O/S Radio Midterm

Rheumatoid arthritis dx (at least 4)

• Morning stiffness

• Arthritis in three or more joints

• Symmetrical arthritis

• Rheumatoid nodules

• Serum rheumatoid factor

• Radiographic changes

Synovitis articular involvement

• Fairly symmetrical

• Bilateral joint involvement

• Sparing of DIP joints of hands

• MCP, PIP and wrist joint involvement

Synovitis tendon and ligament involvement

• Palmar flexor tendinitis

• Rotator cuff tendinitis

• Atlantoaxial ligament involvement

rheumatoid arthritis

rheumatoid arthritis

rheumatoid arthritis

rheumatoid arthritis

rheumatoid pleurisy

rheumatoid pleurisy radiographic features

• Small to moderate effusion

• Unilateral

• Often chronic

rheumatoid interstitial fibrosis and pneumonitis radiographic features

• Linear opacities

• Bases

• Honeycombing

rheumatoid interstitial fibrosis and pneumonitis CT findings

• Reticular opacities

• Subpleural zones

• Thickened interlobular septa

• Honeycombing

rheumatoid interstitial fibrosis

necrobiotic (rheumatoid) nodule

• Multiple

• Well-circumscribed

• Periphery of lung

• Cavitation is common

• Thick, smooth walls

• Change in size

systemic lupus erythematosus - water bottle sign - pericardial effusion

SLE - pericardial effusion

SLE - atelactasis

• Subsegmental

• Generally in bases

• May be migratory and fleeting

• Associated with pleural effusion or diaphragm dysfxn

(right = normal)

SLE - intestinal vasculitis

• Esophagus to colon

• CT findings

  • Dilated bowel

  • Wall thickening

  • Target sign

  • Engorged mesenteric vessels (comb sign)

  • Ascites

SLE - CNS vasculitis

SLE - Jaccouds arthropathy

SLE - soft tissue calcifications

Scleroderma

• Progressive systemic sclerosis

• Widespread fibrosis and atrophy

  • Skin

  • Lung (2^nd most common site)

  • GI tract (esophagus most common)

• Limited form and diffuse form

• Females > Males

• Age 40 to 70 years

Scleroderma - skin, GI tract, lung

• Skin

  • Fingers and hands

  • Raynaud’s phenomenon

  • Subcutaneous calcifications

• GI tract

  • Esophageal motility dysfunction

  • Small bowel dysfunction

• Lung

  • Isolated pulmonary hypertension

  • Interstitial lung disease

CREST syndrome

• Calcinosis

• Raynaud’s phenomenon

• Esophageal dysmotility

• Sclerodactyly

• Telangiectasia

scleroderma - raynauds missing tip finger

scleroderma calcification in the fingers and hands

Scleroderma: lung fibrosis (2nd most common site)

scleroderma: fibrosis

• Linear opacities

• Bases

• Calcinosis of soft tissues

Scleroderma - esophagus

• Proximal third unaffected

• Incompetent LES

• Patulous G-E junction

• No normal peristalsis

• Resultant reflux

• Eventual structure

scleroderma - esophagus - “bird’s beak”, achalasia

scleroderma - small bowel

• Narrow separation between folds “hide bound” 

• Small-bowel dilatation and air-fluid levels 

• Wide-mouthed diverticula

Polymyositis/dermatomyositis

• Idiopathic inflammatory muscle disease

• Peak incidence in childhood and late adulthood

• Woman > Men (2:1)

• ? Viral infection with altered immune response

• Minority of cases a/w malignancy

polymyositis

• weakness

• Muscle enzyme elevation

• Characteristic EMG

• Inflammatory infiltrates on Bx

dermatomyositis

• sxs of polymyositis, with characteristic rash

skin in polymyositis/dermatomyositis

• Erythematous patches: face, neck, chest, extensors surfaces

• Heliotrope lids: violet discoloration/swelling of eyelids

• Gottron’s sign: heaped-up erythematous papules over MCP /PIP joints

muscle in polymyositis/dermatomyositis

• Gradual/steady progression of muscle weakness

• Skeletal muscles, including diaphragm, pharynx, upper esophagus

lung in polymyositis/dermatomyositis

• Dyspnea on exertion

• Non-productive cough

• Aspiration pneumonitis

air space consolidation???

