Tuberculous syringomyelia in an HIV-infected patient: a case report

A 37-year-old HIV-positive Gambian woman presented with spastic weakness of the right leg six years after receiving treatment for tuberculous meningitis (TBM). Magnetic resonance imaging (MRI) of the spine showed a multiloculated syrinx in the thoracic spinal cord extending from the T2 to the T11 level. Syringomyelia and syringobulbia have been reported as complications of TBM. We describe the first case of syringomyelia as an uncommon late complication of treated TBM in the setting of HIV infection. Early recognition of this rare entity may avoid irreversible neurological sequelae.     

Comparison of in-office magnetic resonance imaging versus conventional radiography in detecting changes in erosions after one year of infliximab therapy in patients with rheumatoid arthritis

The objective of this study was to compare standard hand radiographs with in-office 0.2 T magnetic resonance imaging (MRI) in monitoring response to therapy in patients with rheumatoid arthritis (RA) who were receiving infliximab, to evaluate the frequency and location of erosions, and to determine if there were differences in outcome based on disease duration at baseline. Patients who satisfied the American College of Rheumatology criteria for RA and were receiving infliximab therapy were evaluated with a baseline and 1-year follow-up MRI. Magnetic resonance images were interpreted by two blinded, board-certified radiologists. Bone erosions were identified as well-defined defects extending through the cortical margin. The mean age of the 48 patients was 58.5 years. The median infliximab dosage was 4 mg/kg. Baseline data showed that 41 patients had abnormal MRIs. The mean time between the baseline and follow-up MRI examinations was 10.5 months. Follow-up MRI revealed regression in 11 patients. Thirty-one patients had both MRIs and radiographs. Magnetic resonance imaging was approximately twice as sensitive as radiography in detecting erosions at baseline. In-office MRI was useful in monitoring disease response after the initiation of infliximab treatment. Magnetic resonance imaging is potentially a very valuable diagnostic tool and prognostic indicator for use in patients with RA.     

Comparison of in-office magnetic resonance imaging versus conventional radiography in detecting changes in erosions after one year of infliximab therapy in patients with rheumatoid arthritis

Abstract

The objective of this study was to compare standard hand radiographs with in-office 0.2?T magnetic resonance imaging (MRI) in monitoring response to therapy in patients with rheumatoid arthritis (RA) who were receiving infliximab, to evaluate the frequency and location of erosions, and to determine if there were differences in outcome based on disease duration at baseline. Patients who satisfied the American College of Rheumatology criteria for RA and were receiving infliximab therapy were evaluated with a baseline and 1-year follow-up MRI. Magnetic resonance images were interpreted by two blinded, board-certified radiologists. Bone erosions were identified as well-defined defects extending through the cortical margin. The mean age of the 48 patients was 58.5 years. The median infliximab dosage was 4?mg/kg. Baseline data showed that 41 patients had abnormal MRIs. The mean time between the baseline and follow-up MRI examinations was 10.5 months. Follow-up MRI revealed regression in 11 patients. Thirty-one patients had both MRIs and radiographs. Magnetic resonance imaging was approximately twice as sensitive as radiography in detecting erosions at baseline. In-office MRI was useful in monitoring disease response after the initiation of infliximab treatment. Magnetic resonance imaging is potentially a very valuable diagnostic tool and prognostic indicator for use in patients with RA.     

Anorectal malignant melanoma: preoperative usefulness of magnetic resonance imaging

Magnetic resonance imaging (MRI) findings in three patients with primary anorectal malignant melanoma are described. Two patients had melanotic and one had amelanotic anorectal melanoma. The findings of MRI with a pelvic coil and an endorectal coil were consistent with pathologic findings. MRI with a pelvic coil demonstrated the melanotic component as high signal intensity on T1-weighted imaging. MRI with a pelvic coil and an endorectal coil was useful for staging anorectal melanoma. This article describes the initial report of the use of an endorectal coil for malignant melanoma of the anorectum.     

