Pelvi-abdominal ACTINOMYCOSIS as a complication of long-term use of intrauterine device (IUD). The important role of imaging in diagnosis and follow-up.

ACTINOMYCOSIS is a rare chronic granulomatous disease caused by anaerobic filamentous gram-positive bacteria, the most common of which is Actinomyces israelii. Actinomycetes are commensal inhabitants of the oral cavity and gastrointestinal tract, but they may become pathogenic through invasion of breached or necrotic tissue. Pelviabdominal ACTINOMYCOSIS is uncommon and can mimic a variety of disease processes, including abdominal mass mimicking malignancy, acute abdomen, asthenia, and weight loss. We describe a 38-year-old woman who presented with acute abdominal pain and tenderness, as well as constitutional manifestations and elevated inflammatory markers. On initial computerized tomography (CT) and MRI, a large fluid collection underlining the anterior abdominal wall at the false pelvic cavity, as well as parietal peritoneal enhancement and smudging of the mesenteric fat and a bulky fibroid uterus with an implanted IUD, were identified. The ultrasound guided aspiration and anaerobic culture revealed positive growth for Actinomyces bacteria. An exploratory laparoscopy revealed extensive adhesions between the abdominal wall and the small intestine, as well as hyperemic and thickened peritoneum, and peritoneal biopsy confirmed ACTINOMYCOSIS. After the diagnosis was established, the IUD was removed and the patient was given Ceftriaxone 2 gm once daily for 6 weeks before switching to oral doxycycline 100 mg twice daily for another 3 months. A significant regression of the suprapubic fluid collection, and peritoneal-mesenteric changes were confirmed on follow-up. The case is discussed, and the relevant literature reviewed and analyzed.

Atlas of the OMERACT Heel Enthesitis MRI Scoring System (HEMRIS).

OBJECTIVE: Assessment of enthesitis, a key feature in spondyloarthritis (SpA) and psoriatic arthritis (PsA), using objective and sensitive methods is pivotal in clinical trials. MRI allows detection of both soft tissue and intra-osseous changes of enthesitis. This article presents an atlas for the Outcome Measures in Rheumatology (OMERACT) Heel Enthesitis Magnetic Resonance ImagingMRI Scoring System (HEMRIS). METHODS: Following a preliminary selection of potential examples of each grade, as per HEMRIS definitions, the images along with detailed definitions and reader rules were discussed at web-based, interactive meetings between the members of the OMERACT MRI in Arthritis Working Group. RESULTS: Reference images of each grade of the MRI features to be assessed using HEMRIS, along with reader rules and recommended MRI sequences are depicted. CONCLUSION: The presented reference images can be used to guide scoring Achilles tendon and plantar fascia (plantar aponeurosis) enthesitis according to the OMERACT HEMRIS in clinical trials and cohorts in which MRI enthesitis is used as an outcome.

Mycophenolate mofetil for induction and maintenance of remission in naïve patients with granulomatosis with polyangiitis without renal involvement.

Antineutrophil cytoplasmic antibodies (ANCA) associated vasculitides include granulomatosis with polyangiitis (GPA, previously called Wegener's), microscopic polyangiitis (MPA) and eosinophilic granulomatosis with polyangiitis (EGPA), previously called Churg-Strauss). In this report we used mycophenolate mofetil (MMF) and steroids to induce and maintain remission in two newly diagnosed cases with c-ANCA associated GPA. The two patients' maintained remission with no disease relapses during one year follow-up.

Study of the osteoprotegerin/receptor activator of nuclear factor-kB ligand system association with inflammation and atherosclerosis in systemic sclerosis.

OBJECTIVE: we aimed to study systemic sclerosis patients in order to assess osteoprotegerin/Receptor activator of nuclear factor-kB ligand (OPG/RANKL) system and find the relation of these biomarkers with the clinical features of the disease, the carotid intima thickness, markers of inflammation, lipid profile, and other laboratory characteristics. METHODS: both the level of (RANKL), (OPG) in sera of participants, in 30 (SSc) patients and the atherosclerotic changes affecting the common carotid artery were measured and, were compared to 30 healthy controls matched for age and sex. All participants were assessed clinically and subjected to the Revised Medsger SSc severity scale and underwent carotid Doppler ultrasound examination. RESULTS: OPG, RANKL, and RANKL/OPG were 1.9 ± 0.4 ng/ml, 24.3 ± 17.25 ng/ml, and 13.5 ±9.8 versus 0.77 ± 0.25 ng/ml, 7.13 ± 3.02 ng/ml, and 9.6 ± 3.1 in the SSc patients and the controls with significance (P = 0.001, P = 0.001, P = 0.045) respectively. The OPG- RANKL axis in the SSc patients correlated significantly with carotid intima thickness, arthritis, arthralgia, inflammatory markers, Medsger joint, Medsger vascular, Medsger skin, and dyslipidemia. CONCLUSION: In cardiovascular risks, OPG serum level might increase as a preventive compensatory mechanism to neutralize the RANKL level increment. The determination of the OPG-RANKL system is a diagnostic indicator for the intensity of vascular calcification and atherosclerosis in SSc patients.