polymyositis CT findings

• Linear abnormalities

• Ground-glass attenuation 

• Air-space consolidation 

  • mainly in the middle and lower lung zones

  • peribronchial and subpleural distribution

polymyositis

• Chronic interstitial pneumonitis

• Aspiration pneumonia

  • Due to hypotonic esophagus/pharynx

• Hypostatic pneumonia

  • Due to chest wall involvement/hypovent

  • Diffuse soft tissue calcifications

ankylosing spondylitis

• Autoimmune disease of unknown pathogenesis 

• Primarily affects the axial skeleton

•  Male > Female (3:1)

• Involvement of thoracic spine is most common

• Pleuro-pulmonary manifestations in 1-2%

ankylosing spondylitis - bamboo spine

ankylosing spondylitis - anterior syndesmophytes

ankylosing spondylitis - fused SI joints

ankylosing spondylitis - Radiographic findings

• Reticulonodular opacities in the lung apices 

• Become confluent as the disease progresses

• Upper-lobe fibrotic and bullous disease

  • can mimic tuberculosis

ankylosing spondylitis - CT findings

• Peripheral interstitial lung disease

• Bronchiectasis

• Paraseptal emphysema

• Apical fibrosis 

Sjogren syndrome

• Idiopathic , autoimmune disorder

• Characterized by dry mouth and dry eyes

• Woman > Men (9:1)

• Infiltration of exocrine glands by immunoglobulin-producing lymphocytes

• Salivary and lacrimal glands most frequently involved

• Extraglandular involvement occurs in 5%–10% of cases

Primary Sjogren’s Syndrome

• Skin: Dry skin, Raynaud’s, purpura

• Lung: Recurrent infection & interstitial fibrosis

• GI: Angular cheilitis, oral candidiasis, beefy glositis

• Kidney: RTA, interstitial nephritis

• Endocrine: chronic thyroiditis

Secondary Sjogren’s Syndrome

• Associated with other rheumatic disorders (RA, SLE, scleroderma)

Sjogren Syndrome

• bronchiectasis - all the small holes in the periphery of the lung

lower lung predominant

• bronchiolar inflammation

• increased parenchymal lines

• pulmonary fibrosis (10-15% of cases)

sjogren syndrome - lymphocytic interstitial pneumonitis

• reticulo-nodular pattern, especially lower lobes

• pulmonary cyst (arrow pointing at in later aspect of lower lobe)

right = normal

sjogren’s syndrome - big inflamed parotid glands

AIDS classification

• infects CD4+ T-cell lymphocytes

• AIDS defined as ≤200 CD4 cells ***

cerebral atrophy - AIDS

• Most common post-mortem finding in patients who die of AIDS

• Poor correlation between severity of imaging abnormality and degree of cognitive impairment

• Widened sulci and cisterns (CSF spaces) 

• Enlarged ventricles

Mass lesions - Mass effect present

• Toxoplasmosis

• Primary CNS Lymphoma

• Cryptococcal disease

• Other infections including Herpes simplex/zoster, M. tuberculosis, M. avium intracellulare, T. pallidum, Fungi (Aspergillosis, Candidiasis, Nocardiosis, Coccidioidomycosis), Amebiasis

• Infarction

Mass lesions - mass effect absent

• PML (progressive multifocal leukoencephalopathy)

• HIV encephalitis

• CMV encephalitis

• Cerebral Atrophy

toxoplasmosis

• Most common opportunistic CNS (central nervous system) infection in AIDS

• Caused by Toxoplasma gondii (reservoir: infected cats)

• Radiographic features:

  • Solitary or multiple ring-enhancing lesions on post-contrast imaging (MRI and CT)

  • Target appearance

  • Marked surrounding edema

toxoplasmosis - most common opportunistic CNS infection in AIDS

• target appearance

primary CNS lymphoma - AIDS

• 2nd most common focal brain lesion in adults with AIDS

• typically low CD4 counts <50

primary CNS lymphoma - AIDS

toxoplasmosis vs CNS lymphoma ***

Toxoplasmosis

• More likely to present with multiple ring-enhancing intracranial masses

• Random distribution 

• Empiric treatment with anti-protozoan drugs and reassessment of lesions on follow up imaging is often used to distinguish between the two

