Ultrasound imaging in crystal arthropathies: a pictorial review.

OBJECTIVE: The prevalence of crystal arthropathies in the general population is rising. The purpose of this pictorial study is to describe the sonographic elements of the most prevalent crystal arthropathies by emphasizing particular sonographic findings using illustrative images and cases while considering technical details and common pitfalls. METHODS: Using established recommendations, specialists in the fields of sonography and crystal arthropathies agreed by consensus on the unique ultrasound signs associated with each of the conditions. RESULTS: Gout, calcium pyrophosphate deposition arthropathy, and hydroxyapatite arthropathy are the three most prevalent crystal arthropathies. Today's high-resolution sonography enables reliable evaluation of the underlying crystal deposits, post-inflammatory changes, and a precise description of joint inflammation. CONCLUSIONS: High-prevalence crystal arthropathies are reliably detectable by ultrasound with current ultrasound equipment. It is necessary to have extensive ultrasound training, know specific sonographic findings, and understand all possible differential diagnoses for disorders affecting the musculoskeletal system.

[Rare cause of acute neck pain]. / Eine seltene Ursache akuter Nackenschmerzen.

The acute calcific tendinitis of the longus colli muscle is a rare inflammatory process of the prevertebral muscles. The clinical picture includes acute neck pain, limited range of motion of the cervical spine with stiffness and odynophagia. The laboratory findings demonstrate inflammatory signs. The incidence of the disease peaks between the third and sixth decade. The knowledge of the characteristic radiologic findings and the self-limiting course prevents the patient from needless medical and surgical interventions.

[Musculoskeletal ultrasound I - «pearls and crystals¼]. / Ultraschall am Bewegungsapparat I - «Perlen und Kristalle¼

This article reviews the applications of high resolution ultrasound (HRUS) which were discussed at the SGUM congress in Davos in the talk «pearls and crystals¼. Sonography is an excellent and validated tool in the diagnostics and assessment e.g. of spondylo-arthritis and crystal deposition diseases. Enthesitis is a typical feature of SpA. The Sensitivity of HRUS diagnosing enthesitis is higher compared to the clinical examination. High frequency US probes allow furthermore an accurate assessment in crystal deposition diseases. Sonography is able to detect various typical pathologies in gout, pseudogout and apatite deposition disease. Will HRUS in the near future be able to replace microscopy in the diagnostics of crystal deposition diseases?

[Musculoskeletal ultrasound II - «why are bats better than physicians¼]. / Ultraschall am Bewegungsapparat II oder - wieso Fledermäuse Besser sind als Ärzte.

This article reviews the aspects which were discussed at the SGUM congress in Davos in the talk «why are bats better than physicians¼. The talk focussed on modern aspects of Ultrasound (US) diagnostics at the locomotor system. High frequency US probes allow accurate diagnosis, initial assessment and follow up in Rheumatoid Arthritis and Osteo-Arthritis. Basic pathologic features in these pathologic conditions in form of synovitis, erosion and cartilage damage are described. In case of entrapment neuropathies - first of all in carpal tunnel syndrome - pathognomonic sonomorphologic changes can be detected and allow to confirm a clinical suspicion. The correct indication for diagnostic or therapeutic interventions at the musculoskeletal system can be critically verified and if necessary revised. The guidance of the intervention by US guarantees high accuracy of needle placement and thereby increases the diagnostic yield and the therapeutic success of injections/infiltrations.

[The rheumatic hand - diagnostics in practice]. / Die rheumatische Hand - Diagnostik in der Praxis.

Many rheumatic diseases show changes and are visible in the hands. The pattern of distribution in the relevant joints, soft-tissue changes, skin manifestations, neurological and vascular symptoms and clinical findings provide fundamental information. Imaging and lab results provide diagnostic support. In this review, common diseases are presented in terms of their clinical expressions in the hands: osteoarthritis, rheumatoid arthritis, gout, calcium pyrophosphate dihydrate deposition disease, psoriatic arthritis, reactive arthritis, systemic sclerosis, dermatomyositis/polymyositis and systemic lupus erythematosus. Furthermore, we discuss pathological findings of the hands as a result of diabetic cheiroarthropathia, endocarditis, secondary hypertrophic osteo-arthropathy and chronic regional pain syndrom.

[Recurrent Baker's cyst]. / Rezidivierende symptomatische Bakerzyste.

A 50-year old female patient with unilateral knee pain demonstrated a recurrent ultrasound-proven popliteal cyst (Baker's cyst). Even though a proper differential diagnosis was done, the MRT of the knee showed in a secondary step a tibial fissure as the cause of the treatment-refractory knee pain and Baker's cyst. A fracture of the tibia is a rare cause for a symptomatic Baker's cysts. Mechanical, degenerative or inflamed diseases of the joint are more frequent associated with a Baker's cyst.

