Lo ms dificil es ver lo que esta delante de tus ojos W.

Goethe

Seminarios Anatoma Clnico Radiolgica Tel. 22781169,22703359, 88825513 09/03/2012

NEW !

Apuntes de Anatoma radiolgica-clnica

Clasificacin de la Artritis III. parte.

Clnica de Asma y Alergia

Lean las notas al pie de las diapositivas

09/03/2012

Seminarios Anatoma Clnico Radiolgica Tel. 22781169,22703359, 88825513

Natura sanat medicus curat morbus

Asociacin de Mdicos Catlicos de Nicaragua

Bibliografa
Atlas Netter IV edicin Interactiva. Atlas Netter II edicin. Atlas, Anatomy,Carmine de Clemente 3rd ed.. Gray s Anatomy Ed. Longman 1973.

Moderni Aspetti di Semeiotica Medica. Testo Atlante. N. Dioguardi. G. P. Sanna.

Societa editrice Universo. 1976. pag.673-711. DRA. CARMEN ROJAS C. MEDICINA INTERNA-REUMATOLOGIA. PROFESOR ASISTENTE.UNIVERSIDAD DE ANTOFAGASTA
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Emedecine collection
CRYSTAL-INDUCED ARTHRITIS Calcium Pyrophosphate Deposition Disease Gout and Pseudogout Progression of Osteoarthritis

Bibliografa

09/03/2012

Seminarios Anatoma Clnico Radiolgica Tel. 22781169,22703359, 88825513

Clasificacin de la Artritis Dra. Lieberman Harvard School of Medecine

Qu tienen en comn estos pacientes?

Gout and Pseudogout Bruce M Rothschild, MD; Herbert S Diamond, MD

Emedecine updated 9 de febrero 2012

Podagra aguda en un paciente mayor

Depsitos tofaceos , cristales de cido rico

Artritis de Origen Metablica Gota

Cristales en forma de aguja de cido rico, obtenidas de una articulacin inflamada.

Fluido obtenido de un depsito tofaceo de un paciente con gota.

Gota

Presentacin radiolgica de la Gota

Distribucin asimtrica. Afecta comunmente la primera articulacin metacarpo-falangea.
Inlamacin, nodular+/derrame+/ bursitis Tofos opacos Se mantiene el espacio articular ( fase temprana). Erosiones periarticulares.

Descripcin radiolgica
Espacio articular conservado. Erosiones periarticulares, con bordes esclerticos. Los tejidos blandos una densidad mayor debido al los tofos

Descripcin radiolgica
Se conserva el espacio articular. Erosiones periarticulares con bordes esclerticos. Presencia de Tofos
1ra. Articulacin Metacarpo-falangea

Caractersticas Radiolgicas Gota

Inflamacin tejidos blandos

Se conserva el espacio articular. Tofos gotosos opacos

Erosiones periarticulares, bordes esclerticos.

MRI: proliferacin sinovial

Signologa radiolgica
Inflamacin de los tejidos blandos Aumento de la densidad compatible con tofo gotoso en la 5ta. articulacin proximal interfalangea. Erosiones periarticulares con mrgenes esclerticos.

Signologa Radiolgica
Pat. 5
Erosiones periarticulares del calcaneo y pie medio. Prominente seales de baja atenuacin ( proliferacion sinovial en los espacios articulares que causan erosiones.

Pat.6 Tofos gotosos en tejidos blandos. Erosiones con bordes esclerticos

Artropatas por Deposicin Metablicas.

Gota CPPD. Artropata por
Deposicin de Calcio Pirofosfato.

Tendinitis y bursitis calcfica. Amiloidosis Enfermedad de Wilson Acromegalia

Artritis Metablica. Deposicin Calcio dehidrato pirofosfato. CPPD

This condition is the most common cause of secondary metabolic osteoarthritis.
Calcium Pyrophosphate Deposition Disease Constantine K Saadeh, MD; Herbert S Diamond,MD.
Emedecine collection, updated 19 de enero 2012.

