SEPTILISED PÕLETIKUD MUSKULOSKELETAALSÜSTEEMIS. MRT kool aprill 2012 Karin Veske SATÜK radioloogiakliinik
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1 SEPTILISED PÕLETIKUD MUSKULOSKELETAALSÜSTEEMIS. MRT kool aprill 2012 Karin Veske SATÜK radioloogiakliinik
2 MUSKULOSKELETAALSED INFEKTSIOONID Nahk/nahaalune rasvkude Bursad Kõõlused Fastsia Lihased tselluliit infektsioosne bursiit infektsioosne tenosünoviit fastsiit mittenekrotiseeriv fastsiit nekrotiseeriv fastsiit müosiit/ püomüosiit flegmoon/pehmete kudede abstsess Luukorteks Luuüdi Liigesed osteiit osteomüeliit septiline artriit
3 SOODUSTAVAD FAKTORID ülekaalulisus alatoitumus, madal elatus ja hügieenitase i/v narkootikumid (IVDU), alkoholism immuunpuudulikkus, HIV, AIDS kortikosteroidid RA organite transplantatsioon diabeet (naha haavandid, mikrotsirkulatsiooni häirumine) baktereemia sirprakuline aneemia perifeerne vaskulaarne haigus lümfostaas iatrogeenne (postop seisundid, i/v kateetrid, ortopeedilised implantaadid, nahka läbivad fiksaatorid, liigesesisesed süstid) trauma, võõrkehad, putuka/looma/inimese hammustus
4 TEKITAJAD. Staphylococcus aureus 50-60% Escherichia coli 29% streptokokid 8% Staphylococcus epidermidis Mycobacteria HIV atüüpiline mükobakter 30% anaeroobid + aeroobne G- bakter nekrotiseeriv fastsiit sõltlased Pseduomonas 86%, klebsiella, enterobakterid Septiline artriit < 4 a. Streptococcus pyogenes Staphylococcus aureus Haemophilus influenzae > 4 a. St. aureus >10 a. St. aureus, Neisseria gonorrhoeae Harva Clostrdium, Nocardia viirused, seened, parasiidid
5 KLIINIK. Lokaalsed sümptomid valu, turse, punetus, soojuse produktsioon, funktsiooni piiratus palpatoorne tihenemine, nahaalune krepitatsioon (pehmete kudede infektsioon) lastel äge kliinik TK loium kulg, sümptomid mittespetsiifilised - septiliste põletike diagnoosimine hilineb, pöördumisel esinevad juba tüsistused. Üldsümptomid. palavik (66%), nõrkus, väsimus, sepsis leukotsütoos, SR, CRV tõus baktereemia (UG põletik, kopsupõletik, endokardit, hambajuure põletikud) Osteomüeliit - verekülvid 50% positiivsed, 25% ei leita võetud materjalist tekitajat
6 PILTDIAGNOSTIKA RÖ UH KT MRT luumuutused > pehmete kudede muutused trauma, subluksatsioonid, võõrkehad, gaas/õhk, kr. OM, postop seisundid subperiostaalne /pehmete kudede abstsess, hüperperfusioon, interventsioonid pehmete kudede turse, gaas, abstsessid, võõrkeha periostaalne reaktsioon, luuüdi rasva tiheduse muutused luuerosioonid/destruktsioonid KT biopsia valikmeetod MS infektsiooni leviku ja tüsistuste hindamiseks DDX OM septilisest artriidist, pehmete kudede abstsessist, muu organlähtega põletikust (appenditsiit, tuboovariaalsed abstsessid) pehmete kudede kontrastsus MRI > KT T2W, STIR, T2FS kujutised informatiivsed ka ilma i/v KA kasutamata Isotoopuuring mitmekoldeline infektsioon, halb ruumiline lahutusvõime
7 MRT Kujutise tasapinnad Vaagen, puusaliigesed, ranne, õlg ax, cor Põlv, hüppeliiges, küünarliiges ax, sagit Labajalg ax, cor, sagit Sekventsid T1W, T2W, STIR, T2FS postkontrast T1FS Gd+ muutused T1W ja vedeliktundlikes sekventsides Tõstab tundlikkust 88% -> 93% ja spetsiifilisust 53% -> 79%. - abstsess/ tselluliit/ flegmoon - suurendab fistuli ja sekvestri leidmise tõenäosust - reieluu pea perfusioon
