[Transient regional osteoporosis]. / Le osteoporosi transitorie regionali.

Transient osteoporosis of the hip and regional migratory osteoporosis are uncommon and probably underdiagnosed bone diseases characterized by pain and functional limitation mainly affecting weight-bearing joints of the lower limbs. These conditions are usually self-limiting and symptoms tend to abate within a few months without sequelae. Routine laboratory investigations are unremarkable. Middle aged men and women during the last months of pregnancy or in the immediate post-partum period are principally affected. Osteopenia with preservation of articular space and transitory edema of the bone marrow provided by magnetic resonance imaging are common to these two conditions, so they are also known by the term regional transitory osteoporosis. The appearance of bone marrow edema is not specific to regional transitory osteoporosis but can be observed in several diseases, i.e. trauma, reflex sympathetic dystrophy, avascular osteonecrosis, infections, tumors from which it must be differentiated. The etiology of this condition is unknown. Pathogenesis is still debated in particular the relationship with reflex sympathetic dystrophy, with which regional transitory osteoporosis is often identified. The purpose of the present review is to remark on the relationship between transient osteoporosis of the hip and regional migratory osteoporosis with particular attention to the bone marrow edema pattern and relative differential diagnosis.

Rheumatoid arthritis: sequences.

OBJECTIVE: Rheumatoid arthritis (RA) is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis and sometimes multisystem involvement. It affects 1% of the adult population and exhibits a chronic fluctuating course which may result in progressive joint destruction, deformity, disability and premature death. We review the literature data relative to the peculiar pathologic features of the disease shown by diagnostic imaging techniques. METHODS: All our patients were classified according to the diagnostic criteria of the American Rheumatism Association (1987). Plain radiography remains the diagnostic technique of choice, but ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are also used. RESULTS: Clinically articular involvement presents as pain, swelling, stiffness and motion impairment. The patients with positive rheumatoid factor are > 70% likely to develop joint damage or erosions within 2 years of disease onset. Any joint can be involved, but the proximal interphalangeal and metacarpophalangeal joints of the hand and the wrist are preferential sites, as well as the metatarsophalangeal joint of the foot, the knee and the joints of the shoulder, the ankle and the hip. Symmetry is the hallmark of joint involvement. The synovium of bursae and tendon sheaths is also affected. Soft tissue (subcutaneous nodules), muscles (weakness and atrophy) and vessels (vasculitis) may also be involved. Systemic involvement may result in Felty's syndrome, metabolic bone disorders (i.e. osteoporosis), Sjögren syndrome and pleuropulmonary abnormalities (pleural effusion, fibrosing alveolitis, constrictive bronchiolitis). The earliest abnormalities consist in synovial proliferation, soft tissue swelling, and osteoporosis. At a slightly later stage, the inflamed synovial tissue ('pannus') extends across the cartilage surface, leading to chondral erosions and small bone erosions at the joint margin (bare areas). Marginal and central erosions follow in advanced stages and finally fibrous ankylosis, joint deformities (subluxations and dislocations), fractures and fragmentations are typical findings of more advanced RA. CONCLUSION: RA is a frequent joint disorder with a characteristic radiographic picture. Joint involvement patterns are sufficiently common to permit accurate diagnosis, especially when fusiform soft tissue swelling, regional osteoporosis, marginal and central erosions and diffuse loss of interosseous space are present. Conventional radiography remains the standard imaging technique for joint studies in the patients with suspected RA. US is recommended to diagnose soft tissue involvement (joint effusion). CT is very useful for showing abnormal processes in complex joints (sacroiliac and temporomandibular joints and craniocervical junction) which are difficult to depict completely with conventional radiography. Magnetic resonance applications include the assessment of disease activity: in particular, this technique may be the only tool differentiating synovial fluid and inflammatory pannus.

Platyspondyly in treated beta-thalassemia.

Flattening of the vertebral bodies with a platyspondyly appearance is described in 14 patients selected for evaluation of short stature from 106 patients affected by thalassemia major, who received an intensive transfusion regimen combined with continuous chelation therapy. The vertebral body height/width ratio was decreased at the level of all the investigated tracts, namely, cervical and/or dorsal and/or lumbar. The flattening of the vertebral bodies may be due to suppression of intramedullary hematopoiesis by a high transfusion regimen. The reduced intravertebral pressure due to disturbed hemopoiesis could cause weight-bearing and other biological stresses to provoke a reduction in vertebral body height.

Colon involvement in systemic sclerosis: clinical-radiological correlations.