Presentacin clnica: Lantnica, griego lantano, que pasa

desapercibida .

Pseudo gota aguda Pseudo artritis reumatoidea Pseudo osteoartitis Pseudo artritis neuroptica.

CPPD Artritis

Calcium pyrophosphate deposition disease.

Radiograph of the knee showing chondrocalcinosis involving the meniscal cartilage, also showing evidence of osteoarthritis.

Calcium pyrophosphate deposition disease. Radiograph of the wrist and hand showing chondrocalcinosis of the articular disc of the wrist and atypical osteoarthritis involving the metacarpophalangeal joints in a patient with underlying hemochromatosis.

Anatoma del Carpo

Anatoma del Complejo Fibrocartilagineo del Carpo

Anatoma del Complejo Fibrocartilagineo del Carpo

( triangular, fibrocartilago radiocarpal )

Nota: El menisco!

Identificacin de los cristales: luz polarizada.

Calcium pyrophosphate deposition disease. Appearance of calcium pyrophosphate dihydrate crystals obtained from the knee of a patient with pseudogout. The crystals are rhomboid-shaped and weakly positively birefringent as seen by compensated polarized microscopy. The black arrow indicates the direction of the compensator.

CPPD vs Osteoartritis Mismas caractersticas radiolgicas

Presentacin clnica:

Bilateral: rodillas>mueca/manos>cadera. Mueca: articulacin radiocarpal; Colapso escafoide-lunar ( SLAC).

Radiologa: Condrocalcinosis Reduccin del espacio articular Hueso subcondral Osteofitos

Condrocalcinosis

CPPD en radiografa Estandard

Condrocalcinosis de los meniscos, reduccin del espacio articular patelo femoral. Signo femoral notching , muescas del femur .

Compare la distancia escafoide -lunar del paciente 2 y 3. Ahora resulta fcil el diagnstico de colapso ( SLCA).

Artropatas Metablicas por deposicin

Calcifying Tendonitis Anthony H Woodward, MD; Harris Gellman, MD

Emedecine collection Updated 12 de agosto 2011

See EMedicine article Rotator Cuff Disease.) Amas de casa

Supraspinatus, Infraspinatus y Teres minor

Los rotadores
Radiografa estandard del hombro. Posicin del hombro: Rotacin externa, interna y posicin neutral.

Enfermedad Metablica Deposicin de Hidroxi-apatite HADD

Tendinitis o bursitis calcfica. Deposicin en tendones, bursa, msculos y capsula articular. Asociado a enfermedades sistmicas: collagenosis vasculares, insuficiencia renal , hipervitaminosis D Edad 30-60 F> M. Hombros ms afectados. Se presentan crisis agudas

Tratamiento: aspiracin , lavado , esteroides inyectados.

Consideraciones clnicas
Afecta: Hombro > cadera >

mueca/manos>codo. Calcificacin alrededor de articulaciones , tendones. MRI ayuda a distinguir la FASE SINTOMATICA. Fase asintomticacalcificaciones bien definidas( well marginated) Tipicamente, no hay remodelamiento oseo, ni derrames adyacentes.

Galera de Imgenes HADD calcificaciones articulares y tendones.

Galera de Imgenes HADD calcificaciones de los tendones.

Pat. 5. Calcificacin indistinta, tendn del gluteo,adjacente al gran trocanter. Pat. 6. calcificacin bien definida, sugiere estar en fase aintomtica. Pat. 7 MRI. Low signal con edema alrededor de la calcificacin.

Pat. 8 Calcificacin del tendn extensor del pulgar.

Radiografa estandar : calcificacin del tercer flexor metacarpo- falangeo. MRI con medio de contraste apariencia normal del 2do y 4to. Tendones flexores , aumento del tercer tendn flexor,

Deposicin de Amiloide. Pacientes en Dilisis.

