Parotid abscess secondary to brucellosis in a patient with primary Sjögren's syndrome.

Swelling in the salivary glands, particularly parotid glands, is observed in approximately one third of Sjögren's syndrome patients. However, such patients should be assessed in terms of causes such as malignancies, infections, amyloidosis, sarcoidosis, and other autoimmune diseases when parotid gland swelling is noted. It should be considered that the incidence of lymphoma increases in Sjögren's syndrome. Unilateral parotid swelling, especially if accompanied by severe pain and redness, should be monitored for suppurative bacterial infections. Brucellosis is a systemic disease that may involve one or multiple organs. It can appear with different clinical manifestations and nonspecific symptoms. Although local abscess formations secondary to brucellosis in different organs have been reported, no evidence for parotid involvement has yet been reported. In this study, a case with primary Sjögren's syndrome and parotid abscess secondary to brucellosis is presented.

Utility of semiquantitative strain elastography for differentiation between benign and malignant solid renal masses.

OBJECTIVES: The aim of this study was to determine the role of semiquantitative strain elastography for differentiation of benign and malignant solid renal masses. METHODS: Seventy-one patients with solid renal masses were prospectively examined with ultrasound elastography after grayscale sonography. Strain elastography was used to compare the stiffness of the renal masses and renal parenchyma. The ratio of strain in a renal mass and nearby renal parenchyma was defined as the strain index value. Mean strain index values for benign masses (n = 29; 24 angiomyolipomas and 5 oncocytomas) and malignant masses (n = 42; 34 renal cell carcinomas, 4 transitional cell carcinomas, 3 metastases, and 1 lymphoma) and mean strain index values for angiomyolipomas and renal cell carcinomas were compared. RESULTS: There were no significant differences in the mean age of the patients, mean diameter of the masses, and mean probe-mass distance between benign and malignant groups. The mean strain index value ± SD for malignant masses (4.05 ± 2.17) was significantly higher than the value for benign masses (1.43 ± 0.94; P < .05). The mean strain index value for renal cell carcinomas (4.30 ± 2.27) was significantly higher than the value for angiomyolipomas (1.28 ± 1.01; P < .0001). CONCLUSIONS: Strain elastography may be a useful imaging technique for differentiation between benign and malignant solid renal masses.

Magnetic resonance imaging findings of musculoskeletal brucellosis.

OBJECTIVE: The aim of this retrospective study was to determine the magnetic resonance imaging (MRI) findings of patients with musculoskeletal brucellosis. MATERIALS AND METHODS: Sixty-eight among 304 patients with musculoskeletal brucellosis, aged 12-82 years (average, 50.2 years), were included in the study. Patients were diagnosed based on clinical findings, Brucella agglutination tests, and MRI findings. MRI was performed to all of the patients with sacroiliitis, spondylitis-spondylodiscitis, and peripheral arthritis. RESULTS: Brucella serum agglutination test was >1/160 in all cases and blood cultures were positive in twelve cases. The most commonly affected site was the spine (57.3%), wherein lumbar vertebrae were found to be most commonly affected. The second most common affected site was sacroiliac joint (26.4%), whereas peripheral joints were affected in 11 cases (16.1%). CONCLUSION: Brucellosis may affect various sites in musculoskeletal system. The spine was the most frequently affected site in our study. Sacroiliac joints and the other peripheral joints were less commonly involved sites. Brucellosis should be included in the differential diagnosis of a patient with arthralgia or symptoms of musculoskeletal system disorders especially in endemic areas.

The role of diffusion weighted magnetic resonance imaging in oncologic settings.

There is growing interest in the applications of diffusion-weighted-imaging (DWI) in oncologic area for last ten years. DWI has important advantages as do not require contrast medium, very quick technique and it provides qualitative and quantitative information that can be helpful for tumor assessment. In this article, we present oncologic applications of DWI in the parts of the body. DWI has been applied to the evaluation of central nervous system (CNS) pathologies. Some technologic advances lead to using of DWI in the extracranial sites such as abdomen and pelvis. As well as tumor detection and characterization, DWI has been widely used for predicting and monitoring response to therapy. One of the most prominent contributions of DWI is differentiation of between malignant and benign tumoral process. Apparent-diffusion-coefficient (ADC) value is quantitative parameter of DWI which reflects diffusion movements of water molecules in various tissues. Most of the studies suggested that malignant tumors had lower ADC values than benign ones. DWI may be a routine sequence in oncologic settings and it provides much useful information about tumoral tissue. We think it can be added to conventional magnetic resonance imaging (MRI) sequences.

