Imaging of supra-thoracic tuberculosis.

Tuberculosis (TB) typically affects the lungs, but may involve many extra-pulmonary sites; with the latter especially prone in patients with human immunodeficiency virus infection. The clinical features of extra-pulmonary TB are often non-specific, mimicking many different disease entities. Application of the most appropriate imaging modality and knowing the imaging findings with clinical context awareness help initiation of further investigations, diagnosis and early treatment. This pictorial essay highlights the imaging spectrum of extra-pulmonary TB affecting the supra-thoracic region, i.e. brain, neck, and ear, nose and throat.

Imaging of musculoskeletal tuberculosis.

Extra-pulmonary tuberculosis (TB) of the musculoskeletal system usually manifests with non-specific clinical features, mimicking a variety of diseases. Diagnosis and treatment of spinal and extra-spinal musculoskeletal TB are often challenging. Imaging has an important role in detecting this disease, aiding diagnosis, identifying complications, and monitoring disease progression. Radiographs and magnetic resonance imaging are the key imaging modalities utilized. Radiologists should aim to be familiar with the spectrum of imaging features of TB affecting spinal and extra-spinal locations in the musculoskeletal system.

Imaging of infra-thoracic tuberculosis.

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Early Identification of Sacroiliitis in Patients with Suspected Spondyloarthritis: A Challenging Task.

OBJECTIVE: The purpose of this study was to assess the performance of computed tomography (CT) scan and magnetic resonance imaging (MRI) for detecting sacroiliitis in nonradiographic SpA (nr-SpA). METHODS: This cross-sectional monocentric double-blind study included 63 patients consulting for symptoms suggestive of SpA between February 2014 and February 2017. Patients with conventional radiographs showing a confirmed sacroiliitis (grade 3 or 4) were not included. Eligible patients underwent CT and MRI of sacroiliac joints (SIJ). CT and MR images were interpreted by 2 experienced musculoskeletal radiologists blinded to clinical and laboratory data. Two professors in rheumatology blinded to radiologists' conclusions analyzed clinical data, laboratory tests, HLA typing, X-rays, CT and MRI images, and divided the patients into 2 groups: confirmed nr-SpA or no SpA. This classification was considered the gold standard when analyzing the results. RESULTS: 46 women and 17 men were included in this study. 47 patients were classified as confirmed nr-SpA (74.6%) and 16 patients as no SpA (25.4%). Sensitivity, specificity, and positive and negative predictive values of CT and MRI for detecting sacroiliitis were, respectively, estimated at 71.7%, 71.4%, 89.2%, 43.5%, and 51.2%, 100%, 100%, and 40%. CT and MRI findings were found to be statistically associated (p<0.001). CONCLUSION: SIJ MRI is a highly specific method in the detection of sacroiliitis, but with a moderate sensitivity. SIJ CT scan, usually known as the third option after radiography and MRI, has much greater diagnostic utility than it has been documented previously.

Performances of single tube nested polymerase chain reaction and GeneXpert ultra on Formalin fixed paraffin embedded tissues in the diagnosis of tuberculous spondylodiscitis.