[Web-based learning in musculoskeletal ultrasound]. / Webbasiertes Lernen in der Sonographie des Bewegungsapparates.

Education and training in musculoskeletal ultrasound (MSUS) comprises attendance at theoretical and practical courses and independent study. Web-based learning as a novel teaching method has previously been described. The present study summarizes normal and pathological findings in a web-based approach using widely accepted guidelines. In a prospective study over a period of 3 years normal and pathological images of the musculoskeletal system have been documented and catalogued. Overall 1240 ultrasound images and 183 ultrasound videos were collected. A total of 14.4% were normal and 85.6% were pathological MSUS findings; 61% concerned the upper extremity, while 39% were images and videos of the lower limbs. The most captured conditions included synovitis (33.3%), pathologies of the tendons e.g., tenosynovitis or tendinosis (19.6%) and normal findings (14.4%). The most represented diseases were rheumatoid arthritis (20%), calcium deposition disease (8.2%), gout (7.1%) and osteoarthritis (6.9%). The images and videos were edited and integrated in a web-based tool.

[Ultrasound and arthritis]. / Ultraschall und Arthritis.

Musculoskeletal ultrasonography (US) is an established and validated imaging technique in rheumatology. Ultrasonography is able to directly visualize soft tissue pathologies such as synovial tissue changes. Pathological findings in superficial cartilage, bone lesions and synovial tissue changes in the context of rheumatoid arthritis, spondyloarthritis or crystal arthropathies may only be seen by sonography or detected earlier by ultrasonography compared to conventional imaging techniques. The activity of an inflammatory arthropathy can be visualized using Doppler and power Doppler US. US is helpful in the detection of early inflammatory changes, particularly in patients with undifferentiated arthritis and/or unremarkable conventional radiography. In addition to diagnosis in early arthritis and monitoring of therapy in rheumatoid arthritis, sonography is able to detect pivotal pathologies in spondyloarthritis and crystal deposition diseases such as gout, pseudogout and apatite deposition disease. Ultrasound-guided diagnostic and therapeutic interventions are characterized by their excellent accuracy and improvement of clinical effectiveness compared to unguided procedures. In conclusion, ultrasonography plays a pivotal role in the assessment and monitoring of therapy in rheumatic diseases.

[Update in pulmonary hypertension associated with connective tissue diseases - a systematic literature review]. / Neues zur pulmonalen Hypertonie bei Kollagenosen - eine systematische Literaturübersicht.

Pulmonary hypertension (PH) is a common complication of connective tissue disease. While there are no reliable epidemiological data, the prevalence of systemic sclerosis (SSc) has been estimated as being 8-12%. Mixed connective tissue disease (MCTD) and systemic lupus erythematodes (SLE) are thought to have a lower prevalence. PH associated with SSc has a poor prognosis, a two-year survival rate of approximately 50%, if untreated. Systematic literature search for studies of PH and CTD between 02/2007 and 02/2008 found 38 articles, a selection of which is reviewed here. One epidemiological study showed that nowadays PH is together with interstitial pulmonary fibrosis the most common cause of death in patients with SSc. Before the introduction of angiotensin- converting enzyme inhibitors the most frequent cause of death was acute renal crisis. Investigations of the pathogenesis of PH in CTD revealed that in patients with a severe, treatment-resistant course there is frequent histological evidence of pulmonary veno-occlusive disease. A prospective study on diagnosis revealed that transthoracic echocardiography (TTE) is better than magnetic resonance imaging or pulmonary function tests especially in screening for PH in patients with SSc, because of its high specificity and good predictive value at higher pulmonary pressures. But because of the low sensitivity of TTE right heart catheterization is the gold standard for verifying PH also in patients with SSc. A therapeutic uncontrolled trial indicated that treatment with bosentan combined with sildenafil results in clinical stabilization, but patients with idiopathic PHT responded better.

[Myositis with pulmonary fibrosis and eosinophilia]. / Myositis mit Lungenfibrose und Eosinophilie.

A 74-year old female patient suffered from dyspnoea, subfebrile body temperature, myalgias, arthralgias and presented a transitory skin rash. Further findings were an eosinophilia, synovitis, a myositis and pulmonary fibrosis. There was no evidence for a malignancy or an infectious disease. We diagnosed an Anti-Jo-1-Syndrome with a secondary Sjoegren syndrome. Immunsuppressive therapy with steroids, later in addition methotrexate led to improvement of the patient's clinical condition. Above mentioned symptoms and its differential diagnosis are discussed in this article.