Low back pain in patients with rheumatoid arthritis: clinical characteristics and impact of low back pain on functional ability and health related quality of life.

OBJECTIVES: The aim of this study was to assess the point prevalence of low back pain (LBP) in patients with rheumatoid arthritis (RA); and to compare radiological and clinical aspects, as well as impact of LBP on health related quality of life (QoL), depression and disability in control patients with mechanical LBP (mLBP). METHODS: Patients with RA and patients with mLBP of at least 3 months duration were consecutively recruited. All patients were examined and underwent lumbar X-ray and magnetic resonance (MR) imaging. Disc intensity, annulus fibrosis rupture, herniated nucleus pulposus (bulging, protrusion, extrusion or sequestration), stenosis, Schmorl nodes, hemangiomas, Tarlov cysts, Type I or II degeneration, ligamentum flavum hypertrophy and loss of lordosis were assessed on MR. Assessments included QoL and disability scales like RAQoL, Short Form-36, Health Assessment Questionnaire (HAQ) and Oswestry Disability Index (ODI) and depression and anxiety scales as well. RESULTS: Chronic LBP coexisted in 64.5% of patients with RA. Patients with LBP had higher scores on VAS-LBP compared to patients with RA+LBP. Additionally, patients with RA+LBP had the poorest scores on quality of life, functional disability and depression. Patients with mLBP had more frequent clinical manifestations and neurologic deficits. Patients with RA+LBP had more frequent Schmorl nodes compared to patients with mLBP. CONCLUSION: The association of RA with LBP leads to a significant decrease in the functional capacity and QoL as well as increase in depression risk. Appropriate diagnostic procedures and treatments should be administered to avoid further deterioration in functional disability and QoL.

Semiquantitative strain elastography of liver masses.

OBJECTIVES: This study was designed to determine the utility of semiquantitative strain elastography in differential diagnosis of solid liver masses. METHODS: A total of 103 patients with focal liver masses underwent abdominal sonographic examinations and freehand elastography of focal hepatic lesions. Eighty-two patients (79.7%) with 93 focal hepatic lesions were included in the study. Twenty-one patients (20.3%) were excluded from the study because of technical limitations of semi-quantitative strain elastography and difficulty in detection of normal liver parenchyma on gray-scale sonography. We evaluated different focal hepatic lesions such as hemangiomas, focal nodular hyperplasia, nodular regenerative hyperplasia, adenomas, hepatocellular carcinomas, metastases, and cholangiocarcinomas. The stiffness of the lesions was determined by measurement of strain values on semiquantitative strain elastography. The strain index value (strain ratio of liver parenchyma and focal lesions) of each lesion was calculated. Mean strain index values of benign and malignant liver lesions were compared. RESULTS: The mean strain index value of malignant liver lesions ± SD (2.82 ± 1.82) was significantly higher than that of benign liver lesions (1.45 ± 1.28; P< .0001). Hemangiomas had a significantly lower mean strain index value than other benign lesions (P < .0034). There was no statistically significant difference between strain index values of different types of malignant lesions (P > .05). CONCLUSIONS: Semiquantitative strain elastography may be helpful for differentiating benign and malignant liver masses. The substantial overlap between strain index values of benign and malignant liver masses limits clinical usefulness of this technique.

Paraplegia in pregnancy: a case of spinal vascular malformation with Klippel-Trenaunay syndrome.

STUDY DESIGN: A case report. OBJECTIVE: To present improvement of paraplegia due to spinal vascular malformation after delivery with no intervention. SUMMARY OF BACKGROUND DATA: Pregnancy has been reported rarely in patients with Klippel-Trenaunay syndrome (KTS). A combined case of spinal arteriovenous malformations (AVMs) within KTS has not been reported before. METHODS: A case report of KTS with paraplegia is presented and the pertinent literature is then reviewed. RESULTS: A pregnant woman who was diagnosed with KTS in childhood presented with newly developed paraplegia due to spinal AVMs. Magnetic resonance image showed a vascular malformation at the T9-T12 levels without evidence of spinal cord hemorrhage. Diagnostic angiography that was performed after delivery revealed a high-flow arteriovenous fistula with AVM. CONCLUSION: Pregnancy complicated by paraplegia is thought to be secondary to venous engorgement and to the resulting spinal cord ischemia in this case. Her neurological symptoms and signs gradually improved over the few days after cesarean delivery.