8 T1W norm TSELLULIIT. Äge naha ja nahaaluskoe infektsioon, ei ulatu sügavamale pindmisest fastsiast. DGN on kliiniline. Naha vigastus võib olla väga väike. DDX perifeersed tursed, lümfostaas,veenitromboos T1W STIR MRT protsessi ulatus, sügavus, tüsistused nahk, nahaalune kude paksenenud nahaaluskoe septide turse T1W madal signaal T2W/STIR kõrge signaal tursealad Gd+ erineva intensiivsuse ja ulatusega. Tüsistused: infektsiooni levik sügavamale -> müosiit/ nekrotiseeriv fastsiit/ osteomüeliit /pehmete kudede abstsess
9 INFEKTSIOOSNE FASTSIIT. Mittenekrotiseeriv fastsiit. Nekrotiseeriv fastsiit. Fayad L M et al. Radiographics 2007;27: harv polümikrobiaalne infektsioon immuunpuudulikkus kiirelt progresseeruv pindmised ja süvafastsiad lihased on haaratud sekundaarselt kudede nekroos, gaas, veresoonte trombid scrotum, perineum, alajäsemed, kael surevus 70 80% kiire fastsiotoomia, debridement RÖ pehmete kudede turse ja gaas KT lihaste ja süva fastsiate turse, vedelik ja gaas piki fastsiaid.
10 INFEKTSIOOSNE FASTSIIT. MRT. T1W T2FS tselluliit fastsiit T2FS/ STIR fastsiad kõrge signaaliga (turse/nekroos/vedelik) gaas piki fastsiaid- signaalita alad Gaasi puudumine ei välista nekrotiseerivat fastsiiti! lihase turse T2W/STIR halvasti piirdunud kõrge signaaliga kolded PostGd T1/T1FS MNE fastsiit - fastsiate ja lihaste kontrasteerumine korreleerub T2/STIR kujutistel patoloogilise signaali tõusuga Nekroos - fastsiad ei kontrasteeru Oht protsessi mahu alahindmisele STIR > GdT1W aitab eristada abstsessikollet tursest T1FS Gd MRI võib olla mittespetsiifiline, oluline on kliinik! MRT aitab omavahel diferentsida tselluliiti nekrotiseerivast fastsiidist.
11 INFEKTSIOOSNE MÜOSIIT. PÜOMÜOSIIT. Harv. Immuunpuudulikkus HIV/AIDS Hematogeenne levik seedetrakti, kuseteede infekts-d Otsene infitseerumine - i/m süstid, postop Pidev levik - OM, septiline artriit. Terve lihas on infektsioonile resistentne. Tugeva pingutuse järgne rabdomüolüüs, lihase trauma, hematoomi infitseerumine, diabeet. Fayad L M et al. Radiographics 2007;27: m. quadriceps femoris, m. gluteus, m. iliopsoas ülajäseme lihased harva. 3 staadiumi invasiivne - turse -> lihasvalu suppuratiivne - palavik, nekroos, abstsess/-id sepsis mitmekoldeline 11% 43%. MRT > KT kaasuv osteomüeliit, septiline artriit
12 T2FS T1W T1FSGd MRT lihase läbimõõt suureneb tselluliit lihase turse T1W madala/stir,t2w kõrge signaaliga flegmoon fokaalne halvasti piirdunud, Gd+ lihasesisene abstsess on hästi piirdunud tsentraalosa nekrotiseerunud kude T1W keskmine, madal signaal (veri,valgusisaldus S) STIR, T2W kõrge (inhomnogeenne) signaal gaas signaalita kõikides rezhiimides abstsessi pseudokapsel Gd+ T1W penumbra sign pseudokapsel keskmise S-ga (granulatsioonkude, eristab abstsessi tuumorist) abstsessi ümber halvasti piirdunud turseala, mis võib kontrasteeruda MRT sensit. 89%, spetsiifil. 80% DDX primaarne tselluliit, tuumori nekroos spontaanne lihase nekroos diabeet, leukotsütoos puudub, võib olla kahepoolne