Diagnostic Role of Magnetic Resonance Imaging in Identifying Aortic Arch Anomalies

Purpose. The aim of this article was to assess the role of MRI in the diagnosis and management of a variety of complex aortic arch anomalies. Materials and Methods. Imaging was performed on a 1.5T Philips Gyroscan Intera. We retrospectively reviewed all cardiac MR scans performed from November 2003 to February 2007 at our institute to identify aortic arch anomalies. Magnetic resonance imaging included three‐dimensional (3D) sagittal volume images, cine images, short axis ventricular volumes, phase contrast flow of great vessels, and 3D gadolinium magnetic resonance angiogram. Results. Three major categories of anomalies were identified in 47 patients: double aortic arch (n = 9), right‐sided aortic arch with mirror image branching (n = 28), and aberrant right subclavian artery (n = 10). In the double aortic arch group, six patients were symptomatic, and four of them underwent a surgical division. Magnetic resonance imaging was used to plan the surgical management. In the other two groups, no patient presented with symptoms of airway or esophageal compression, and the arch abnormalities were noticed during investigation for other associated cardiac disease. However, we noticed a strong correlation with well‐defined subgroups of congenital heart disease. Right‐sided aortic arch was seen in patients with pulmonary atresia with ventricular septal defect (46.4%), tetralogy of Fallot (32.1%), and double outlet right ventricle with right atrial isomerism (14.2%). Seventy percent of the patients with aberrant right subclavian artery had aortic coarctation, and another case presented a complete aortic arch interruption. Conclusion. Magnetic resonance imaging is an important diagnostic tool in identifying anomalies of the aortic arch and its branches and can be considered the imaging technique of choice when planning surgical management, especially when there are associated cardiac anomalies.     

Noninvasive detection of myocardial fibrosis in arrhythmogenic right ventricular cardiomyopathy using delayed-enhancement magnetic resonance imaging

OBJECTIVES: We evaluated the role of myocardial delayed-enhancement (MDE) magnetic resonance imaging (MRI) for noninvasive detection of fibrosis in Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). BACKGROUND: Arrhythmogenic right ventricular dysplasia/cardiomyopathy is characterized by fibro-fatty replacement of the right ventricle (RV) leading to arrhythmias and RV failure. Endomyocardial biopsy can demonstrate fibro-fatty replacement of the RV myocardium; however, the test is invasive and carries a risk of perforation. METHODS: Thirty consecutive patients were prospectively evaluated for ARVD/C. Magnetic resonance imaging was performed on a 1.5-T scanner. Ten minutes after intravenous administration of 0.2 mmol/kg of gadodiamide, MDE-MRI was obtained. Diagnosis of ARVD/C was based upon the Task Force criteria and did not include MRI findings. RESULTS: Twelve (40%) of 30 patients met the Task Force criteria for ARVD/C. Eight (67%) of the 12 ARVD/C patients demonstrated increased signal on MDE-MRI in the RV compared with none (0%) of the 18 patients without ARVD/C (p <0.001). Endomyocardial biopsy was performed in 9 of the 12 ARVD/C patients. Of the nine patients, four had fibro-fatty changes consistent with the diagnosis of ARVD/C. Each of these patients had increased RV signal on MDE-MRI. None of the patients without ARVD/C had any abnormalities either on histopathology or on MDE-MRI. Electrophysiologic testing revealed inducible sustained ventricular tachycardia (VT) in six of the eight ARVD/C patients with delayed enhancement, compared with none of the ARVD/C patients without delayed enhancement (p=0.01). CONCLUSIONS: Noninvasive detection of RV myocardial fibro-fatty changes in ARVD/C is possible by MDE-MRI. Magnetic resonance imaging findings had an excellent correlation with histopathology and predicted inducible VT on programmed electrical stimulation, suggesting a possible role in evaluation and diagnosis of patients with suspected ARVD/C.     

Burkitt's non-Hodgkins lymphoma presenting as facial nerve palsy in HIV-positive patients

An isolated facial nerve palsy is rare as the presentation of a central nervous system lymphoma. In this case series, we present the clinical features of three HIV-positive patients presenting with facial nerve palsies due to HIV-associated Burkitt's lymphoma. These patients had a non-resolving facial paralysis, which occurred during a late stage of HIV. Magnetic resonance imaging (MRI) did not show leptomeningeal enhancement. Cerebrospinal fluid revealed a lymphocytosis with elevated protein and low glucose levels. The diagnosis of Burkitt's lymphoma was made on histology which showed the characteristic 'starry sky' appearance due to scattered tangible body-laden macrophages. The patients were commenced on the intensive chemotherapy regimen of CODOX-M/IVAC. Two patients died of disease progression and the third patient died of chemotherapy toxicity. This case series highlights the need for a high index of suspicion for underlying malignancy when a patient presents with a persistent facial paralysis in the later stages of HIV infection.     

Growing wrist mass

A 46 year old man presented with a growing mass over his wrist. Erosions of the triquetrum and hamate were present radiographically. Magnetic resonance imaging (MRI) showed a solid mass arising from the extensor carpi ulnaris tendon, which was T(1) hypointense and isointense, T(2) hypointense, and bloomed on gradient echo images. The preoperative diagnosis of giant cell tumour of the tendon sheath was confirmed on histopathological examination of the excised specimen. The clinical, pathological, and imaging features, with emphasis on MRI findings, of this condition are reviewed.     

