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Age / Sex : 55 / M
Chief complaint : Left knee swelling & pain (Spontaneous, 5months)
What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of this case. (Please submit only one answer)
Courtesy: Juhng Seon Kwan, WONKWANG
UNIVERSITY SCHOOL OF MEDICINE & HOSPITAL
Diagnosis: Tuberculous arthritis
Discussion
Findings:
Plain radiograph – Diffuse soft tissue
swelling and increased knee joint effusion with ill-defined periarticular
osteopenia and marginal bony erosions
MR – Large amount of joint effusion with
distended subpopliteal bursa are seen. Multifocal peripheral located osseous
erosions are noted with adjacent bone marrow edematous change. Diffuse
proliferated synovium with hypointensity on T2-weight images is noted and amorphous
dark signal intensity areas within
synovial fluid of the distended joint space and subpopliteal bursa are seen. Gadolinium-enhanced
T1-weighted MR image demonstrates strong enhancement of thickened synovium.
Differential Diagnosis: Chronic rheumatoid
arthritis, Diffuse tenosynovial giant cell tumor (PVNS), Gouty arthritis, Hemophilic
arthropathy,.
Diagnosis: Tuberculous arthritis
Discussion:
Tuberculous arthritis is typically monoarticular
and primarily involves the large weight-bearing joints such as the hip and
knee. A triad of radiologic abnormalities (Phemister triad) is periarticular
osteoporosis, peripherally located osseous erosion, and gradual diminution of
the joint space.
On MR, synovial proliferation is typically hypointense on
T2W images because of presence of hemorrhage, inflammatory debris, fibrosis,
and caseation necrosis. Marginal
erosions may simulate rheumatoid arthritis; however, the monoarticular
involvement and preservation of joint space in tuberculosis helps distinguish
between the two conditions.
Bone marrow edema and
soft tissue abnormalities such as para-articular abscess formation may be seen.
References:
Harisinghani MG, McLoud TC,
Shepard JA, Ko JP, Shroff MM, Mueller PR. Tuberculosis from head to toe. RadioGraphics. 2000;20:449–70
Suh JS, Lee JD, Cho JH, Kim MJ,
Han DY, Cho NH. MR imaging of tuberculous arthritis: clinical and experimental
studies. J Magn Reson Imaging. 199;6(1):185-189
Choi JA, Koh SH, Hong SH et-al. Rheumatoid
arthritis and tuberculous arthritis: differentiating MRI features. AJR Am J
Roentgenol. 2009;193 (5): 1347-53
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