Shoulder arthroscopy remains superior to direct MR arthrography for diagnosis of subtle rotator interval lesions.

PURPOSE: To assess the sensitivity, specificity and accuracy of MR arthrography, as opposed to shoulder arthroscopy, in diagnosing individual rotator interval (RI) structures lesions at different levels of severity. MATERIALS AND METHODS: Seventy-five patients were enrolled in a prospective study. All the patients were diagnosed with full-thickness rotator cuff tendon tears on unenhanced MRI and had complimentary MR arthrography to search for obscure RI lesions. All the patients then underwent shoulder arthroscopy. The arthroscopist was blinded about the MR arthrography results. RESULTS: At arthroscopy, 42 patients (56 %) were found to have RI lesion(s) and represented the study group. The remaining 33 patients represented the control group. The sensitivity, specificity and accuracy of MR arthrography for detecting individual RI lesions varied widely depending on the location and severity of the lesions. MR arthrography showed intermediate sensitivity of 67-80 %, specificity of 83-89 % and accuracy of 89-92 % for diagnosing subtle RI lesions; and perfect (100 %) sensitivity, specificity and accuracy for diagnosing biceps long head tendon dislocation. For the rest of RI lesions, MR arthrography showed high sensitivity, specificity and accuracy. Inter-observer agreement was found to be almost perfect (K = 0.81-1.0). CONCLUSION: Shoulder arthroscopy remains the gold standard for diagnosing subtle RI lesions. Although MR arthrography has proved to be a valuable tool for diagnosing established RI lesions, it is of intermediate sensitivity for diagnosing subtle RI lesions resulting in early insufficiency of the biceps pulley system.

Transient osteoporosis of the hip, complete resolution after treatment with alendronate as observed by MRI description of eight cases and review of the literature.

Transient osteoporosis of the hip (TOH), also referred to as transient bone marrow edema syndrome, is most common in middle-aged men and often after trivial trauma or sport-related injuries. Diagnosis is usually made by eliminating other possible causes of hip pain. Magnetic resonance imaging (MRI) plays an important role in diagnosis and demonstrates a typical pattern of bone marrow edema (BME) in the form of diffuse low signal on T1-weighted images and high signal on T2 fat-suppressed or short T1 inversion recovery images. No consensus exists about the management of TOH, as it may progress to avascular necrosis. We describe eight cases of TOH treated with alendronate resulting in improvement of pain and function and complete resolution of BME on MRI. The literature is reviewed regarding TOH and the relationship with bone marrow edema syndrome, avascular necrosis of the hip, and regional migratory osteoporosis. To our knowledge, this is the first report describing the improvement of this condition after of alendronate with documented radiological improvement on follow-up MRI.

Elevated BAFF (BLyS) and APRIL in Juvenile idiopathic arthritis patients: relation to clinical manifestations and disease activity.

OBJECTIVE: To assess the level of B-cell activating factor belonging to the tumor necrosis factor family (BAFF) also known as B-lymphocyte stimulator (BLyS) and A proliferation-inducing ligand (APRIL) in the serum of Juvenile idiopathic arthritis (JIA) patients and to detect their relation to the clinical manifestations and disease activity in the different subtypes of the disease. METHODS: Seventy-four consecutively recruited JIA patients were clinically examined, the Juvenile arthritis disease activity score in 27 joints (JADAS-27) calculated and Childhood Health Assessment Questionnaire (CHAQ) used to measure the functional status. Thirty-four healthy matched children served as controls. Routine laboratory examinations were recorded and serum BAFF and April were determined. RESULTS: The JIA patients were 20 systemic-onset, 31 oligoarticular and 23 polyarticular. Serum BAFF and APRIL were elevated in JIA patients being higher in systemic onset and both significantly correlated. APRIL significantly correlated with both JADAS-27 and CHAQ scores while BAFF correlated only with JADAS-27. The APRIL serum levels were significantly associated with the presence of RF and ANA. The BAFF serum levels were significantly higher in oligoarticular onset JIA patients with uveitis compared to those without. CONCLUSION: Our results suggest increased BAFF and APRIL serum levels in JIA patients denoting their possible role in the disease and calling for additional research to elucidate the intrinsic mechanisms explaining APRIL and BAFF over expression.