Magnetic resonance iron-free nodules in genetic hemochromatosis

OBJECTIVE: In hemochromatosis, areas of normal hepatic magnetic resonance (MR) signal intensity indicate the presence of iron-free-nodules, which are strongly suspected of being neoplastic. The goal of the study was to define the prevalence and the nature of these iron-free MR nodules at the time of diagnosis in 116 patients included in a prospective study assessing the accuracy of MR imaging (MRI) in the quantification of liver iron overload. METHODS: Seventy-nine of the 116 patients had homozygous hemochromatosis on a phenotypic basis. Fifteen-millimeter-thick contiguous slices were performed using T1- and T2-weighted gradient echo sequences with a 0.5 Tesla magnet. RESULTS: Six of 79 homozygous hemochromatotic patients had one or more MR iron-free nodules. Five of the six patients proved to have malignant tumors. Four of six iron-free nodules were hepatocellular carcinoma (5% in the hemochromatosis group and 17.5% in hemochromatotic patients with severe fibrosis). CONCLUSIONS: The present data confirm the high prevalence of liver cancer at the time of diagnosis, mainly in cirrhotic patients greater than 45 years of age, and indicate that, when performing MRI for liver iron quantification, a complete hepatic MRI examination is preferable to a simple signal measurement in patients at risk for hepatocellular carcinoma.     

Tc99m sulfur colloid scintigraphy for detection of intrathoracic extramedullary hematopoiesis in patient with beta-thalassemia major--a case report

Extramedullary hematopoiesis (EMH) refers to the production of blood cells outside the bone marrow and is a compensatory mechanism for bone marrow dysfunction. A 34 year-old female patient with beta thalassemia major was found to have multiple large, well-circumscribed radiopaque paravertibral mass lesions in chest radiography. Magnetic resonance imaging (MRI) of the thorax disclosed a right upper apical and two lower thoracic paraspinal mass lesions with heterogeneous isointensity on T1-weighted images and hypointensity on T2-weighted images. Because intrathoracic EMH is suspected in our case, which had obvious bone marrow dysfunction, radionuclide bone marrow scintigraphy is helpful in supporting the diagnosis. Tc99m sulfur colloid scintigraphy demonstrated three intense radioactive thoracic paraspinal mass lesions corresponding to the lesions seen on MRI. We believe whole body bone marrow scintigraphy with Tc99m sulfur colloid is the best convenient noninvasive method for supporting the diagnosis of EMH.     

Lymphoepithelial cyst of the pancreas

A case of lymphoepithelial cyst (LEC) of the pancreas is presented. A 48-year-old man complaining of general fatigue was found to have a heterogeneous water-dense mass protruding from the surface of the pancreas on plain computed tomography (CT). Dynamic CT disclosed septa within the mass. Magnetic resonance imaging (MRI) showed a hypoiintense mass on T1-weighted imaging, and a hyperintense mass on T2-weighted imaging. MRI with gadolinium enhancement revealed septa within the mass. Endoscopic ultrasonography showed septa and fine echogenic structures within the cystic echoic lesion. Endoscopic retrograde pancreatecraphy showed a normal duct system. Distal pancreatectomy with splenectomy was performed, with a suspected diagnosis of cystic neoplasms of the pancreas. Histopathologic examination disclosed LEC of the pancreas. Our case suggests that LEC should be considered in the differential diagnosis of cystic neoplasms of the pancreas.     

Imaging in CNS lupus

The diagnosis of neuropsychiatric systemic lupus erythematosus (NPSLE) is complex not only on account of the heterogeneous nature of neurological presentation but also because of the difficulty of differentiating lupus-related pathology from other neuropsychiatric diseases. Magnetic resonance imaging (MRI) remains the gold standard for the non-invasive assessment of NPSLE but there are problems, both with sensitivity and specificity. Both T(2) quantitation and the use of gadolinium have shown promise in differentiating acute from chronic lesions. Nonetheless, the lack of sensitivity of conventional MRI has led to the exploration of other MR-based techniques. Magnetic resonance spectroscopy (MRS) allows the measurement of brain metabolites, whereas diffusion weighted imaging and diffusion tensor imaging allow assessment of white matter structure and integrity. MRS studies in NPSLE have consistently shown a reduction in N-acetyl aspartate (a neuronal marker). Diffusion weighted imaging has had only limited application in lupus and the results to date have shown abnormal diffusivity in lupus patients consistent with inflammation and loss of white matter structure. These techniques remain research tools at this early stage. Positron emission tomography (PET) and single photon emission computed tomography (SPECT) have also been explored as functional imaging tools in lupus and both appear to be more sensitive in detecting subtle brain changes in NPSLE but there are issues with specificity which deter their use in the clinical setting.     

