Imaging Rheumatoid Arthritis

Transcription

1 April 2002 Imaging Rheumatoid Arthritis Aimee Shu, Harvard Medical School, Year III

2 Meet Ms. M 50-year old female 22-year history of seronegative rheumatoid arthritis (RA) Followed at BIDMC rheumatology department Films from present in BIDMC Film Library 2

3 Ms. M s RA at a Glance Netter, The Ciba Collection of Medical Illustrations Age 28: trouble opening jars, episodic swelling of hands Principle sites: hands, wrists, feet Initially, rapid bony changes Developed osteoporosis Past DMARDs*: azathioprine, hydroxychloroquine, gold Present drugs: leflunomide, prednisone, piroxicam Disease now relatively stable Left wrist continues to give her most trouble *DMARD = disease-modifying anti-rheumatic drug 3

4 Rheumatoid Arthritis: Definition Chronic, inflammatory, systemic disease Etiology unknown Prominent characteristic = symmetric polyarthritis Extra-articular manifestations in 20% of patients Variable presentation at onset Variable clinical features 4

5 Diarthrodial Joint Anatomy synovium fibrous capsule cartilage Marginal areas where synovium directly touches bone (without cartilage in between) are designated with small black arrows. Resnick & Niwayama, Diagnosis of Bone and Joint Disorders Cross section through cadaveric MCP joint 5

6 Joint Pathology: Progressive Stages Synovitis pannus* joint destruction Pannus = granulation tissue Netter, The Ciba Collection of Medical Illustrations 1. acute synovitis 2. continued synovitis, pannus formation, cartilage destruction, mild osteoporosis 3. fibrous ankylosis, subsidence of inflammation 4. bony ankylosis, advanced osteoporosis 6

7 American College of Rheumatology Criteria for RA 4 of the following 7: Morning stiffness Arthritis of > 3 joint areas Arthritis of hand joints Symmetric arthritis Rheumatoid nodules Serum rheumatoid factor Radiographic changes Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:

8 Rheumatoid Arthritis: Epidemiology 1.0% of Americans 2.5 female : 1 male Onset between ages Peak incidence between ages Associated with certain HLA-DR haplotypes 8

9 Agenda Broad overview of systemic manifestations Focus on Ms. M Focus on imaging hand pathology conventional radiography MRI Brief visit to Ms. T 9

10 Articular Manifestations Areas of joint involvement Symmetrical involvement, listed from most least commonly affected Hands, wrists Feet, ankles Knees Hips Cervical spine Shoulders Elbows Klippel, John, Primer on the Rheumatic Diseases, 2 nd ed,

11 Hands & Wrists Almost always affected in RA MCPs, PIPs swollen and/or deformed DIPs spared Ulnar deviation at MCP Radial deviation at the carpals Swan-neck deformities Boutonnière deformities Neuropathy, e.g. carpal tunnel syndrome ulnar deviation Image from: Eric A. Brandser on Virtual Hospital site, 11

12 Extra-Articular Manifestations Nodules Vasculitis Rheumatoid factor = anti-igg antibodies Ocular: keratoconjunctivitis sicca, scleritis Nodular episcleritis Radiograph showing right lung nodule Netter, The Ciba Collection of Medical Illustrations 12

13 Extra-articular manifestations Pulmonary: interstitial lung disease, pleural effusion Cardiac: pericardial effusion, pericarditis Subcutaneous nodules over knuckles 3 rd phalange: swan-neck deformity Ulnar deviation Muscle atrophy Subcutaneous nodules in olecranon bursa and just distal to olecranon process Netter, The Ciba Collection of Medical Illustrations 13

14 Imaging Modalities Conventional radiography Magnetic resonance imaging (MRI) Bone densitometry (DEXA) Evaluate osteoporosis Ultrasound Not often used for RA in US; more often in Europe Computed tomagraphy Only as adjunct; not as primary modality Bone scintigraphy Confirm disease presence Evaluate disease distribution & activity 14

15 Role of Imaging in RA Assist in diagnosis Early & aggressive treatment is now the standard of care Track disease progression Evaluate response to treatment Classify disease severity for research/clinical trials 15

16 Characteristic Changes on Plain Film Individual findings are non-specific since synovium reacts in limited # of ways But patterns and combinations of findings can suggest RA 16

17 Characteristic Changes on Plain Film Soft tissue changes Early swelling Later atrophy Periarticular fat displacement (large joints) Cartilage changes Joint space wide narrow wide Secondary to inflammation, cartilage destruction, ligamentous laxity, respectively 17