13 m.ex. carpi ulnaris INFEKTSIOOSNE TENOSÜNOVIIT. Sünooviaga kõõlustupe mädane põletik. Torkehaav või infektsiooni otsene levik. T2FS T1W MRT kõõlustupes rohkenenud vedelik T1W madala / T2W kõrge signaaliga. sünoovia pakseneb, Gd+ (hüpereemia) kõõlus pakseneb, eristub halvasti, kaotab madala signaali tselluliit (võib olla tagasihoidlik) DDX Mitteinfektsioosne /tb tenosünoviit RA Septilist ja aseptilist tenosünoviiti ei ole ainult piltdiagnostika alusel võimalik diferentsida. T1FS Gd
14 STIR postgdt1fs INFEKTSIOOSNE BURSIIT. Sünooviaga bursa äge põletik. Torkehaav, võõrkeha pindmised bursad (bursa olecranii, prepatellaarne bursa) Hematogeenne külv - süvabursad Infektsiooni levik liigesest bursasse Trauma anamnees puudub -> DDX TBC AJR July 2004 vol. 183 no RÖ mittespetsiifiline pehmete kudede varju laienemine, gaas/õhk bursades (harva), luulised muutused MRT - bursa vedelik T1W madal signaal T2/STIR kõrge signaal - õhumullikesed signaalita - sünoovia Gd+ - ümbritsevate kudede turse T1W madal signaal STIR/T2 W kõrge signaal - kaasuv liigesefusioon reaktiivne või infitseeritud Septilist/ aseptilist bursiiti kujutiste alusel diferentsida ei saa. Septilise bursiidi tõenäosus on väiksem kui bursa seinad ja ümbritsev pehme kude ei kontrasteeru.
15 OSTEOMÜELIIT Luukorteksi ja luuüdi põletik Äge < 2 nädala Alaäge Krooniline > 6 nädala ravimata OM/ ebaadekvaatne ravi Fayad L M et al. Radiographics 2007;27: OM eritüübid Brodie abstsess Krooniline mitmekoldeline osteomüeliit Skleroseeriv e. Garré osteomüeliit Infektsiooni levik Hematogeenne levik 85% < 17 a., kiirelt kasvav luu, 70% toruluud - femur, tibia, humerus TK 53% > 50 a. lülisammas, vaagen, väikesed luud Pidev levik - TK,diabeetiline jalg, lamatis, HIV, IVDU Otsene saastumine (trauma, iatrogeenne)
16 HEMATOGEENSE OM EALISED ERINEVUSED. < 18 elukuud Fetaalne luuverevarustus. Peale 1 e.a. kasvuplaadi veresooned sulguvad. Metafüüs on infektsioonidele vastuvõtlikum: korteks õhem, vähem fagotsüteerivaid rakke, rikkalik kapillaarne aeglane verevarustus. Põletikuline eksudaat, veresoonte obstruktsioon -> intraossaalse rõhu tõus -> leevendub mäda liikumisega piki Volkmanni kanaleid subperiostaalsele (periost on luuga lõdvalt seotud) metafüüs -> subperisotaalne abstsess metafüüs -> epifüüs -> septiline artriit (sage) Väljendunud periostaalne reaktsioon, pehmete kudede abstsessid, tselluliit
17 HEMATOGEENSE OM EALISED ERINEVUSED. 18 kuud 16 a. Epifüüsi/metafüüsi verevarustus eraldunud. Kasvuplaat kõhreline, avaskulaarne. Metafüüs hästi vaskulariseeritud, arterid teevad tagasipöörduva lingu -> põletik-> subperisotaalne abstsess (periost luuga lõdvalt seotud) Septiline artriit- tavaliselt ei teki v.a.puusa-, õla-, küünar-, põlveliiges Tõusnud luusisene rõhk, infitseerunud trombid, eleveerunud periost -> verevarustuse -> luunekroos -> sekvester (sage) -> periostaalne reaktsioon (piirab põletikku ja sekvestrit, lastel väljendunud)
18 HEMATOGEENSE OM EALISED ERINEVUSED. Täiskasvanud Peale kasvuplaadi sulgumist esineb ühine verevarustus epi-, meta- ja diafüüsi vahel. Metafüüsi piirkonna põletik levib kergelt subkondraalsele -> septiline artriit on sage Infektsiooni levik subperisotaalsele ja diafüüsile halvendab veelgi luu verevarustust > sekvestreerumine Periost on luuga tihedalt liitunud ja subperiostaalne abstsess ning periostaalne reaktsiooni vähene.