Idiopathic postpartum intussusception: a rare cause of acute abdominal pain.

OBJECTIVES: To present a case with acute abdominal pain due to idiopathic intestinal intussusception diagnosed by ultrasound and computed tomography (CT) during the early postpartum period. CLINICAL PRESENTATION AND INTERVENTION: A 21-year-old female patient was admitted to our hospital with abdominal pain, nausea and emesis after a normal vaginal delivery. Laboratory tests done at admission were within normal limits except for leukocytosis. Physical examination revealed abdominal distention, guarding and rebound tenderness. Abdominal ultrasound and oral contrast-enhanced CT showed a complex mass in the hypogastrium, with a typical configuration of intussusception. Emergent laparotomy revealed ileoileal invagination approximately 70 cm to the ileocecal valve but no lead point. A partial ileal resection was performed. CONCLUSION: This case shows that when intussusception is suspected, an abdominal ultrasound should be performed even in patients with atypical symptoms. CT may be used to confirm the diagnosis.

Evaluation of liver hemangiomas using three different b values on diffusion MR.

PURPOSE: To determine which diffusion-weighted MR technique (i.e., b-100, b-600, b-1000 s/mm(2)) is most useful in depicting liver hemangiomas. We also aimed to assess the effect of lesion size on apparent diffusion coefficient (ADC) values. MATERIALS AND METHODS: Diffusion-weighed MR (DWMR) was performed for 61 hemangiomas in 32 patients. DWMR images were obtained before contrast administration using three different b values of 100, 600, and 1000 s/mm(2). ADCs were measured for each lesions and compared with normal liver parenchymal ADCs on different b values. Hemangiomas were subdivided according to lesion size (less than 3 cm and 3 cm or greater). Data were analyzed using SPSS software by analysis of variances (ANOVA) and post hoc values were tested using HSD Tukey test. RESULTS: There was no significant relation between lesion size and ADC values on different b values. Lower ADC values were obtained for higher b values in normal liver tissue and hemangiomas. Although there is significant difference between normal liver tissue and hemangiomas; this is more apparent on b-1000 images (p=0.022 on b-100, p=0.003 on b-600, and p=0.000 on b-1000 images). Variance analysis revealed hemangiomas had higher ADC values than normal liver tissue on b-1000 images. CONCLUSION: Mean values for ADCs of hemangiomas were lower than ADCs of the normal liver except for b-1000 value. Higher b values are useful for the differentiation between normal liver tissue and hemangiomas. Lesion size does not affect ADC measurement on different b values.

Hepatic and portal venous Doppler waveforms and flow velocities in normal pregnancy.

BACKGROUND: Although the flow velocities of portal veins (PV) and flow patterns of hepatic veins (HV) during pregnancy were evaluated in the literature, changes in PV flow pattern during pregnancy have not been assessed. The aim of this study was to detect changes in HV and PV flow velocities and patterns during pregnancy. MATERIAL/METHODS: One hundred sixty-three healthy pregnant women aged 17-42 years-old (mean: 26.9+/-5.1) were included in the study. Twenty-seven were in the first trimester (group 1), 89 in the second trimester (group 2), and 47 in the third trimester (group 3). Maximum and minimum flow velocities and waveforms were obtained from the hepatic vein (HV) and the main portal vein (PV) of the subjects. The flow patterns were recorded as monophasic, biphasic, and triphasic waveforms. RESULTS: Maximum flow velocity of PV was higher in group 1 than in groups 2 and 3 (p<0.05). Although some subjects had a monophasic flow pattern of the PV, a biphasic flow pattern was prominent in all groups. A triphasic PV waveform was not observed in any of the groups. In the HV the triphasic waveform was prominent in the first trimester and biphasic in the second and third trimesters. CONCLUSIONS: When evaluating physiological changes in pregnancy, flow pattern changes of the HV and flow velocity changes of the PV may be accepted as sensitive parameters and may be indicators of physiological alterations related to pregnancy.

Diffusion-weighted MR imaging of thyroid nodules.