Amyloidosis: Robert O Holmes Jr, DO; Herbert S Diamond, MD.

Emedecine updated:19 enero 2012

Amorphous eosinophilic interstitial amyloid observed on a renal biopsy.

Paucicellular birefringent material (amyloid) between skeletal muscle fibers of the tongue in light chain amyloidosis. (Courtesy Robert O. Holmes Jr, DO, and the Walter Reed Army Medical Center Pathology Department)

Pathologic diagnosis (Congo red staining and immunohistochemistry)

Hemocromatosis
Hemochromatosis Andrea Duchini, MD; Julian Katz, MD
Emedecine collection update 1 de diciembre 2011. Hemochromatosis is the abnormal accumulation of iron in parenchymal organs, leading to organ toxicity. This is the most common inherited liver disease in white persons and the most common autosomal recessive genetic disorder

Hemocromatosis Primaria Hemocromatosis Secundaria.

Hemocromatosis
Enfermedad autosmica recesiva , genes,HFE. Secundaria: Trastornos de la eritropoiesis
( Thalassemia, sickle cell anemia, Xlinked sideroblastic anemia, pyruvate kinase deficiency, hereditary spherocytosis, and congenital dyserythropoietic anemia (CDA).

Transfusiones,

Hemochromatosis Imaging, Transfusion-Induced Iron Overload.

Hallazgos radiolgicos
Condrocalcinosis Osteofitos a pico de pjaro. Reduccin del espacio articular. Esclerosis subcondral de las articulaciones 2 y 3ra. metacarpofalangeas.

Complicaciones potenciales de la hemocromatosis

Cirrosis . Hepatocellular carcinoma Insuficiencia cardaca congesticia. Aritmias Cardacas Diabetes mellitus Hipogonadismo Impotencia

Artropata
Trastornos Tiroideos Sepsis

Noncontrast CT scan in a 47-year-old man with sickle cell disease who had undergone multiple transfusions demonstrates diffuse increased attenuation of the liver, representing abnormal iron deposition. The spleen is small and calcified from autosplenectomy

Enfermedad de Wilson
Wilson Disease , Richard K Gilroy, MBBS, FRACP; Julian Katz, MD
Emedecine Updated: 9 de diciembre 2011.

Diagnstico : Niveles de ceruloplasmina. Excrecin urinaria de cobre. Anillos de KayserFleischer Biopsia heptica : contenido de cobre.

Enfermedad de Wilson Caractersticas radiolgicas

Condrocalcinosis Irregularidades corticales y subcorticales, paintbrush. Cuerpos sueltos intraarticulares ( loose bodies).

Acromegaly Hasnain M Khandwala, MD, FRCPC; George T Griffing, MD

Emedecine updated:15 de noviembre 2011

Symptoms due to excess of GH/IGF-I Soft tissue swelling and enlargement of extremities Increase in ring and/or shoe size Hyperhidrosis Coarsening of facial features Prognathism

Macroglossia Arthritis
Increased incidence of obstructive sleep apnea Increased incidence of glucose intolerance or frank diabetes mellitus, hypertension, and cardiovascular disease Hyperphosphatemia, hypercalcuria, and hypertriglyceridemia possible Increased incidence of congestive heart failure, which might be due to uncontrolled hypertension or to an intrinsic form of cardiomyopathy attributable to excess GH/IGF-I Increased incidence of colonic polyps and adenocarcinoma of the colon

Acromegalia

Sugiera el diagnstico de estos pacientes

Sugiera un diagnstico

Pat. 4 Pat.3 Ver notas

Pat.6

Pat.5

Esclerodema: Criterios American College of Rheumatology (ACR)

Mayores
Escleroderma proximal.

Proximal scleroderma is characterized by symmetric thickening, tightening, and induration of the skin of the fingers and the skin that is proximal to the metacarpophalangeal or metatarsophalangeal joints.