• Nuclear medicine thallium scan appears as a cold lesion

CNS lymphoma

• Lymphoma is more likely to present with a single intracranial mass than toxoplasmosis

• Though lymphoma can present as multiple ring enhancing lesions in immunocompromised PTs 

• Periventricular location and subependymal spread

• Nuclear medicine thallium scan appears as a hot lesion

progressive multifocal leukoencephalopathy

• bilateral and asymmetrical

HIV encephalopathy

• bilateral and symmetric

most common pulmonary infection

streptococcal pneumonia ***

infectious pulmonary disease in HIV/AIDS

• pyogenic bacterial pneumonia (strep)

• pneumocystis pneumonia (PCP)

• myobacterium tuberculosis

non-infectious pulmonary diseases in HIV/AIDS

• asthma

• emphysema

• kaposi sarcoma

pneumocystic jirovecii pneumonia (PCP)

upper lobe air-filled cysts or pneumatoceles —> cause pneumothorax ***

pneumocystis jirovecii pneumonia ***

• fine reticular markings on the periphery of the lungs

Mycobacterial infection - post primary TB

• upper lung zone consolidations with cavitation

• CD4 <350

Mycobacterial infection - primary TB

• patchy areas of consolidation in any lung zone, effusions

• CD4 <200

• hilar and/mediastinal adenopathy

mycobacterial infection - miliary TB

• hematogenous spread of diffuse tiny nodules, all lung zones

fungal pneumonia

dysphagia

candidiasis, viral esophagitis (herpes, CMV, HIV), KS

GI manifestations - diarrhea

cryptosporidiosis, giardia, mycobacteria

GI manifestations - colitis

CMV, mycobacteria, C. diff

GI manifestations - cholangitis

CMV and/or cryptosporidiosis

esophagitis - candidiasis

• “shaggy” mucosa from plaques

esophagitis - HSV ulcers

• “target” shaped small, superficial ulcers

HIV ulcers

• larger and deeper ulcers compared to Herpes

acalculus cholecystitis (acute inflammation of the gallbladder that occurs without the presence of gallstones)

biliary disease

biliary disease

biliary disease

• focal stenosis

pancreatic disease

HIV & AIDS - The Renal System

• may be an early, unsuspected manifestation of HIV infection

• most patients are asymptomatic

• sonographic findings include enlarge echogenic kidneys with poor corticomedullary differentiation

HIV nephropathy

study of choice to identify renal stones ***

non-contrast CT scan

***

renal colic ***

cellulitis

• Swelling, calor, pain

• Staph and strep most common

• Subcutaneous fat stranding

necrotizing fasciitis

soft tissue abscess

pyomyositis

• Staph most common

• Infection of the muscle

• Can lead to abscess formation and myonecrosis

osteomyelitis

• Hematogenous spread, direct extension, direct inoculation

• Staph most common

• Tibia, wrist, femoral heads, ribs, spine TL junction

• X-ray changes not evident for 10-14 days***

• Nuclear medicine (MDP, Ga-67, In-111)

• MRI with contrast (decreased T1 signal)

osteomyelitis with brodie abscess

septic arthritis

• Important to keep in the differential diagnosis with a mono-articular process

• Early diagnosis with aspiration and culture is key to correct diagnosis and determining bug sensitivity

• Can be aggressive and lead to early destruction of cartilage and bone

kaposi sarcoma

• AIDS defining malignancy

• Associated with human herpesvirus 8 (HHV-8)

• Low-grade vascular tumor that involves the lymphovascular system

kaposi sarcoma - skin manifestation

• cutaneous and subcutaneous nodules

kaposi sarcoma - GI manifestations

• involves the liver, spleen, and bowel

• liver and spleen - multiple nodules

• bowel - early disease consists of flat lesions that are not demonstrated on barium studies

• Lesions coalesce, enlarge and become more nodular

• Extension into the muscular wall🡪 large bulky polypoid masses and irregular fold thickening

• higher risk of developing malignancies

kaposi sarcoma

• left = small bowel wall thickening

• right = large bowel involvement

kaposi sarcoma - GI manifestation

• lobulated mass involving the rectosigmoid

kaposi sarcoma - pulmonary manifestation

• nodules, linear opacities, 40% have pleural effusion, adenopathy

• present with cough, fever, shortness of breath, hemoptysis and chest pain

• occurs in 45% kaposi sarcoma cases