INTRODUCTION: The purpose of our study was to determine the diagnostic role of diffusion-weighted imaging (DWI) in the differentiating of malignant and benign thyroid nodules by using fine needle aspiration biopsy cytology criteria as a reference standard. The apparent diffusion coefficient (ADC) values of the normal-looking thyroid parenchyma were also evaluated both in normal patients and in patients with nodules. METHODS: Between March 2007 and February 2008, 76 consecutive patients with ultrasound-diagnosed thyroid nodules and 20 healthy subjects underwent diffusion-weighted MR imaging by using single-shot spin echo, echo planar imaging. A total of 93 nodules were included in the study using the following b factors 100, 200, and 300 mm(2)/s. ADC values of thyroid nodules and normal area in all subjects were calculated and compared using suitable statistical analysis. RESULTS: Mean ADC values for malignant and benign nodules were 0.96+/-0.65 x 10(-3) and 3.06+/-0.71 x 10(-3)mm(2)/s for b-100 factor, 0.56+/-0.43 x 10(-3) and 1.80+/-0.60 x 10(-3)mm(2)/s for b-200, and 0.30+/-0.20 x 10(-3) and 1.15+/-0.43 x 10(-3)mm(2)/s, for b-300, respectively. Mean ADC values of malignant nodules were lower than benign nodules. There were significant differences in ADC values between benign and malignant nodules. ADC values among normal-appearing thyroid parenchyma of patients and normal-appearing thyroid parenchyma of healthy subjects were insignificant at all b factors. CONCLUSION: Benign nodules have higher ADC values than malignant ones. DWI may be helpful in differentiating malign and benign thyroid nodules.

Diffusion-weighted MR imaging findings of kidneys in patients with early phase of obstruction.

BACKGROUND: Diffusion-weighted (DW) magnetic resonance (MR) imaging is an MR technique used to show molecular diffusion. The apparent diffusion coefficient (ADC), as a quantitative parameter calculated from the DW MR images. The purpose of this study is to evaluate the ability of DW MR imaging in early phase of obstruction due to urolithiasis. MATERIALS AND METHODS: Twenty-six patients with acute dilatation of the pelvicalyceal system detected by intravenous urography were included in this study. MR imaging was performed using a 1.5 T whole-body superconducting MR scanner. DW imaging can be performed using single-shot spin-echo, echo-planar imaging (EPI) sequences with the following diffusion gradient b values: 100, 600, 1000 s/mm(2). Circular region of interest (ROI) was placed in the renal parenchyma for the measurement of ADC values in the normal and obstructed kidney. For statistical analyses, Paired t test were used. RESULTS: In spite of obstructed kidneys had the lower ADC values compared to normal kidneys, these alterations were statistically insignificant. CONCLUSION: We did not observe significantly different ADC values of early phase of obstructed kidneys compared to normal kidneys.

Age-related metabolic changes in the corpus callosum: assessment with MR spectroscopy.

PURPOSE: The aim of this study was to examine metabolite changes in different parts of the corpus callosum (CC), and to relate these changes to different age groups using magnetic resonance spectroscopy (MRS). MATERIALS AND METHODS: A total of 76 healthy subjects participated in the study with MRS analyses (39 females and 37 males). Subjects were grouped by age into four groups, in increasing order: Groups 1, 2, 3, and 4. Single-section 2D multivoxel spectroscopy was performed using chemical-shift imaging techniques. The voxels were placed on the rostrum, genu, corpus, and splenium of the CC. Peak metabolite ratios of N-acetylaspartate (NAA)/choline (Cho), NAA/creatine (Cr), and Cho/Cr were calculated from the rostrum, genu, body, and splenium. One way analysis of variance test was performed for the detection of changes in different age groups. Pearson correlation test was performed for correlation of metabolite ratio related to age. RESULTS: Statistically significant differences were found for NAA/Cho ratios for the rostrum, corpus, and splenium, and NAA/Cr ratios for the corpus and splenium between Groups 1 and 2, Groups 1 and 3, and Groups 1 and 4. Metabolite ratios of the corpus and splenium were similar. This similarity was also valid for parts of the rostrum and genu. CONCLUSION: Metabolite ratios in the CC are influenced by age. Age-related changes and regional metabolite levels may cause these alterations. Analyses of the CC may be informative for the evaluation of white matter. MRS may help to demonstrate metabolite levels and ratios of the CC.