Menores Esclerodactilia Cicatrices en los dedos por isquemia. Fibrosis pulmonar basal bilateralpatrn reticulonodular honey combing , en panal de abejas

These changes may affect the entire extremity, face, neck, and trunk (thorax and abdomen

Escleroderma
Enfermedad sistmica Sndrome CREST Reflujo Teleangectasias Pulmn en panal de abejas en estadio terminal. Cancer
( adenocarcinoma bronquioloalveolar ) adenocarcinoma del esfago

Fingernail capillary bed demonstrating capillary dropout with large dilated vessels.

Caractersticas radiolgicas
Reabsorcin de las falanges distales. Amputaciones -falanges Anquilosis Erosiones como en la A R, pero localizadas a las articulaciones distales y proximales interfalangeas.
Diferencial Acro-osteolisis

Respondamos al Quiz :
Escleroderma Caractersticas radiolgicas

Clasificacin de la Artritis

Lupus Eritematoso Sistmico

The classic malar rash, also known as a butterfly rash, with distribution over the cheeks and nasal bridge. Note that the fixed erythema, sometimes with mild induration as seen here, characteristically spares the nasolabial folds.

Lupus Eritematoso Sistmico

Systemic Lupus Erythematosus (SLE) Christie M Bartels, MD, MS; Herbert S Diamond, MD. Emedecine updated: 18 de e nero 2012

The 1982 American College of Rheumatology (ACR) criteria summarize features necessary to diagnose SLE. The presence of 4 of the 11 criteria yields a sensitivity of 85% and a specificity of 95% for SLE. Keep in mind that individual features are variably sensitive and specific. Patients with SLE may present with any combination of clinical features and serologic evidence of lupus.

The ACR Criteria: mnemonic "SOAP BRAIN MD"

Serositis Oral ulcers Artritis no erosiva
Fotosensibilidad ( photosensitivity).

Immunologic phenomena dsDNA; anti-Smith (Sm) antibodies; antiphospholipid antibodies (anticardiolipin immunoglobulin G [IgG] or immunoglobulin M [IgM] or lupus anticoagulant);

Blood disorders , (anemia

hemoltica, linfopenia, trombocitopenia).

Renal: proteinuria, ANA

Neurolgicos Trastornos. Malar rash . En mariposa. Discoide rash.

SLE can be diagnosed if any 4 or more of the 11 criteria are present, serially or simultaneously, during any interval of observation. ACR criteria table

Dermatomiositis
Miopata inflamatoria. Debilidad muscular Rash heliotrpico Calcificaciones musculares. Inflamacin articular.

Dermatomiositis. Calcificaciones en banda de los muslos

 Su diagnstico ?

Ver nota al pie de pgina

Artritis Sptica
Infeccin del espacio articular. Estafilococo, Estreptococo, son grmenes casuales comunes. TB a curso indolente. Diagnstico: aspiracin y cultivo.

Artritis Sptica
Derrame articular fase aguda. Osteoporosis Prdida del cartlago articular, destruccin inflamatoria. Perdida de la cortical ( white line). Absceso , hallazgos tpicos de la osteomielitis.

Monoarticular Usualmente , 1 articulacin.

Artritis sptica
MRI T2 recordar que los derrames y el edema son high signal. Derrame articular Erosiones Qusticas de la cabeza femoral.

Artritis sptica
Amputacin del ortejo. Ulcera de tejidos blandos. Osteoporosis. Prdida del cartlago Prdida de la cortical. Destruccin osea

Gas e inflamacin en proximidad de la snfisis pbica. Alargamiento de la snfisis pbica.

Marcada destrucin osea. de los huesos pbicos bilateralmente. Artritis sptica y osteolmielitis.

Artritis sptica post traumtica

Rodilla normal

Fractura y desplazamiento patelar

Remocin quirrgica patelar Osteoporosis , prdida del cartilago articular, prdida de la linea blanca cortical, destruccin osea, fragmentacin osea.

