CASE 1577 Published on 08.10.2002

Teaching Case

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

B. Taouli, A. Guermazi, C.G. Peterfy, H.K. Genant

Patient

71 years, female

Categories

No Area of Interest ; Imaging Technique MR, MR ;

No Procedure ; No Special Focus ;

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Clinical History

A patient with rheumatoid arthritis (RA) presented with pain and morning stifness of the hands.

Differential Diagnosis List

Rheumatoid arthritis

Imaging Findings

A patient with a known diagnosis of rheumatoid arthritis (as defined by the Amrican College of Rheumatology 1987 revised criteria) presented with pain and morning stifness of the hands.

Conventional radiography and MRI of the left hand and wrist without gadolinium injection were performed.

Discussion

Rheumatoid arthritis (RA) is the most common type of inflammatory arthritis, with an estimated prevalence of 1% in the United States. The joints of the hands are among the first to be affected in RA.

Multiple imaging modalities can be used in RA of the hand and wrist, in order to evaluate for bone erosions, and synovial hypertrophy: 1. Conventional radiography is still the most routinely used modality, but is prone to errors caused by superimposition, and has shown a poor sensitivity in detecting bone erosions in early stages of RA, limiting its utility in early RA. In addition, conventional radiography cannot detect synovial hypertrophy with good accuracy.

2. Magnetic resonance imaging (MRI) has been shown to be more sensitive than radiography in detecting bone erosions in the hands and wrists of patients with RA, especially in early stage disease. MR imaging can provide a good visualisation of the synovial pannus with the use of gadolinium injection, and can also show joint effusion, joint-space narrowing, tenosynovitis, bone oedema and bone erosions. MRI can be used not only to diagnose early RA, but also to monitor drug therapy. 3. Ultrasound: in recent studies, ultrasound of the fingers was able to demonstrate bone erosions, cartilage damage, joint effusion, tenosynovitis as well as intraarticular synovial pannus. Doppler US has also been used to demonstrate pannus hypervascularization with success. However, ultrasound is operator-dependent.

References

[1] Sugimoto H, Takeda A, Hyodoh K. Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. Radiology. 2000 Aug; 216(2):569-75. (PMID: 10924587)

[2] Backhaus M, Kamradt T, Sandrock D, Loreck D, Fritz J, Wolf KJ, Raber H, Hamm B, Burmester GR, Bollow M. Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum. 1999 Jun;42(6):1232-45. (PMID: 10366117)

[3] Peterfy CG. Magnetic resonance imaging of the wrist in rheumatoid arthritis. Semin Musculoskelet Radiol. 2001 Sep;5(3):275-88. (PMID: 11595971)

[4] Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen T, Ostergaard M. Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging.
Arthritis Rheum. 2001 Sep;44(9):2018-23. (PMID: 11592362)

[5] Ostergaard M, Hansen M, Stoltenberg M, Gideon P, Klarlund M, Jensen KE, Lorenzen I. MRI-determined synovial membrane volume as a marker of disease activity and a predictor of progressive joint destruction in the wrists of patients with rheumatoid arthritis. Arthritis Rheum. 1999 May;42(5):918-29. (PMID: 10323447)

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