Evaluation of the effects of sildenafil citrate (viagra) on vertebral artery blood flow in patients with vertebro-basilar insufficiency.

OBJECTIVE: To investigate the effects of sildenafil citrate (Viagra) on the vertebral artery blood flow of patients with vertebro-basilar insufficiency (VBI) using color duplex sonography (CDS). MATERIALS AND METHODS: The study included 21 patients with VBI (aged 31-76; mean 61.0 +/- 10.5 yrs). We administered a 50 mg oral dose of sildenafil citrate to all patients. Next, we measured the peak systolic velocity (Vmax), end diastolic velocity (Vmin), resistive index (RI), pulsatility index (PI), diameter, area, and flow volume (FV) of vertebral arteries using CDS before the administration of sildenafil citrate; 45 minutes after, and 75 minutes after administration. Statistical testing was performed using SPSS for windows version 11.0. The statistical test used to determine the outcome of the analysis was the repeated measures analysis of variance (ANOVA) test. RESULTS: Compared to the baseline values, the vertebral artery diameter, area, and FV increased significantly following the administration of sildenafil citrate. The diameter, area and FV increased from 3.39 mm at 45 minutes to 3.64 mm at 75 minutes, 9.43 cm(2) to 10.80 cm(2) at 45 minutes and 10.81 cm(2) at 75 minutes, as well as from 0.07 L/min at baseline to 0.09 L/min at 45 minutes and unchanged at 75 minutes, respectively. CONCLUSION: Sildenafil citrate elicited a significant effect on vertebral artery diameter, area and FVs.

Role of diffusion-weighted MRI in the detection of early active sacroiliitis.

OBJECTIVE: This study proposed to evaluate the value of diffusion-weighted MRI (DWI) to detect active inflammatory changes in the sacroiliac joints of patients with early axial spondyloarthritis (also spelled spondylarthritis). SUBJECTS AND METHODS: Forty-two patients with chronic low back pain underwent clinical and MRI evaluation for axial spondyloarthritis or early ankylosing spondylitis. STIR, contrast-enhanced T1-weighted, fat-saturated T2-weighted, and diffusion-weighted (b values: 100, 600, 1,000 s/mm(2)) images were obtained. The presence of subchondral bone marrow edema, subchondral fatty marrow infiltration, or contrast enhancement in the sacroiliac joints or adjacent enthesitis sites was considered a marker for active inflammatory changes. All MRI sequences were evaluated for the presence of acute inflammatory changes and inter- and intrarater reliability of the sequences. Mean apparent diffusion coefficient (ADC) values of diffusion-weighted images were calculated from normal and involved iliac and sacral bones of sacroiliac joints. RESULTS: ADC values measured from the lesions at b values of 1,000 and 600 s/mm(2) in patients with sacroiliitis (n = 13) were significantly higher than values measured from iliac and sacral bones in patients with low back pain of mechanical origin (n = 29). DWI showed sensitivity for detecting acute lesions in early sacroiliitis similar to that of T1-weighted gadolinium images (area under the curve, 0.843-0.971). Intra- and interrater reliability of DWI was acceptable. CONCLUSION: DWI is a sensitive, fast sequence and does not require a contrast agent, which makes it a good and cost-effective alternative for imaging sacroiliac joints. DWI also offers the possibility of quantifying diffusion coefficients of the lesions, which helps to discriminate between normal and involved subchondral bone.

Polyorchidism with lobulation and septa in supernumerary testis.

Polyorchidism is a rare anomaly of the genitourinary system which is defined as the presence of more than two testes within the scrotum. Lobulation of a testis is also a rare anomaly. To the best of our knowledge, this is the first report of polyorchidism with lobulation of a supernumerary testis. We present ultrasonography findings of lobulation of a supernumerary testis in a 38-year-old man.

The value of sacroiliac pain provocation tests in early active sacroiliitis.