19 RÖ päev 95% luulise patoloogiata 28 päev 90% patoloogiaga 3-10 p. pehmete kudede muutused (turse, rasvatriipude kadumine) 7-14 p. osteopeenia destruktsiooni kolle/d involucrum perisotaalne uus luu stafülokokksepsis 30 p. peale haigestumist 3-8 näd. sekvester granulatsioonkoega ümbritsetud irdunud nekrootiline luu, histoloogiliselt kroonilise OM tunnus cloaca kanal luukorteksis/periostis, dreneerib luusisest abstsessi reaktiivne skleroos
20 ÄGE OSTEOMÜELIIT. Uuringute sensitiivsus spetsiifilisus RÖ 43-75% 75-83% MRT % (53%) 75-96% Isotoopuuring 85% 25% MRT OM algstaadiumis kõrge tundlikkus luuüdi turse ja kontrasteerumine (hüpereemia) on nähtav h pärast madal spetsiifilisus negatiivne eeldatav väärtus 100% - normaalne luuüdi signaal välistab osteomüeliidi
21 MRT STIR T1W T1FS Gd Luuüdi turse T1W madal signaal T2W /STIR kõrge signaal Gd+ Ümbritsevate pehmete kudede turse T1W madal signaal T2W kõrge signaal Subperiostaalne abstsess T1 keskmine signaal T2W/STIR kõrge signaal Korteksi destruktsioon kontuur hägustub, katkeb Normipäraselt on periost/korteks madala signaaliga kõikides rezhiimides
22 T1W T1WpostGd Abstsess T1W keskmine/madal signaal T2W kõrge signaal tsentraalne osa Gdsein Gd+ (granulatsioonkude) T1W penumbra sign MRT 2 nädalat peale haigestumist STIR T1W T1FSpostGd
23 T2FS T1W STIR KROONILINE OM. Involucrum Sekvester Granulatsioon madal signaal kõikides rezhiimides madal signaal kõikides rezhiimides, Gd- STIR,T2 kõrge signaal T1 keskmine-madal signaal Gd+, sekvester tuleb paremini esile T2 kõrge S defekt luukorteksis/ periostis Cloaca Fistul T1W madal signaal /T2W kõrge signaal T1FS Gd+ tram-track sign (granulatsioon) I/medull./subperiostaalne/pehmete kudede abstsess T1W madal S/ T2W kõrge S T1W penumbra sign Sein Gd+/ tsentraalne vedelik Gdpehmekoe põletikuline infiltratsioon, Gd+ Flegmoon Kortikaalsed destruktsioonid, gaas, sekvester KT > MRT Luuüdi turse põletikule viitab ghost sign T1W luuüdi signaal langeb ( kaob ) STIR, T2W, postgd T1FS tuleb selgelt nähtavale, S Põletiku taandumisel luuüdi turse asendub normipärase rasvasignaaliga -> STIR signaal /T1 signaal
24 BRODIE ABSTSESS Alaäge püogeenne OM, luuabstsess, lapsed > TK, M > N tibia > femur metafüüs/ < 2 a. epifüüs RÖ sääreluu metafüüsis (epifüüsis) piklik ebakorrapärase kujuga sklerootilise äärisega kolle, vastu kasvuplaati Pehmete kudede turse +/- Periostaalne reaktsioon/ sekvester tavaliselt puuduvad T1W MRT intraosaalne abstsess T1W madal/keskmine signaal T2W/STIR kõrge signaal Abstsessi sein T1W penumbra sign Sisemine kiht keskmise signaaliga granulatsioonkude Välimine kiht madala signaaliga turse/ reaktiivne skleroos ümbritseva luuüdi turse - T1 madala/t2 kõrge signaaliga, Gd+ ümbritsev skleroos T1W ja T2W madala signaaliga STIR DDX Epifüüsi/apofüüsi Brodie abstsess vs kondroblastoom. Brodie abstsess kontrasteerub perifeerias, kondroblastoom kontrasteerub difuusselt ja ebaühtlaselt.