INTRODUCTION: Tuberculous Spondylodiscitis is the most common form of musculoskeletal tuberculosis. Molecular techniques on fresh tissues are proved to improve the diagnosis of tuberculous spondylodiscitis and to allow a rapid diagnosis to initiate the treatment and prevent neurological complications. OBJECTIVES: The objective of the present study was to assess the diagnostic performances of single tube nested PCR and GeneXpert ultra in the diagnosis of tuberculous spondylodiscitis on formalin fixed paraffin embedded tissues. METHODS: This study included 63 tuberculous spondylodiscitis cases collected from June 2014 to January 2020 and corresponding to 27 definite tuberculous spondylodiscitis with positive microbiology, and 36 probable tuberculous spondylodiscitis, with histopathological, clinical and radiological findings consistent with tuberculous spondylodiscitis but with negative microbiology. The sensitivity, specificity, positive predictive value and negative predictive value of nested PCR and GeneXpert ultra were determined with reference to microbiology. RESULTS: Nested PCR was positive in 47 (75%) cases: 26/27 definite tuberculous spondylodiscitis and 21/36 probable tuberculous spondylodiscitis. GeneXpert ultra was positive in only 6 (10%) cases corresponding to definite tuberculous spondylodiscitis. The sensitivity, specificity, positive predictive value and negative predictive value of nested PCR on formalin fixed paraffin embedded tissues were 96%, 100%, 100%, 83% respectively. For GeneXpert ultra, these rates were 22%, 100%, 100% and 25% respectively. CONCLUSION: Nested PCR and GeneXpert ultra on formalin fixed paraffin embedded tissues are useful tools for the diagnosis of tuberculous spondylodiscitis, especially for cases where microbiological investigations were not carried out. Both techniques have excellent specificity but single tube nested PCR is more sensitive. Key Points • Molecular techniques are routinely performed on fresh tissues • GeneXpert and nested PCR on formalin fixed paraffin embedded tissues are reliable for the diagnosis of tuberculous spondylodiscitis • Nested PCR is more sensitive than Genexpert for diagnosing tuberculous spondylodiscitis.

Granulomatous spondylodiscitis: A case series with focus on histopathological features.

Objective: To report a series of Granulomatous Spondylodiscitis (GS) with focus on the histopathological features of the different forms of GS.Design: Case series.Setting: Pathology department of Charles Nicolle's Hospital of TunisiaParticipants: This study included 57 patients diagnosed with GS. There were 44 (77.2%) female patients and 13 (22.8%) male patients (sex ratio = 0.28).Intervention: Not applicable.Outcome measures: Clinical, microbiological and histopathological features were assessed in this study.Results: Fifty-seven patients with GS were enrolled: 51 tuberculous spondylodiscitis (TS), 2 fungal spondylodiscitis (FS), 3 brucellar spondylodiscitis (BS) and 1 case of sarcoidosis. Granulomas with necrosis were seen in 38 (66.6%) cases: 36 TS and 2 FS, while granulomas without necrosis were observed in the remaining 19 cases: 15 TS, 3 BS and 1 sarcoidosis. In all cases of TS, granulomas were epithelioid type, associated with histiocytic type granulomas in 7 cases. Caseous necrosis was seen in 35 cases of TS and suppurative granuloma in one case. The 3 cases of BS exhibited non-necrotizing and histiocytic type granulomas. The 2 cases of FS showed histiocytic, epithelioid and necrotizing granulomas. Necrosis was mixed: suppurative and caseous in both cases of FS. Sarcoidosis was characterized with epithelioid type granulomas without necrosis.Conclusion: Granuloma with caseous necrosis is highly suggestive of TS but does not rule out FS. Certain fungi can exhibit this type of necrosis as do tuberculosis species. Suppurative inflammation, although rare in TS, does exist. Histiocytic type granuloma without necrosis is suggestive of brucellosis.

Brucellar spondylodiscitis: A case series with focus on histopathological features.

Brucellar spondylodiscitis (BS) is the most common form of musculoskeletal brucellosis. The isolation of Brucella spp from blood, other body fluids or tissue cultures is the gold standard for definitive diagnosis of BS. BS shows a large histopathological spectrum of lesions with non-specific and granulomatous forms, and its histopathological features are not widely reported. This case series study reported the histopathological features of a series of 21 BS. Ten cases revealed nonspecific forms of BS. Lymphocytes were the predominant inflammatory cells in this group. In one case neutrophils were predominant. The eleven remaining were granulomatous. The 11 exhibited histiocytic type granulomas. Ten were non-necrotizing. One case, taken from abscess wall, contained minimal deposition of caseous like necrotic material. This case and 2 others corresponding to abscess wall biopsies, showed histiocytic granulomas mixed with small aggregates of epithelioid cells without well-formed epithelioid granuloma nor giant cell. The histopathological diagnosis of BS is challenging. Nonspecific forms of BS, mimiking pyogenic spondylodiscitis, are observed in about half of the cases. Although nonspecific forms of BS are characterized by the predominance of lymphocytes and plasmocytes, BS forms with predominant neutrophil cell infiltration do exist. Histiocytic granuloma is highly suggestive of BS. Purely epithelioid forms of BS were not observed in the present series. Caseous like necrosis suggestive of tuberculosis is a possible feature of BS.

