Age / Sex : 25 / M

Age / Sex : 56 / M
Chief complaint: Pain and swelling in both shoulder joints for one month

1) What is your impression?

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

* Send Application Answers to In Sook Lee, MD (lis@pusan.ac.kr)

Courtesy :

Amyloid Arthropathy

Discussion

Findings: Fig.1. AP radiograph of the right shoulder shows soft tissue swelling around the shoulder joint and multiple radiolucent lesions of variable size in the diaphysis of the humerus.

          Fig.2,3. Transverse US images obtained over the right biceps tendon and left             suprasupinatus tendon demonstrate swelling of them with hypoechoic soft tissues.    

          Fig.4-6. On T2-weighted spine echo MR images, rotator cuff tendons are swollen and have heterogeneous signal intensities. Rotator interval and subdeltoid bursa are filled with soft tissues of heterogeneous signal intensities.     

Differential Diagnosis: Pigmented villonodular synovitis  

                      Uncalcified synovial osteochondromatosis

                      Tuberculous arthritis

                      Rheumatoid arthritis

                      Silicone synovitis

                      Gout

Discussion:

• Amyloidosis is defined as the extracellular deposition of the fibrous protein amyloid in one or more sites in the body.


• Amyloid protein is not filtered by standard dialysis membranes and tends to accumulate within the musculoskeletal system; therefore, amyloid arthropathy is seen in patients undergoing long-term hemodialysis.


• Amyloid arthropathy may involve the axial skeleton, especially the cervical spine, or the peripheral skeleton.


• Patients can also develop carpal tunnel syndrome and osteolytic bone lesions (amyloidomas).


• Shoulder pain and carpal tunnel syndrome are the most common clinical manifestations.

Imaging Findings for Amyloid arthropathy

• In the glenohumeral joint and other large joints, amyloid arthropathy resembles inflammatory arthritis with juxtaarticular soft-tissue swelling, mild periarticular osteoporosis, and subchondral cystic lesions, usually with well-defined sclerotic margins.


• Usually, the joint space is normal in width until late in the course of the disease.


• Patients with amyloidomas of bone or with large subchondral lesions have a high prevalence of pathologic fractures.


• The MR imaging appearance of amyloid infiltration within or around the joint consists of extensive deposition of an abnormal soft tissue that has low or intermediate signal intensity on T1-weighted images and low to intermediate signal intensity on T2-weighted images.


• This abnormal material covers the synovial membrane, fills subchondral defects, and extends to periarticular soft tissue.

References:

Patrick J. Sheldon, Deborah M. Forrester.Imaging of amyloid arthropathy. Semin Musculoskelet Radiol 2003; 7(3): 195-204

Llauger J, Palmer J, Rosón N, Bagué S, Camins A, Cremades R. Nonseptic Monoarthritis: Imaging Features with Clinical and Histopathologic Correlation. RadioGraphics 2000 20: 263S-278S.