About one third of all patients with systemic sclerosis (SS) presents colon abnormalities, although these may be underestimated because they frequently remain asymptomatic for a long time. Thirty-five patients (33 women and 2 men; mean age 56.5 years; mean disease duration 11.9 years) affected by SS (25 with limited and 10 with diffuse pattern of skin involvement) were investigated using barium enema to detect radiological changes in the colon, and to correlate them with other visceral involvement, autoantibody profile, abdominal symptoms and duration of the disease. Ten patients (28.6%) showed X-rays abnormalities (excluding isolated diverticula), wide-mouthed sacculations being the most frequent finding. Our data confirm that the colon is frequently involved in SS, even in the limited form of the disease. The most relevant finding was the dissociation between clinical symptoms and radiological features which proved to be more evident among the patients with limited SS. No correlations were found between the radiological picture and any other parameter, thus suggesting that careful evaluation of the colon should be performed in any patient suffering from the disease.

Radiological features of dialysis amyloid spondyloarthropathy.

Nine patients undergoing regular dialytic treatment (RDT) for more than 60 months (mean 125 +/- 33 months) showed clinical and radiological evidence of non-infective destructive spondyloarthropathy (DSA). The cervical spine was the skeletal segment most affected (100% of cases). Three patients were found also to be suffering from discal and bone alterations of the dorsal column, and in two other patients the vertebral bodies L4-L5 were changed. Typical radiological pictures showed a narrowing of intervertebral spaces with the destruction or sclerosis of adjacent subchondral bones, erosions of vertebral body plates and cavitations. CT studies of the altered spines confirmed discal lesions and osteolytic areas with bone condensation at each level. Ligamentous lesions resulting in severe disorders of spinal statics were discovered during autopsy of three patients. Histological study of disc and peridiscal ligaments indicated the presence of large amyloid deposits containing beta-2-microglobulin (B2-m). It is possible that the minor biocompatibility of the cuprophan membrane of dialyzers is the most significant factor responsible for the hyperproduction of B2-m and thus of the osteo-articular deposition of a new type of amyloidosis.

Clinical and radiological features of bone disease in long-term (15 or more years) hemodialysis patients.

Fifteen patients on regular dialytic treatment for more than 15 years were given X-rays of the skull, spine, shoulders, wrists, pelvis and knees with the purpose of studying the principal skeletal and articular alterations due or not due to the uraemic status. Serum calcium, phosphorus, parathyroid hormone, alkaline phosphatase and basal aluminium were recorded. Osteopenia was evident in all the patients. Ten of whom (67%) showed alterations due to hyperparathyroidism. Nine patients presented the marks of dialysis spondyloarthropathy; in 14/15 cases geodes were present in the wrists, humeral heads or hip-joints; in ten patients there were multiple amyloid lesions. Two patients with serum basal aluminum above 100 micrograms/L showed the typical radiographic marks of osteomalacia. The majority of the long-term survivors showed multifactorial osteo-articular alterations resulting mainly from the combination of hyperparathyroidism and dialysis-related amyloidosis. The less frequent joint alterations were represented by arthrosis, enthesopathy and chondrocalcinosis. Disability and decreased articular mobility resulted in being mainly due to amyloid osteo-arthropathy.

Humeral head osteonecrosis caused by electrical injury: a case report.

Various musculoskeletal abnormalities caused by electrical injury are described. Such abnormalities usually include fractures or dislocation of adjacent bones and joints. Osteonecrosis is a noteworthy, but less common, consequence of electric shock. The case is discussed of a 52-year-old woman who had received an electric shock (220-V alternating household current) to the right hand and developed osteonecrosis in the ipsilateral humeral head, most likely caused by bone "melting." An osteonecrotic lesion may therefore develop in a joint at a distance from the point of electrical contact, and this must always be kept in mind in diagnosis and treatment.

[Xanthogranulomatous pyelonephritis. Radiological and ultrasonographic aspects]. / La pielonefrite xantogranulomatosa. Aspetti radiologici ed ultrasuonografici.

Clinical, radiological and ultrasonographical features of three cases of xanthogranulomatous pyelonephritis, one of which in a child, are reported. Presurgical diagnosis of xanthogranulomatous pyelonephritis is difficult and infrequent to date (10-14% of cases according to different workers). This complaint is generally mistaken for other types of kidney infections or tumours. The use of ultrasonography and computed tomography in particular help recognition of the disease and above all help to assess its extra-renal spread: something that has only recently been made possible.