The Value of Histology in the Diagnosis of Tuberculous Spondylodiscitis.

BACKGROUND: Tuberculous spondylodiscitis (TS) is the most common form of musculoskeletal tuberculosis. Currently, histology is widely used to distinguish tuberculous from nontuberculous disease. OBJECTIVES: The aim of the present study was to assess the accuracy of histology compared with bacteriology in the diagnosis of TS. METHODS: This is a single-center case series carried out from January 2014 to February 2018 in a pathology department. It included 121 discovertebral biopsies of infective spondylodiscitis. The measures of diagnostic accuracy of histology were determined taking bacteriology as criterion standard. RESULTS: Among the 121 cases, 55 (45.4%) were diagnosed as TS by histological and/or bacteriological findings, 17 (30.9%) were classified as definite TS by bacteriology, and the remaining 38 (69.1%) had positive histology and negative bacteriology. There were 2 false-negatives, which histologically displayed suppuration without granuloma, and 3 false-positives; in one case, histology displayed granulomas without necrosis and culture isolated Brucella. In the 2 others, histology revealed granulomas with caseous-like necrosis and microbiology isolated fungal species. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of histology in the diagnosis of TS were 88.2%, 93.4%, 83.3%, 95.5%, and 92%, respectively. CONCLUSIONS: Histology is proved to be an accurate diagnostic tool in TS. Suppurative forms of TS without granuloma are rare and represent the main cause of false-negative histology. Suggestive histology of TS does not rule out fungal and brucellar spondylodiscitis. Caseous necrosis is not pathognomonic of tuberculosis. Fungal infection can also exhibit such type of necrosis.

Skeletal fluorosis: don't miss the diagnosis!

Skeletal fluorosis is a rare toxic osteopathy characterized by massive bone fixation of fluoride. The disease occurs as an endemic problem in some parts of the world and is the result of prolonged ingestion or rarely by inhalation of high amounts of fluoride. Radiographic presentation is mainly characterized by bone changes with osteocondensation and later ossification of many ligaments and interosseous membranes. Skeletal fluorosis is not clinically obvious and can be confused with other rheumatologic disorders. Its severity lies in the development of skeletal deformities and neurological complications. Management of fluorosis generally focuses on symptom treatment.

Chronic arthritis revealing sarcoidosis in a patient exposed to silica.

Sarcoidosis is a systematic, granulomatous disease of unknown cause which can affect any organ in the body. Pulmonary involvement is the most common. Musculoskeletal manifestations of sarcoidosis are less common affecting 10-25% of patients and chronic arthritis occurs rarely. We report the case of sarcoidosis revealed by left knee chronic and destructive monoarthritis with only asymptomatic pulmonary involvement in a Caucasian male miner exposed to silica. The patient was treated with corticosteroids during 2 years after diagnosis. In addition, arthroplasty with total left knee prosthesis was performed. The patient is well without any recurrence of symptoms of the musculoskeletal system for a 2 years follow-up period after surgery.

Uncommon etiology of knee pain: Lipoma arborescens.

 Lipoma arborescens is a rare intra-articular benign tumor. It affects mostly the knee and the diagnosis is usually difficult due to resembling symptomatology of osteoarthritis. CASES PRESENTATION: We report herein 3 new cases of lipoma arborescens of the knee in which a patient has synovitis associated. In 2 cases, the discovery was intraoperatively. We also report a tumor relapse 2 years after surgery.