Bilateral brachial neuritis secondary to varicella reactivation in an HIV-positive man

We present the case of a 48-year-old HIV-positive man, who developed acute onset of pain in both upper limbs associated with proximal weakness and distal paraesthesia. Eight weeks prior to this presentation he had had varicella zoster affecting his right S1 dermatome. CD4 count was 355 cells/mm(3) and he was antiretroviral therapy (ART) naive. Power was 0/5 proximally and 4/5 distally in the upper limbs. Reflexes were absent and there was sensory loss in the C5, C6 and T1 dermatomes. Cerebrospinal fluid (CSF) examination showed a lymphocytosis with low glucose; however, CSF Mycobacterium tuberculosis (TB), and herpes simplex virus polymerase chain reaction (HSV PCR) were negative as was syphilis serology. Electromyography showed marked motor axonal loss. Magnetic resonance imaging (MRI) did not show any cervical spinal lesion. Varicella zoster virus (VZV) PCR was positive in the CSF. He was treated with high-dose intravenous aciclovir with good resolution of his syndrome over time and was commenced on ART. We believe this to be the first case report of varicella reactivation causing bilateral neuralgic amyotrophy in an HIV-positive patient.     

Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department

The onset of tuberculous spondylitis is insidious in nature, with various clinical presentations, slow development of radiographic abnormalities, and nonspecific constitutional symptoms. This lack of specific symptoms causes delays in diagnosis. Magnetic resonance imaging demonstrates osteitis, intraosseous abscesses, paravertebral and epidural soft tissue extensions and abscesses, discitis, multilevel involvement of spinal cord or nerve root compression, and scoliosis. We present six patients with tuberculous spondylitis referred to our outpatient department with back pain resistant to medical therapy. All of them were women aged from 25 to 58 years (mean 44.6). The diagnosis of tuberculous spondylitis was based on clinical presentation, radiographic and/or MRI evidence of focal destructive vertebral lesions (with paravertebral mass), and positive bacteriological findings of Mycobacterium tuberculosis. The combined antituberculous chemotherapy consisted of 1.0 g/day streptomycin for 1 month, 25 mg/kg ethambutol or 25 mg/kg pyrazinamide, 600 mg/day rifampicin, and 300 mg/day isoniazid. The duration of therapy was 12 months. All the patients recovered without any sequelae. The mean follow-up period was 28 months (range 12–48). Magnetic resonance imaging is considered the main imaging modality for patients with suspected tuberculous spondylitis; it must be included in differential diagnosis of back pain and, if it is diagnosed in early stages, antituberculous chemotherapy enables satisfactory outcome.     

Imaging findings of biliary hamartomas

AIM: To evaluate the imaging findings of biliary hamartomas (von Meyenburg complexes, VMCs) and discuss the differential diagnosis with other related diseases. METHODS: Imaging findings of biliary hamartomas on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), MR cholangiopancreatography (MRCP)and hepatobiliary scintigraphy were retrospectively analyzed in six patients. RESULTS: On ultrasound images, five of the six cases showed multiple small hyper- and hypo-echoic lesions with comet-tail echoes, especially when magnified by US with the usage of zoom function. In all the six cases, multiple tiny hypodense lesions less than 10 mm in diameter were revealed as scattered throughout the liver with no enhancement on CT. These tiny lesions were demonstrated to be hyper- and hypo-intensity on T2- and T1-weighed images, respectively, in three patients who underwent MRI examinations. MRCP was performed in two patients, and clearly showed multiple tiny irregular- and round-shaped hyper-intensity lesions. MRCP and hepatobiliary scintigraphy showed normal appearances of intra- and extra-hepatic bile ducts in two and one patients, respectively. CONCLUSION: Imaging modalities are useful in the diagnosis and differential diagnosis of VMCs. A correct diagnosis might be obtained when typical imaging findings are present even without a histological confirmation.     