Detection of preradiographic sacroiliitis is important for early diagnosis of ankylosing spondylitis (AS) and related spondyloarthropathies. Magnetic resonance imaging (MRI) is a valuable tool for the diagnosis of sacroiliitis in the early and active stages. The aim of this study is to assess the value of pain provocation tests in detecting early active sacroiliitis. Chronic low-back pain (LBP) patients were recruited and examined by blinded assessors for pain provocation tests: compression, distraction, Gaenslen, Mennel, Patrick, thigh thrust and sacral thrust tests. Patients underwent lumbar and sacroiliac MRI. The percentage of agreement for each pain provocation tests was between 72-95%, and the inter-rater reliability was from moderate to good (kappa, 0.43-0.87). Kappa values ranged from 0.43 to 0.60 with an agreement of 80-95% for clusters of pain provocation tests. As separately evaluated, pain provocation tests did not have favorable accuracy. When evaluated in clusters (out of three and five provocation tests) four positive over five tests on the left side reached an area under the curve 0.693 (95% CI 0.489-0.897), and two positive over three tests reached an AUC 0.697 (95% CI 0.484-0.910). Sacroiliac pain provocation tests had acceptable reliability in early active sacroiliitis; however, the discriminating capacity of these tests is poor. A multi-test regimen of three or five sacroiliac pain provocation tests may improve the accuracy of these tests discriminating sacroiliitis from LBP of mechanical origin. Four out of five selected tests or any of the two out of three selected tests have the highest predictive value.

Clinical evaluation and power Doppler sonography in rheumatoid arthritis: evidence for ongoing synovial inflammation in clinical remission.

OBJECTIVE: This study proposed to assess the relationship between power Doppler ultrasound examination and spectral Doppler analysis of hand joints with clinical and laboratory parameters in rheumatoid arthritis. METHODS: Patients receiving disease-modifying antirheumatic drugs or biologics (infliximab) underwent joint examination and were assessed by a Health Assessment Questionnaire, Duruoz's Hand Index, and Hand Function Test. All were categorized for disease activity using the American College of Rheumatology and disease activity score 28-joint (DAS28) criteria. Ten metacarpophalangeal joints and 4 wrist joints (ulnar-carpal and radiocarpal joints) in each patient were examined by power Doppler and spectral Doppler. Flow signal in the synovium was semiquantitatively graded. A cumulative flow signal score (CFS) and mean resistive index (RI) was calculated in each patient. RESULTS: Patients with active disease had significantly higher CFS compared with patients with inactive disease, but the mean RI was similar. Health Assessment Questionnaire, Duruoz's Hand Index, Larsen, and DAS28 scores correlated significantly with CFS, but the erythrocyte sedimentation rate and C-reactive protein scores did not. Mean RI did not correlate with clinical or laboratory parameters. A majority of patients who were in clinical remission according to American College of Rheumatology or DAS28 criteria had ongoing synovial inflammation on power Doppler ultrasound (58% and 62%, respectively). CONCLUSION: Power Doppler examination of rheumatoid hand joints is a practical method to estimate synovial inflammation. A modification of current remission criteria by combining imaging techniques with clinical and laboratory examination may be conceivable. These results underscore the necessity of more sophisticated research, assessing the agreement between long-term Doppler changes and clinical parameters.

Clinical and MRI findings of brucellar spondylodiscitis.

OBJECTIVE: The aim of this retrospective study was to report the clinical features and MR imaging findings of patients with brucellar spondylodiscitis. MATERIALS AND METHODS: Twenty-two patients with spondylodiscitis, recruited among 152 patients with brucellosis referred from the Department of Infectious Diseases. Patients were diagnosed based on positive clinical findings, > or =1/160 titers of brucella agglutination tests and/or positive blood cultures. Magnetic resonance imaging (MRI) was performed to all of the patients with spondylodiscitis. Signal changes and enhancement of vertebral bodies, involvement of paravertebral soft tissues and epidural spaces, nerve root and cord compression and abscess formation were assessed. RESULTS: All of the patients (n=22; 7 F, 15 M) had > or =1/160 titers of brucella agglutination test and blood culture was positive in 9. A great majority of the patients had involvement at only one vertebrae level (n=21, 95.5%), whereas one patient (4.5%) had multilevel involvement. In MRI, eight patients had soft tissue involvement and three had abscess formation. All cases had vertebral and discal enhancement. Additionally epidural extension was detected in four cases, posterior longitudinal ligament (PLL) elevation in five cases and root compression in two cases. CONCLUSION: Brucella is still a public health problem in endemic areas. MRI is a highly sensitive and non-invasive imaging technique which should be first choice of imaging in the early diagnosis of spondylodiscitis.