18 Characteristic Changes on Plain Film Bony changes Marginal bony erosion: periarticular bare areas Subchondral cyst formation Juxta-articular osteopenia generalized osteopenia Lack of bony response to overwhelming bone and joint destruction is characteristic of RA Subluxation & dislocation Flexion & extension contracture Ankylosis 18

19 Hand Anatomy Review Normal hand radiograph BIDMC Film Library 19

20 Hand Anatomy Review DIP joint Sesamoid bones = ovoid nodules embedded in tendons; # variable in between people PIP joint radius MCP joint Carpal bones ulna Wicke, Atlas of Radiologic Anatomy 20

21 trapezium trapezoid capitate hamate Carpal Bones scaphoid lunate triquetral pisiform 21

22 Conventional Radiography of Hands ABC S Alignment Bone mineralization Cartilage Soft tissue PA and oblique views low dose radiation for hands, therefore serial studies are relatively safe 22

23 Ms. M s Initial Presentation, Age , age 28, episodic pain & swelling Right lateral oblique view ( Zither player position ) Normal mineralization Normal joint space 4 th digit, middle phalanx: small cystic changes & minimal soft tissue swelling, consistent with post-traumatic cyst BIDMC Film Library 23

24 Ms. M s Initial Presentation 1981, age 28 Left lateral oblique BIDMC Film Library 24

25 Ms. M, 1983, Age 30 Right AP (dorsopalmar) view Changes since 1981 Erosions: 2 nd metacarpal, 3 rd DIP, 4 th PIP Soft tissue swelling Consistent with RA BIDMC Film Library 25

26 Ms. M, 1983, Age 30 Left AP view Erosions: 3 rd & 5 th PIPs Cyst: 1 st IP Soft tissue swelling around PIPs, MCPs BIDMC Film Library 26

27 Ms. M, 1986, Age 33 Right lateral oblique Disease progression Erosions: 2 nd MCP, 3 rd & 4 th PIPs, 3 rd DIP, 1 st IP Decreased joint spaces BIDMC Film Library 27

28 Ms. M s RA Progresses, Right AP Views joint space, new erosions: 3 rd MCP, 4 th PIP, 5 th PIP Note 1 st IP fused by screw Erosions: 2 nd -5 th MCPs, 4 th -5 th PIPs, 4th-5 th DIPs Carpal cysts 1988, Age , Age 42 BIDMC Film Library 28

29 Ms. M, Left Lateral Oblique, 1995, Age 42 This view shows ulnar styloid erosion 2 nd MCP subluxation BIDMC Film Library 29

30 Advantages of MRI Better than conventional radiography at imaging soft tissue, marrow, & cartilage Multiplanar Can assess complications Tendon tear or rupture Synovitis, tenosynovitis, bursitis Erosions, cysts, fibrocartilage degeneration May show erosions earlier than plain film Up & coming! 30

31 Ms. M, 2002, Age 49 Anatomy Pointers radius ulna MR (T2), Left wrist, Axial view. BIDMC Film Library flexor retinaculum (Carpal tunnel) contains tendons and median nerve Tendon sheath normally indistinct from tendon (low signal; dark in this view) 31

32 Findings Ms. M, 2002, Age 49 Tenosynovitis Extensor carpi ulnaris tendon Flexor carpi radialis tendon Synovial proliferation MR (T2), Left Wrist Axial view. BIDMC Film Library * Tenosynovitis = tendon sheath inflammation, seen in RA or repetitive trauma. In contrast, tendonitis = tendon inflammation, signal would be within tendon; seen with overuse 32

33 More proximally, flexor carpi radialis appears normal MR (T2), Left Wrist Axial view. BIDMC Film Library 33

34 Extensor carpi ulnaris 34

35 Flexor carpi radialis 35

36 MR Normal Wrist, Coronal View 3 important areas: triangular fibrocartilage (TFC) scapholunate ligament (SL) lunotriquetra ligament (LT) These areas confer stability Commonly injured pain T2-weighted gradient echo. BIDMC Film Library 36

37 Ms. M: TFC Tear & SL Tear Gap > 2 mm indicates SL tear signal = TFC tear * SL tear nickname is David Letterman sign reminiscent of the talk show host s gap teeth. T2-weighted gradient echo. BIDMC Film Library 37