25 1 a. T OM TÜSISTUSED 1 kuu 4 kuud 6 kuud sepsis septiline artriit abstsess,flegmoon, tselluliit, fistul levik teistesse luudesse patoloogiline murd luu abstsess luu nekroos lastel luukasvu häired luu deformatsioonid kroonil. OM - fistuli skvamoosrakuline ca! % 3 a. pärast 10 kuud 2 a.
26 SEPTILINE ARTRIIT 75% alajäse Lapsed hematogeenne, OM otsene levik liigesesse puusa - ja põlveliiges 90%, õlaliiges IVDU AC, SC, SIL, lülisammas, sümfüüs TK torkevigastus, traumad, väikesed liigesed monoartikulaarne mädane sünoviaalvedelik palavik, sepsise kliinik baktereemia, leukotsütoos RÖ ägedas staadiumis luulise patoloogiata pehmete kudede turse lastel liigesefusioon-> õla-, puusaliigese subluksatsioonid Kliiniliselt septiline artriit -> artrotsentees ja külv. TB artriit -> sünoovia biopsia. Pöördumatu liigeskahjustus tekib 48 tunni jooksul põletikulisse sünooviasse kogunevate leukotsüütide proteolüütiliste ensüümide toimel.
27 SEPTILINE ARTRIIT. Äge faas. MRT - kõhre kahjustus - liigesefusioon (mitte alati) T1W madal signaal T2W kõrge signaal Gd- - sünoovia kontrasteerumine (98% ) sünoovia halvasti jälgitav MRT < UH normipärselt kontrasteerub vähe, T1W keskmise/ T2W madala signaaliga - postgd reieluu pea perfusiooni häirumine (eristab lastel transitoorsest sünoviidist).
28 T1W Subakuutne faas 8-10 p. RÖ Liigespinna erosioonid-> kogu liigespinna destruktsioon -> kiire liigesvahemiku ahenemine Tbc puhul marginaalsed erosioonid, kõhr säilub kauem, ümbritseva luu skleroos. MRT Erosioonid T1W madal signaal STIR, T2W kõrge signaal pehmete kudede turse T2W, STIR kõrge signaal luuüdi turse T2W, STIR kõrge signaal T1W madal signaal hüpereemia Gd+ Luuüdi hüpereemia ja reaktiivne turse on eristamatud infektsioonist (ghost sign). T2WFS Tüsistused. Infektsiooni levik ümbritsevatesse kudedesse -> osteomüeliit, abstsessid AVN
29 Tüsistused. kasvuplaadi enneaegne konsolideerumine luu deformatsioonid, atroofia sek. OA anküloos 44a. M
30 1. Use of MR Imaging in Diagnosing Diabetes-related Pedal Osteomyelitis1 Andrea Donovan, MD and Mark E. Schweitzer, MD /rg May 2010 RadioGraphics, 30, Superficial Soft-Tissue Masses: Analysis, Diagnosis, and Differential Considerations1 3. Francesca D. Beaman, MD2, Mark J. Kransdorf, MD, Tricia R. Andrews,MD March 2007 RadioGraphics, 27, Imaging Findings in Musculoskeletal Complications of AIDS1 5. C. Santiago Restrepo, MD, Diego F. Lemos, /rg July 2004 RadioGraphics, 24, Superficial Soft-Tissue Masses: Analysis, Diagnosis, and Differential Considerations1 7. Francesca D. Beaman, MD2, Mark J. Kransdorf, MD, /rg March 2007 RadioGraphics, 27, MR Imaging of Squamous Cell Carcinoma Complicating Chronic Osteomyelitis of the Femur MRI Findings of Septic Arthritis and Associated Osteomyelitis in Adults 11. Michael Karchevsky1, Mark E. Schweitzer2, AJR January 2004 vol. 182 no American Journal of Roentgenologywww.ajronline.orgdoi: /AJR AJR August 2007 vol. 189 no Septic Arthritis Versus Transient Synovitis of the Hip: Gadolinium-Enhanced MRI Finding of Decreased Perfusion at the Femoral Epiphysis Kyu-Sung Kwack1, Jae Hyun Cho1, /AJR AJR August 2007 vol. 189 no Musculosceletal MRI Helms, Major, Anderson 2009 a.
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