[The hand in hematologic diseases]. / La mano nelle malattie ematologiche.

Radiography of the hand often reflects the picture of generalized diseases, affecting both the muscolo-skeletal system and the others. Some of the most common hematologic disorders may be detected in roentgenograms of the hand, especially in the anemias, but also in plasma cell dyscrasias and proliferative malignant diseases (i.e., lymphomas and leukemias). On the basis of their experience, the authors have reviewed and discussed the radiographic "pattern" of the hand in several hematologic conditions (i.e., anemias; thalassemias; sickle-cell disease; lymphomas; multiple myeloma; etc.), and their pathogenesis. Radiographies of both the hands, in antero-posterior view, were performed using Kodak-Min R film; xeroradiography was performed--in the same projection--using Rank Xerox plate, developed always in "positive mode" in 125 Rank Xerox System, conditioned with contrast "D", for emphasizing osseous details. Recently, digital radiography--employing PCR system--has substituted xeroradiography, because of its well-known properties and diagnostic advantages: in this manner, changes in bone and soft tissue are demonstrated on the same image, with augmentation of diagnostic information, with reduced dose to patient. In our series, hand is always involved (100% of cases) in thalassemias: lesions are characterized by diffuse osteopenia (washed out melted appearance), with widening of bone marrow space, diaphyseal convex aspect of the long bones, thinning of the cortex, and cyst-like changes (rain drops). Lesions disappear completely after the hypertransfusion regimen (HTR). Following chelation therapy, lesions of the wrist and hand are similar to those described in rickets and/or scurvy. Sometimes, the hand is characteristically affected in sickle-cell disease--particularly in the so called hand-foot syndrome--as "cone-deformity". In multiple myeloma incidence of hand involvement is 2.9%: lesions reflect general abnormalities observed in other skeletal sites, and they consist in multiple well-circumscribed lytic lesions. In amyloidosis, poorly defined radiolucent areas may be discovered. In non-Hodgkin lymphoma, incidence of hand involvement is less frequent, approximately 0.2%: the radiographic pattern is aspecific (mottled lytic lesions), sometimes simulating multiple myeloma and/or leukemias. In hemophilia, swelling of soft tissues, around the interphalangeal joint, related to intra-articular and/or per-articular hematoma, is observed. The other conditions reflect general radiographic features of anemias, which are of three main types: 1. the over active marrow (i.e., polycythemia); 2. the infarction of bone (i.e., sickle-cell disease); 3. non-specific findings, resulting from chronic illness (delays of maturation; dwarfism; osteopenia; tendency to infection).

[The hand as an indicator for the diagnostic orientation in various systemic diseases involving the bones]. / La mano come indice di orientamento diagnostico di alcune malattie sistemiche con compromissione ossea.

Radiological aspects of the hand are presented and discussed in connection with some of the more common systemic diseases involving the bones, in which the hand is an ideal diagnostic indicator. Suitable X-ray techniques and xeroradiography are used to identify alterations to the periostium, the bone cortex and marrow and the soft tissues. The different diseases were classified according to the part of the hand involved: a) distal extremities; b) proximal phalanges and metacarpals; c) entire hand; d) wrist area.

[Intramural pseudodiverticulosis of the esophagus. Presentation of 2 cases]. / Pseudodiverticolosi intramurale dell'esofago. Presentazione di due casi.

Two cases intramural pseudodiverticulosis of the oesophagus are presented. The importance of a radiological examination when studying this condition is underlined.

[The elbow exposed to vibrating instruments and idiopathic diffuse skeletal hyperostosis: association or pure coincidence?]. / Gomito da strumenti vibranti ed iperostosi scheletrica idiopatica diffusa: un'associazione puramente casuale?

A group of 11 patients with chronic enthesopathy of the elbow caused by vibrating instruments was systematically examined for spinal signs of diffuse idiopathic skeletal hyperostosis (DISH). Nine patients revealed spinal involvement, the two exceptions probably relating to the patients' youth. The findings support the hypothesis that DISH is not a disease but rather a tendency to excessive ossification of ligamentous structures in response to stimuli that generally produce only modest new bone formation. Those suffering from such ossifying diathesis should be directed towards work unlikely to damage the enthesis.

[Skeletal changes in intermediate beta-thalassemia. Clinical and radiological study]. / Le alterazioni scheletriche delle beta-talassemie intermedie. Studio clinico e radiologico.