38 Ms. M: Erosions on MRI T2-weighted gradient echo. BIDMC Film Library 38

39 Sagittal View of Normal TFC triquetral ulna Notice ample joint space between ulna and triquetral bones T1 MRI, left wrist. BIDMC Film Library 39

40 Ms. M: TFC Tear ulna and triquetral bones touch Carpal tunnel T1 MRI, left wrist. BIDMC Film Library 40

41 What is This Bulge on Ms. M? No, it is not her thumb T2 MRI, left wrist. BIDMC Film Library It is a vitamin E tablet to mark the area of her pain! 41

42 Now Meet Ms. T 62yo woman, h/o RA and 50 lb weight loss, right leg shorter than left, inability to ambulate. Please evaluate Acetabuli protrusio into ilium hips involved in 50% RA patients cartilage allows femoral head to migrate superomedially within acetabulum more severe with time BIDMC Film Library 42

43 Normal shoulder BIDMC Film Library 43

44 Ms. T s Shoulder Findings on Ms. T: erosions, fusions, superior subluxation Shoulders involved in 50% RA patients Narrowing of all compartments of shoulder glenohumeral acromiohumeral acromioclavicular humeral head migrates proximally & superiorly BIDMC Film Library 44

45 Arthritides monoarticular polyarticular trauma infection gout pseudogout rhematoid types RA SLE scleroderma DM inflammatory degenerative metabolic deposition rheumatoid variants OA ankylosing spondylitis Reiter s syndrome psoriatic arthritis IBD Gout Amyloidosis 45

46 Arthritides Radiographic findings rarely pathognomonic for arthritides Must use radiographic findings in conjuction with clinical presentation 46

47 Feature Carpal erosions Differential Diagnoses Ulnar deviation & volar subluxation of proximal phalanges Narrow joint space Bony destruction ( punched-out lesion) Swell, erode, cyst Also seen in Gout SLE, Jaccoud s syndrome 2º to rheumatic fever Osteoarthritis Sarcoid Psoriatic arthritis 47

48 RA: Distinguishing Features Diffuse (vs. limited to juxta-articular) osteoporosis Lack of new bone formation 48

49 Summary: Key Points Conventional radiography and MRI are especially useful in imaging RA Chronic, progressive changes are evident in the hands and wrists Characteristic changes on plain film include bony erosions, joint space narrowing, & osteoporosis On MRI: tenosynovitis, synovial proliferation, cartilage tear, tendon rupture 49

50 References American College of Radiology Film Library Britton, Cynthia A. and Mary Chester Wasko, Rheumatoid Arthritis, Seminars in Roentgenology 31 (3): , July Brower, Anne C., Arthritis in Black and White, 2 nd ed., W.B. Saunders, Edeiken, Roentgen Diagnosis of Diseases of Bone, 3 rd ed., Forrester, D.M. and J.C. Brown, The Radiology of Joint Disease, 3 rd ed., W.B. Saunders, Grassi, Walter, Rossella De Angelis, Gianni Lamanna, and Claudio Cervini, The Clinical Features of Rheumatoid Arthritis, European Journal of Radiology 27:S18-24, Klippel, John H., Primer on Rheumatic Diseases, 2 nd ed., Netter, Frank H., The Ciba Collection of Medical Illustrations, Volume 8: Musculoskeletal System, Part II: Developmental Disorders, Tumors, Rheumatic Diseases, and Joint Replacement, CIBA- GEIGY, Reid, Graham, and John M. Esdaile, Rheumatology: Getting the Most Out of Radiology, Canadian Medical Association Journal 162(9): , May Resnick & Niwayama, Diagnosis of Bone and Joint Disorders, 2 nd ed., W.B. Saunders, Stoller, David W., The Wrist, Seminars in Roentgenology 30 (3): , July Taveras & Ferrucci, Radiology, J.B. Lippincott Co., Wicke, Lothar, Atlas of Radiologic Anatomy, 5 th English ed., 1994 Winalski, Carl S., William E. Palmer, Danieal I. Rosenthal, and Barbara N. Weissman, Magnetic Resonance Imaging of Rheumatoid Arthritis, Radiologic Clinics of North America 34 (2): , March

51 Acknowledgements, Radiology Course Director, BIDMC Pamela Lepkowski, Student Coordinator, BIDMC Daniel Saurborn, MD, Resident in Radiology, BIDMC Daniel Lim, MD, Radiology Staff, BIDMC Larry Barbaras and Cara Lyn D amour, Webmasters, BIDMC 51