Correlations of urinary biomarkers, TNF-like weak inducer of apoptosis (TWEAK), osteoprotegerin (OPG), monocyte chemoattractant protein-1 (MCP-1), and IL-8 with lupus nephritis.

OBJECTIVE: This case-controlled study was designed to correlate urinary biomarkers, TNF-like weak inducer of apoptosis (TWEAK), osteoprotegerin (OPG), monocyte chemoattractant protein-1 (MCP-1), and interleukin-8 (IL-8) levels, with renal involvement in a cohort of systemic lupus erythematosus (SLE) patients to examine their diagnostic performance. PATIENTS AND METHODS: In 73 SLE patients, and in 23 healthy volunteers, urinary levels of TWEAK, OPG, MCP-1, and IL-8 levels were measured. Disease activity was assessed by total SLE disease activity index, and renal activity by renal activity index (rSLEDAI), and both were correlated with urinary biomarkers. Sensitivity, specificity, and predictive values of individual biomarkers to predict lupus nephritis were also calculated. RESULTS: Significantly higher levels of urinary biomarkers were observed in SLE patients with lupus nephritis (LN) compared with those without LN (TWEAK, p < 0.001; MCP-1, p < 0.001; OPG, p < 0.001; IL-8, p < 0.032). Other significantly higher levels were observed in SLE patients with LN compared with control subjects (TWEAK, MCP-1, OPG, and IL-8 p < 0.001). Positive correlations were observed between rSLEDAI and TWEAK (r = 0.612 and p < 0.001), MCP-1 (r = 0.635 and p < 0.001), and OPG (r = 0.505 and p < 0.001). CONCLUSIONS: Urinary levels of TWEAK, OPG, and MCP-1 positively correlate with renal involvement as assessed by rSLEDAI with reasonable sensitivity, specificity, and predictive values to detect lupus nephritis while IL-8 was not significantly associated with global or rSLEDAI.

Enthesitis and related changes in the knees in seronegative spondyloarthropathies and skin psoriasis: magnetic resonance imaging case-control study.

OBJECTIVE: To describe enhanced magnetic resonance imaging (MRI) features and characteristic entheseal changes in the knees in patients with seronegative spondyloarthropathy (SpA). METHODS: The 56 patients included 30 with psoriatic arthritis, 5 with ankylosing spondylitis, 5 with reactive arthritis, 5 with ulcerative colitis (UC), 5 with Crohn's disease, and another 6 with skin psoriasis. Controls were 20 healthy subjects without knee complaints. MRI was performed in all participants, emphasizing entheseal sites. RESULTS: Both knees were studied in 45 (80.3%) patients and one knee in 11 (19.6%). MRI showed evidence of bone marrow edema in 13 (23.2%) patients, cartilaginous erosions in 18 (32.1%), and bone erosions in 9 (16.1%). Enthesitis was found in medial collateral ligaments in 18 (32.1%), lateral collateral ligaments in 8 (14.3%), posterior cruciate ligaments in 3 (5.35%), patellar tendon in 18 (32.1%), biceps femoris insertion in 3 (5.35%), medial patellofemoral ligaments (MPFL) in 5 (8.9%), and lateral patellofemoral ligament in 1 patient (1.8%). In the UC and Crohn's patients (n = 10), 2 had bone erosions and 5 had enthesitis. In the skin psoriasis group (n = 6), one had bone marrow edema; enthesitis was detected in 5 at the patellar tendon insertion and in one in the MPFL. Entheseal-related changes were absent in the controls. CONCLUSION: This is the first study showing entheseal-related changes in the knees in patients with inflammatory bowel disease or skin psoriasis without clinical arthritis. Enthesitis of the knee on MRI may be an early finding in SpA.

Differentiation of osteoporotic and neoplastic vertebral fractures by chemical shift {in-phase and out-of phase} MR imaging.