Traumatic Meniscus and Cruciate Ligament Tears in Young Patients: A Comparison of 3T Versus 1.5T MRI.

OBJECTIVE: To compare diagnosis value of 1.5T and 3T MRI in the detection of traumatic knee injuries in young patients by reference to arthroscopy. MATERIALS AND METHODS: One hundred patients were prospectively included. All patients randomly underwent standardized knee 1.5T or 3T MRI with subsequent knee arthroscopy. Meniscus and cruciate ligaments tears were blindly assessed by two independent musculoskeletal radiologists. RESULTS: Comparison of 1.5T and 3T MRI groups in the diagnosis of medial and lateral meniscal tears showed significantly higher sensitivity (p = 0.015) of 1.5T MRI in the diagnosis of lateral meniscal tears. Sensitivity and specificity for complete ACL tears were 100 percent [35/35] and 100 percent [23/23] at 1.5T MRI (p = < 0.0001) versus 95.5 percent [21/22] and 100 percent [16/16] at 3T MRI (p = < 0.0001).Only three complete PCL tears were observed in this study. Sensitivity and specificity for all complete CL tears were 100 percent [37/37]; 100 percent [77/77] for 1.5T MRI (p < 0.0001); and 95.7 percent [22/23] and 100 percent [59/59] for 3-T MRI (p < 0.0001). Diagnosis value of 1.5T and 3T MRI was equal for ACL and PCL complete tears. CONCLUSION: Diagnosis value of 1.5T was similar to 3T MRI for medial meniscal and cruciate ligament tears of the knee in symptomatic patients and higher for lateral meniscal tears.

[The value of MRI in the diagnosis of joint involvement in malignant primitive tumors of the knee]. / Valeur de l'IRM dans le diagnostic de l'envahissement articulaire par les sarcomes osseux du genou.

INTRODUCTION: Surgical treatment of malignant primitive tumors of bone needs a precise preoperative assessment of tumor local extension. Joint involvement (JI) represents the most important finding to determine, for the choice of surgical procedure (intra- or extra-articular resection). OBJECTIVE: To determine the value of different MR signs for the diagnosis of joint involvement in malignant primitive tumors of the knee. METHODS: Ten-year period retrospective study of 42 patients. Patients' clinical and imaging data have been studied. Two senior musculoskeletal radiologists have blindly and consensually reviewed imaging data. Histopathological data have been reviewed by an experimented pathologist. The results have been compared using several statistical methods to determine the global and detailed (sign by sign) diagnostic value and accuracy of MRI by reference to histopathology. RESULTS: Some MR signs were performant in the diagnosis of joint involvement. The most sensitive were epiphyseal extension (Se: 100%), osteochondral extension (Se: 87.5%) and extension to the tibial spines (Se: 83.3%). The most specific MR signs were the presence of an intra-articular mass (Sp: 84.62%), extension to the intercondylar notch (Sp: 80.77%) and longitudinal axis≥120mm (Sp: 84.62%). CONCLUSION: A rigorous and reproducible MR technique has to be used, the knee being explored in the transversal, sagittal and coronal planes. MR conclusion has to be clear and simple (intact, doubtful or involved joint). MR interpretation has to consider tumoral extension pathways. In doubtful cases, CT may help in this diagnosis by studying the bone cortex. LEVEL OF EVIDENCE: IV.

Performance of ultrasounds compared with radiographs to detect chronic enthesitis signs in patients with ankylosing spondylitis.

To assess the performance of ultrasound in detecting erosion, swelling, and new bone comparing to radiographs in five lower limb entheses in patients with ankylosing spondylitis (AS). Prospective study of 60 patients meeting modified New York criteria for AS. Lateral radiographs of both knees and ankles followed by a high-resolution Doppler ultrasound examination with a high-frequency (15 MHz) linear probe were performed. Ultrasound had an excellent sensitivity, but specificity was very weak compared to radiographs for erosion, swelling, and new bone formation. Negative and positive predictive values were good only for erosion. Ultrasound seems to be a performant instrument in detecting signs of chronic enthesitis particularly when radiograph is normal.

