly situated in the medulla. Radiologically it usually appears as a well demarcated translucency with a narrow rim and marginal sclerosis. Variations in radiological appearance and the histology and treatment are described. A malignant variant, the "aggressive osteoblastoma", is discussed and one case is described. The classification of these cases is considered.

[CT diagnosis of soft tissue injuries in habitual shoulder dislocation]. / CT-Diagnostik von Weichteilverletzungen bei habitueller Schulterluxation.

Computed tomography can demonstrate most glenohumeral structures accurately. If the articular cavitz is filled with air, CT ist the method of choice in preoperative diagnosis to determine the capsular extension and to assess the destruction of the glenoid bone rim and glenoid labrum.

Megakaryoblastic micromegakaryocytic crisis in chronic myeloid leukemia.

Atypical megakaryoblasts (MKB) or megakaryocytes (MK) are occasionally present in the peripheral blood during the terminal development of chronic myeloid leukemia (CML). We report on a 49-year-old female suffering from Ph1 chromosome-positive CML with typical megakaryoblastic transformation in the peripheral blood and in the bone marrow. The small "blasts" were at the most only slightly larger and were occasionally even smaller than lymphocytes but showed megakaryoblastic or atypical megakaryocytic differentiation. The cytoplasmic cytochemical pattern of the atypical megakaryocytic cells was identical to that of large atypical thrombocytes. Platelet peroxidase was detected upon electron-microscopic (EM) examination. Immunologic characterization disclosed the presence of MK-specific antigens. When cultured in vitro on agar, the blasts transformed spontaneously into large mature MK, exhibiting characteristic cytochemical and immunological patterns. Cytogenetic examination of peripheral blood showed severe abnormalities. The patient did not respond to therapy and died 3 months after manifestation of the blast crisis.

[X-ray diagnostic concept of spondylodiscitis]. / Röntgendiagnostisches Konzept der Spondylodiscitis.

The destructive discovertebral lesions of ankylosing spondylitis are discussed. Their evaluation in the literature is compared with the newer histologic and radiologic results. The X-ray findings in rheumatoid arthritis are also presented. Using radiographs from 16 of our own patients suffering from ankylosing spondylitis and 5 with rheumatoid arthritis, we analyze the radiological appearances in question.

[Diagnostic possibilities of computer tomography in spinal and paraspinal space-occupying lesions]. / Diagnostische Möglichkeiten der Computertomographie bei spinalen und paraspinalen Raumforderungen.

Characteristic CT findings of intramedullary, intradural and epidural as well as of vertebragenic and paraspinal tumours are described, basing on literature and on the authors patient material. The value of CT is discussed and compared with that of other imaging modalities. Attention is also drawn to the value of i.v. application of contrast medium and of primary or secondary CT myelography.