OBJECTIVE: The objective of this study was to establish the cut-off value of the signal intensity drop on chemical shift magnetic resonance imaging (MRI) with appropriate sensitivity and specificity to differentiate osteoporotic from neoplastic wedging of the spine. PATIENTS AND METHODS: All patients with wedging of vertebral bodies were included consecutively between February 2006 and January 2007. A chemical shift MRI was performed and signal intensity after (in-phase and out-phase) images were obtained. A DXA was performed in all. RESULTS: A total of 40 patients were included, 20 with osteoporotic wedging (group 1) and 20 neoplastic (group 2). They were 21 males and 19 females. Acute vertebral collapse was observed in 15 patients in group 1 and subacute collapse in another 5 patients, while in group 2, 11 patients showed acute collapse and 9 patients (45%) showed subacute vertebral collapse. On the chemical shift MRI a substantial reduction in signal intensity was found in all lesions in both groups. The proportional changes observed in signal intensity of bone marrow lesions on in-phase compared with out-of-phase images showed significant differences in both groups (P<0.05). At a cut-off value of 35%, the observed sensitivity of out-of-phase images was 95%, specificity was 100%, positive predictive value was 100% and negative predictive value was 95.2%. CONCLUSION: A chemical shift MRI is useful in order to differentiate patients with vertebral collapse due to underlying osteoporosis or neoplastic process.

Hippocampus dysfunction may explain symptoms of fibromyalgia syndrome. A study with single-voxel magnetic resonance spectroscopy.

OBJECTIVE: (1) To investigate dysfunction of hippocampus in patients with fibromyalgia syndrome (FM) using proton magnetic resonance spectroscopy (1H-MRS), and to compare these findings with healthy controls. (2) To correlate levels of metabolites obtained with aspects of cognition, depression, and sleep symptoms in the patient group. METHODS: The case-control study was performed in 15 female patients, who met American College of Rheumatology criteria for classification of FM, and 10 healthy age-matched female controls. Patients and controls were receiving no medications known to affect cognitive functioning or central nervous system metabolites before their participation in the study. In all patients and controls, 1H-MRS was used to assess N-acetylaspartate (NAA), choline (Cho), creatine (Cr), and their ratios from both hippocampi. Levels of metabolites and their ratios were determined and the findings compared between the groups. All patients and controls underwent psychological assessment to assess cognitive function, depression, and structured sleep interview with sleep diary; Fibromyalgia Impact Questionnaire (FIQ), number of tender points, and visual analog scale (VAS) for pain were assessed in all patients. RESULTS: NAA levels of right and left hippocampi differed significantly between patients and controls (p < 0.05). Cho levels in the right hippocampus were higher in the patient group than in controls (p = 0.005), while no differences were found with respect to Cr levels in both hippocampi. NAA/Cho and NAA/Cr ratios differed significantly between patients and controls (p <0.05), while the Cho/Cr ratio showed no differences. Significant correlations were found between language score and right Cho and right Cr levels (p = 0.041, p = 0.006, respectively), while no significant correlations were found between metabolites and their ratios with FIQ, VAS for pain, or number of tender points. CONCLUSION: The hippocampus was dysfunctional in patients with FM, as shown by lower NAA levels compared to controls, representing neuronal or axonal metabolic dysfunction. As the hippocampus plays crucial roles in maintenance of cognitive functions, sleep regulation, and pain perception, we suggest that metabolic dysfunction of hippocampus may be implicated in the appearance of these symptoms associated with this puzzling syndrome.

Bone marrow edema syndromes of the hip: MRI features in different hip disorders.

The objectives of this study were to describe the essential magnetic resonance imaging (MRI) features of bone marrow edema syndromes affecting the hip joint. In addition, to evaluate the role of MRI in the assessment of hip joint involvement in different clinical settings that may share similar clinical findings. Thirty-four patients who complained of hip pain were studied consecutively. Of these, 21 were men (61.8%) and 13 were women (38.2%). After clinical assessment of possible hip disease, plain radiograph and MRI study of both hips were performed. The literature was searched using keywords: bone marrow edema, hip, and MRI. All patients had antalgic gait and limping. Initial clinical examination revealed painful limited internal and external rotation of the affected hip/hips suspect for hip disease. Unilateral hip involvement was identified in 31 patients (91.2%), and bilateral hip involvement was found in three patients (8.8%), with a total of 37 hips evaluated by MRI. The final diagnoses in our patients were: reactive arthritis (1), transient osteoporosis (7), avascular necrosis (10), osteoarthritis (2), tuberculous arthritis (4), septic arthritis (2), osteomyelitis (2), sickle cell anemia (2), lymphocytic leukemia (1), and femoral stress fracture (3). Bone marrow edema affecting the hip is neither a specific MR imaging finding nor a specific diagnosis and may be encountered in a variety of hip disorders due to different etiologies. MR imaging is the modality of choice when clinical examination is suspect for hip disease and plain radiographs are normal or equivocal. Early diagnosis and treatment is important in many of the disorders. The literature is reviewed regarding bone marrow edema of the hip.