Magnetic resonance imaging in patients with congenital heart disease

Magnetic resonance imaging (MRI) was conducted with use of the spin-echo technique (0.35 Tesla) in 22 patients with a variety of congenital and cardiovascular anomalies and in 16 normal volunteers. Electrocardiographic (ECG) synchronization of the data acquisition produced transverse, parasagittal, and coronal tomograms that were used to define size and relationship of the great vessels and internal cardiac structures. MRI findings were corroborated by angiography and sector-scan echocardiography. In most patients the diagnosis had been established before the MRI study. MRI detected all of 11 abnormalities at the level of the great vessels, all of six atrial septal abnormalities, and 10 of 11 ventricular septal defects. Images of poor quality resulting from patient motion were obtained in the one instance in which a small ventricular septal defect was not imaged. Of two patients with Ebstein's anomaly, the displacement of the tricuspid leaflets was shown in one patient but was not evident in another. Complex anomalies such as double-outlet right ventricle, uncorrected L-transposition, single atrioventricular valve, single ventricle, and common ventricle were clearly shown by MRI. Initial experience with MRI has indicated the effectiveness of this technique for defining great vessel and internal cardiac anatomy in patients with congenital heart disease. This is accomplished without the use of contrast media and is thus a completely noninvasive technique for cardiovascular diagnosis.     

Bone erosions by MRI in first-degree relatives of patients with RA: an exploratory study

Clinical Rheumatology - First-degree relatives (FDR) of patients with rheumatoid arthritis (RA) are at increased risk of RA diagnosis. Magnetic resonance imaging (MRI) has been proposed as a useful...     

Imaging findings of biliary hamartomas

AIM: To evaluate the imaging findings of biliary hamartomas (von Meyenburg complexes, VMCs) and discuss the differential diagnosis with other related diseases.METHODS: Imaging findings of biliary hamartomas on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), MR cholangiopancreatography (MRCP)and hepatobiliary scintigraphy were retrospectively analyzed in six patients.RESULTS: On ultrasound images, five of the six cases showed multiple small hyper- and hypo-echoic lesions with comet-tail echoes, especially when magnified by US with the usage of zoom function. In all the six cases,multiple tiny hypodense lesions less than 10 mm in diameter were revealed as scattered throughout the liver with no enhancement on CT. These tiny lesions were demonstrated to be hyper- and hypo-intensity on T2- and TI-weighed images, respectively, in three patients who underwent MRI examinations. MRCP was performed in two patients, and clearly showed multiple tiny irregular- and round-shaped hyper-intensity lesions.MRCP and hepatobiliary scintigraphy showed normal appearances of intra- and extra-hepatic bile ducts in two and one patients, respectively.CONCLUSION: Imaging modalities are useful in the diagnosis and differential diagnosis of VMCs. A correct diagnosis might be obtained when typical imaging findings are present even without a histological confirmation.     

Abnormalities of magnetic resonance imaging of the central nervous system in patients with systemic lupus erythematosus correlate with disease severity

Summary Forty randomly selected patients with systemic lupus erythematosus (SLE) were studied by clinical and serologic parameters and magnetic resonance imaging (MRI). Abnormal MRI was found in 15/40 patients (37,5%): all 15 cases showed multiple widespread small-sized areas of increased signal in T2 in the white matter; in one of these patients MRI also displayed a large area with a reduced signal in T1 and an increased signal in T2 involving both the white and the gray matter. Among the 15 patients with abnormal MRI, only 7 had neuropsychiatric symptoms. The presence of MRI changes was highest in patients with organic type symptoms and was associated to the highest disease severity scores. A long-term follow up of asymptomatic patients would be useful to establish whether the application of MRI is appropriate for the assessment of CNS involvement in SLE.     

Clinical safety of magnetic resonance imaging early after coronary artery stent placement

OBJECTIVES: Our aim was to examine the rate of adverse cardiac events in patients undergoing magnetic resonance imaging (MRI) <8 weeks after coronary stent placement. BACKGROUND: The risk of coronary stent thrombosis from dislodgement due to MRI early after stent placement is not well defined. Manufacturers recommend postponing MRI studies until eight weeks after coronary stent placement. METHODS: We analyzed the Mayo Clinic Rochester Percutaneous Coronary Intervention Database and examined records of 111 patients who underwent MRI <8 weeks after coronary stent placement treated with aspirin and a thienopyridine. Occurrence of death, myocardial infarction (MI), and repeat revascularization within 30 days of MRI were recorded. RESULTS: Magnetic resonance imaging (1.5 tesla) was performed within a median of 18 days (range, 0 to 54 days) after coronary stent placement. Four noncardiac deaths occurred, and three patients had repeat revascularization procedures. Stent thrombosis did not occur (95% confidence interval, 0% to 3.3%). CONCLUSIONS: Magnetic resonance imaging <8 weeks after coronary stent placement appears to be safe, and the risk of cardiac death or MI due to stent thrombosis is low. Postponing MRI does not appear to be necessary.