Diagnstico requiere aspiracin y cultivo

Artritis sptica
Anular acortado Lesin monoarticular. Destruccin osea Prdida del espacio articular. Irregularidad articular. Osteofitos

Clasificacin de la Artritis

Artritis Neuroptica.
Imaging in Neuropathic Arthropathy (Charcot Joint) Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Felix S Chew, MD, MBA, EdM . Emedecine collection updated 27 de mayo 2011

Artritis Neuroptica
Neuropathic arthropathy (Charcot joint).

Neuropathic arthropathy of the shoulder in a patient with syringomyelia. Note the destruction of the articular surface, dislocation, and debris, which are pathognomonic for a neuropathic joint.

Caractersticas radiolgicas
In the late stage, there is radiographic evidence of destruction of articular surfaces, subchondral sclerosis, osteophytosis. Intra-articular loose bodies (bag of bones), subluxation, Lisfranc fracture/dislocation of midtarsal bones, and rapid bone resorption demonstrating pencil-in-a-cup deformity . Complications of septic arthritis that are demonstrated on radiographs include osteomyelitis and bone ankylosis.
Pies, Tobillos

Neuropathic arthropathy in a patient with syringomyelia. Anteroposterior view of the elbow demonstrates resorption of the bone with opaque subchondral bone.

Lateral view of the elbow shows disorganization of the joint.

Charcot, en un paciente diabtico

Neuropathic arthropathy in a patient with diabetes mellitus. Note the lateral disruption of the base of the metatarsal in relation to the tarsals, representing a Lisfranc fracture/dislocation. Note the soft-tissue gas and osteomyelitis of the second and third metatarsal heads.

Artritis neuroptica Pies y tobillos

Destruccin Osea Aumento de la densidad osea. Destruccin de la articulacin tibio-talar. Talus ( presenta fragmentacin y disolucin). Osteofitos, huesos heterotpicos

Articulaciones: ( intertrsica, tarso-metarsales, Fragmentacin osea, multiples fracturas )

Articulacin normal

Hagamos un breve repaso

En las primeras dos series de slides estudiamos

En esta ltima seccin hemos estudiado

Completemos el estudio

Condromatosis Sinovial

Condromatosis Sinovial

Learning radiology case of the week,2006

Osteocondromatosis sinovial
Primary form of Synovial Osteochondromatosis. There are numerous osteocartilaginous nodules seen around the knee joint space. They are relatively uniform in size and are not associated with osteoarthritis of the knee. This is the appearance of primary synovial osteochondromatosis.

Sinovitis Pigmentaria Vilonodular.

Overview Pigmented villonodular synovitis (PVNS) is a benign proliferative disorder of uncertain etiology that affects synovial lined joints, bursae, and tendon sheaths (see the image below). The disorder results in various degrees of villous and/or nodular changes in the affected structures
Pigmented Villonodular Synovitis Imaging ; Johnny U V Monu, MBBS; Felix S Chew, MD, MBA, EdM. Emedecine collection
updated 18 de mayo 2010.

Pigmented villonodular synovitis of the knee. Plain radiographic findings of the knee apparently are normal except for the curvilinear calcification seen peripheral to the medial femoral condyle.

Pigmented villonodular synovitis of the knee. Coronal T2-weighted magnetic resonance imaging (MRI) scan shows low signal mass above the medial femoral condyle, posteriorly.

Sarcoidosis
Por ser una patologa sistmica y de gran inters pneumolgico dedicamos una presentacin propia para esta entidad

Gracias por la oportunidad

Clnica de Asma y Alergia

Managua , Nicaragua Email: jhsdoctor@hotmail.com

Tel 2278 1169 2270-3359 8946-5022 8882-5513

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Dr. Juan Herrera Salazar

Clnica de Asma y Alergia,Managua , Nicaragua.
Clnica de Asma y Alergia, Dr. Juan Herrera SalazarFacebook.

Foro Mdico Nicaragense Portales Mdicos Medbook Mi blog de Asma y Alergia

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