Assessment of preclinical atherosclerosis in patients with ankylosing spondylitis.

OBJECTIVE: Epidemiological studies recently confirmed the increased risk of vascular morbidity and mortality during ankylosing spondylitis (AS). Increase of intima-media thickness (IMT) of the common carotid artery is a useful and noninvasive marker of preclinical atherosclerosis. The aim of our study was to compare IMT in patients with AS with matched controls and to determine risk factors of atherosclerosis related to AS. METHODS: We performed a prospective study of 60 consecutive patients meeting modified New York criteria for AS, compared to 60 controls matched for age and sex. Disease-specific measures were determined. Measurement of IMT was performed by the same radiologist using the same machine and probe in right and left common carotid arteries, and the average of the 2 measurements was considered. RESULTS: In total 48 male and 12 female patients were recruited, and 60 corresponding controls; mean age was 36 ± 11 years. We found significantly increased IMT in the AS group (0.51 ± 0.12 mm) compared with controls (0.39 ± 0.09 mm; p = 0.001). After adjustment for confounding factors, increased IMT was still present (p = 0.003). Age at onset of AS (p = 0.001), Bath AS Disease Activity Index (p = 0.002), AS Disease Activity Score (ASDAS) erythrocyte sedimentation rate (ESR; p = 0.047), ASDAS C-reactive protein (CRP; p = 0.012), Bath AS Functional Index (p = 0.008), global spine visual analog scale for pain (p = 0.000), Schober index (p = 0.039), Bath AS Metrology Index (p = 0.028), modified Stoke Ankylosing Spondylitis Spine Score (p = 0.035), and high ESR (p = 0.001) and CRP (p = 0.000) were correlated with high IMT in patients with AS. Otherwise, status of arthritis (p = 0.442), enthesitis (p = 0.482), and HLA-B27 (p = 0.528) seemed to have no effect on IMT. CONCLUSION: AS is associated with an increased risk of atherosclerosis independent of traditional risk factors. Disease activity, functional and mobility limitations, structural damage, and inflammation are the most incriminated risk factors.

Correlations among clinical, radiographic, and sonographic scores for enthesitis in ankylosing spondylitis.

OBJECTIVES: To look for correlations among clinical, radiographic, and sonographic scores for enthesitis in patients with ankylosing spondylitis (AS). METHODS: Prospective study of 60 patients meeting modified New York criteria for AS. The clinical evaluation relied on the BASDAI, BASFI, and ASQoL and on a visual analog scale (VAS) for entheseal pain, as well as on two specific enthesitis indices, the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and the Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Radiographs and ultrasound scans were taken of five entheses on both sides (patellar insertion of the quadriceps tendon, proximal and distal insertions of the patellar tendon, and calcaneal insertions of the Achilles tendon and superficial plantar fascia). Ultrasound scans were obtained using a Philips HD 11™ machine with a high-frequency linear probe. RESULTS: We studied 48 men and 12 women with a mean age of 36±11 years. The radiographic score correlated with the VAS pain score, BASDAI, and BASFI. The sonographic score for acute enthesitis correlated only with the MASES, and the sonographic score for chronic enthesitis correlated with none of the clinical scores. The Doppler score correlated with the VAS pain score, BASDAI, BASFI, and ASQoL. The overall sonographic score correlated with the MASES and SPARCC. CONCLUSION: Good correlations were found between the clinical and sonographic scores for enthesitis. The radiographic score seemed correlated with the general AS parameters rather than with the clinical scores. Larger studies are needed to better define the role for radiographs and sonography of the entheses in the diagnosis of AS and follow-up of treated AS patients.