...

No Slide Title

by user

on
Category:

aids and hiv

0

views

Report

Comments

Transcript

No Slide Title
1983-1984
•
•
Carlos Pineda
Roger Kerr
Roger Kerr, Los Angeles, CA
•
49 year old male with 6 month history of
wrist pain and swelling.
•
Past medical history is negative.
•
PE: exquisite tenderness over distal ulna
with loss of extension of 4th and 5th fingers.
•
Routine laboratory studies are negative.
49 year old male with 6 month history of wrist
pain and swelling.
PA view of wrist: Enlargement of ulnar styloid with
lytic/erosive change and soft tissue swelling.
49 year old male with 6 month history of wrist
pain and swelling.
Coronal T1weighted image:
intermediate
signal intensity
mass surrounds
and engulfs ECU
tendon with
erosion of distal
ulna.
49 year old male with 6 month history of wrist
pain and swelling.
Sagittal T1-weighted
image: intermediate
signal intensity
mass surrounds and
infiltrates ECU
tendon.
49 year old male with 6 month history of wrist
pain and swelling.
Consecutive axial T1-weighted images at level of ulnar
styloid: ECU tendon is replaced by predominantly
intermediate signal intensity mass that erodes distal ulna.
49 year old male with 6 month history of wrist
pain and swelling.
Axial T1-weighted and axial T2-weighted images,
respectively, at level of tip of ulnar styloid: mass of
predominantly intermediate signal intensity has
replaced ECU tendon and erodes ulna.
49 year old male with 6 month history of wrist
pain and swelling.
•
Bone scan revealed increased uptake of
radionuclide at both 1st MTP joints,
ankles and knees and at left midfoot and
left shoulder.
Differential diagnosis
•
Tophaceous gout
•
Tendon sheath lesions: giant cell tumor,
fibroma , xanthoma
•
Tuberculous tenosynovitis
•
Rheumatoid arthritis with fibrous pannus
•
Amyloidosis
•
Clear cell sarcoma
Dx: Tophaceous gout of tendon
•
At surgery ECU and EDC (4th,5th)
tendons were debrided of chalky
material and crystalline deposits.
•
Histology: crystals with strong
negative birefringence, dense fibrous
connective tissue and mild chronic
synovitis.
Dx: Tophaceous gout of tendon
•
Gout of tendon: usually in patient with
established diagnosis of gout. Tendon
infiltration, tenosynovitis, tendon rupture,
entrapment neuropathy. Often mis-diagnosed
clinically as tumor or tumor-like lesion.
•
Gout: usually heterogeneous intermediate to
low signal intensity on T2-weighted images
related to fibrous tissue and urate crystals.
Intense gadolinium enhancement.
Roger Kerr, Los Angeles, CA
•
5 year old male presents with a 2 day
history of pain and swelling of left knee.
•
Vague history of knee pain 4 weeks ago
treated with NSAIDS.
•
No history of trauma or recent infection.
•
No other joint problems.
•
WBC=9.4; ESR=44; Febrile (up to 102)
5 year old male presents with a 2 day history of
pain and swelling of left knee.
Lateral radiograph of the knee
5 year old male presents with a 2 day history of
pain and swelling of left knee.
AP radiograph of the knee
5 year old male presents
A
B with a 2 day history of
pain and swelling of left knee.
Immediate (A) and delayed (B) 99mTcMDP images were
interpreted as consistent with septic arthritis with no
evidence of osteomyelitis.
5 year old male presents with a 2 day history of
pain and swelling of left knee.
•
Joint aspiration yielded cloudy fluid with 80,000
WBC/mm3 (99% PMNs) and 100,000
RBC/mm3.
•
Arthroscopic drainage and debridement of the
joint was performed on the third hospital day.
•
Patient was treated with IV antibiotic
(Ceftazidine, then Vancomycin) but knee
swelling and pain and fever persisted. On day
10, an MRI was obtained.
5 year old male presents with a 2 day history of
pain and swelling of left knee.
A sagittal T2weighted image
reveals a large
joint effusion,
synovial
hypertrophy, intraarticular debris and
a large high signal
intensity lesion of
the patella c/w
septic arthritis and
osteomyelitis/bone
abscess.
5 year old male presents with a 2 day history of
pain and swelling Bof left knee.
B
A
Successive axial
intermediate-weighted
images reveal extension of
this lesion through the
anterior cortex of the
patella.
C
Diagnosis: septic arthritis of the knee and
osteomyelitis/bone abscess of the patella
•
Incision and drainage of the patella was
performed and purulent fluid was removed.
•
Histology revealed acute and chronic
inflammation and Staph aureus was cultured.
•
The patient recovered following a course of IV,
followed by oral, antibiotics.
Osteomyelitis of the patella
•
Rare – usually due to direct implantation from a break in
the skin, puncture wound, septic bursitis or septic
arthritis.
•
Hematogenous spread to patella is exceedingly rare; rich
blood supply and no physeal plate with its sluggish
hemodynamics.
•
Acute or insidious onset.
•
Local signs or symptoms vs. systemic illness.
•
Diagnosis is often delayed or overlooked as clinician
assumes patient only has joint, bursal or soft tissue
infection.
Osteomyelitis of the patella
•
Clue to diagnosis: pt. not responding to
standard management of septic arthritis.
•
Surgical debridement indicted for
subperiosteal/bone abscess or chronic
osteomyelitis.
•
In this patient, radiographs and bone scan
were negative for osteomyelitis due to
immaturity of patellar development. MRI was
definitive.
•
Roy DR et al: Osteomyelitis of the patella in
children. J Ped Orthop 1991;11:364-366.
Fly UP