Bone changes of varying degree and distribution were observed by the Authors in 10 carriers of beta-thalassaemia intermedia in skull, ribs, hand, elbow and knee bones. When they are present, skeletal changes are the same of homozygous beta-thalassaemia, but less marked and spread. Instead, symptomatology is more homogeneous, usually characterized by mild anaemia and morphological changes of red cells with haemoglobin values in the 6-11 g/dl range, splenomegaly, jaundice, gallstones, crural ulcers. The clinical state goes through the asymptomatic condition to a more severe condition with typical appearance of Cooley's anaemia.

[Mönckeberg's mediocalcinosis associated with Raynaud's phenomenon]. / Mediocalcinosi di Mönckeberg associata a fenomeno di Raynaud.

A case of Mönckeberg's arteriosclerosis associated with Raynaud's phenomenon and diabetes is reported. It is probable that Mönckeberg's arteriosclerosis could provoke a Raynaud's phenomenon when predisposing local conditions, such as microvasculature and/or haemorheological alterations, are present. Finally our findings seem to demonstrate that xeroradiographic investigation is most important for the early diagnosis of the disease.

[Skeletal changes in non-Hodgkin lymphoma]. / Le alterazioni scheletriche nei linfomi non-Hodgkin.

140 patients affected by non-Hodgkin lymphoma (NHL) are performed by the A. Skeletal involvement of metastatic nature is observed in 14 of these (10%). Only the aggressive lymphomas have radiographic bone disseminations. At beginning of disease no patient has interested by bone changes. The most frequent roentgenographic finding observed by the A. include high incidence of osteolityc lesions: in particularly, pattern so called "permeative" is present in 35.6% of cases. Osteosclerotic and mixed manifestations were much less commonly observed (7,2% respectively). Periosteal reactions is not observed in any cases. The value of roentgen skeletal investigation in diagnosis, staging and therapy of NHL is discussed by the A.

[Value and limitations of scintigraphy of the hand in rheumatoid arthritis]. / Valore e limiti della scintigrafia della mano in corso di artrite reumatoide.

99mTc-polyphosphate joint imaging of the hand has been performed in 18 patients, with evidence of inflammatory joint disease, but without any significant radiographic lesions, which might be related to rheumatoid arthritis. The hand scans were compared to clinical and radiographic data. An year after, the same subjects were re-examined, with both the radionuclide imaging and radiography. Scintigraphy has been shown to be significantly more sensitive for detecting inflammatory joint disease than x-ray, especially in the early stage of rheumatoid arthritis. Although radionuclide imaging is non specific (activity is increased also in osteoarthritis, trauma, metabolic bone disease, infarction, etc.). Radiography is highly specific but relatively non sensitive.

[Clinico-radiologic aspects of calcium pyrophosphate dihydrate deposition disease]. / Aspetti clinico-radiologici della malattia da depositi di pirofosfato di calcio diidrato.

Calcium pyrophosphate dihydrate crystal deposition disease is a clinical condition characterised by Gout-like synovitis (pseudogout), calcification on and around the joints and an arthropathy that is radiologically similar to osteoarthritis (chronic pyrophosphate arthropathy). Though all these radiological clinical aspects may coexist in the same patient this is often not the case. An examination of the X-ray data on the 68 cases studied which were diagnosed on the basis of the criteria proposed by McCarty, shows that the disease is relatively common especially in the over-fifties. When chronic pyrophosphate arthropathy is the only clinical manifestation of the disease differential diagnosis from the osteoarthrosis so common in the elderly is difficult and depends on the greater severity and progression of the joint damage that may often affect joints not subjected to weight such as the shoulder, unlike what happens in osteoarthritis.

[Role of triphasic bone scintigraphy in the diagnosis of osteonecrosis of the femur head]. / Ruolo della scintigrafia ossea trifasica nella diagnosi della osteo-necrosi della testa femorale.

Twelve patients affected by idiopathic osteonecrosis of the femoral head underwent X-ray, triphasic bone scintigraphic (TBS) and CT tests on the femoral head on both sides. TBS revealed arterial hypoperfusion and an area of hypocaptation in the caput femoris in 3 coxofemoral joints which were radiologically "negative" (and of which one was also CT negative); these are scintigraphical signs which are typical of aseptic necrosis. In line with published data, TBS was found to be a more sensitive test in comparison with traditional X-ray techniques and CT, and in the early stages of disease it is more specific in recognising aseptic necrosis of the femoral head. Lastly, it is underlined that magnetic resonance is currently considered to be most sensitive (88%) and most specific (100%) imaging technique in the diagnosis of osteonecrosis of the femoral head.