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Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is an inflammatory clinical condition with aseptic bone lesions and characteristic skin manifestations. A 63-year-old woman presented with vague musculoskeletal symptoms including chronic buttock pain. The clinical work-up revealed multiple spine and osteoarticular involvement. Multilevel bone marrow edema and cortical erosions involving the spine, asymmetric sacroiliitis, and osteosclerosis of the sternoclavicular joint were consistent with a diagnosis of SAPHO syndrome. Considering SAPHO syndrome in the differential diagnosis, subsequent skin inspection revealed plantar pustulosis. Despite the unique feature of accompanying skin and skeletal lesions, skin lesions could be overlooked if not suspected.

In scaphoid nonunion, pseudarthrosis and sclerotic change occur at the nonunion site. These changes make a distal fragment look like a trapezium on plain radiographs and we called this phenomenon the double trapezia sign. The purpose of this study was to estimate the diagnostic reliability of the double trapezia sign and its clinical and prognostic implications for the scaphoid nonunion. A retrospective review of 124 patients who underwent surgical treatment because of scaphoid nonunion between January 2007 and December 2017 was performed. Two hand surgeons and 1 musculoskeletal radiologist reviewed preoperative plain radiographs independently. Each observer evaluated the plain radiographs in 2 separate sessions at least 3 weeks apart to assess intraobserver and interobserver reliabilities of the double trapezia sign. To assess clinical and prognostic implications of the double trapezia sign, the patients were divided into the positive and nonpositive groups, and several variables such as age, sex, duration of nonunion, size of the distal fragment, avascular necrosis (AVN) of the proximal fragment, type of bone graft, healing time, and failure rate were compared between the 2 groups. The kappa values of intraobserver and interobserver reliabilities were >0.8, corresponding to almost perfect agreement. There were 58 patients in the positive group and 66 patients in the nonpositive group. The mean duration of nonunion was 38.5 months in the positive group and 12.2 months in the nonpositive group (P

Objective To identify factors influencing endothelial progenitor cell (EPC) counts in patients with rheumatoid arthritis (RA). Methods The number of circulating CD34+/vascular endothelial growth factor receptor 2–positive EPCs was measured in 126 RA patients and 46 non-RA control patients. Endothelial function was assessed by brachial flow-mediated dilation (FMD). Serum CXCL12 concentrations were determined using an enzyme-linked immunosorbent assay. EPCs and FMD were measured at baseline and after 24 weeks of anti–tumor necrosis factor α (TNFα) therapy in 29 patients with active RA. Results The numbers of circulating EPCs were significantly lower in the RA patients than in the non-RA controls. In multivariate analysis, older age, reduced levels of high-density lipoprotein cholesterol, and higher bone erosion scores were independent risk factors for reduced EPC counts in RA patients. Serum CXCL12 levels correlated negatively with EPC counts, but positively with bone erosion scores. FMD was impaired in RA patients, and a decreased FMD in RA was closely associated with a higher bone erosion score and a reduced EPC count. In addition, EPC counts were restored by anti-TNFα therapy, and this increase was paralleled by improvement in FMD. Interestingly, restoration of EPC counts was attenuated in patients with higher bone erosion scores than in those with lower scores, despite similar levels of improvement in disease activity. Conclusion The numbers of circulating EPCs in RA patients are reduced and are inversely correlated with serum levels of CXCL12. Reduced EPC counts are closely associated not only with bone erosion, but also with endothelial dysfunction.

Introduction/Background A decrement of AMP-activated protein kinase-eNOS bioavailability is critical for the pathogenesis of diabetic peripheral neuropathy. We evaluated the neuro-protective effect of cinacalcet on DPN by activating the AMPK-eNOS pathway using db/db mice. Material and method The db/db mice and db/m controls at 8 weeks of age were divided to receive either a regular diet or a diet containing cinacalcet. Mice were evaluated sciatic motor nerve conduction and tactile response. We performed Mason's trichrome staining and immunohistochemistry for type IV collagen and 8-hydroxy-deoxyguanosine, an oxidative DNA damage marker. For immunofluorescence double staining, apoptosis was detected by ApopTag Fluorescein In Situ Apoptosis Detection Kit. The sciatic nerve specimens were double stained and we measured unmyelinated fiber areas and axonal areas using NIH Image J under a transmission electron microscope. Western blot assay was performed total protein of sciatic nerve with specific antibodies for CaSR, CaMKK, total LKB1, phospho-Ser428 LKB1, total AMPK, phospho-Thr172 AMPK, total eNOS, phospho-Ser1177 eNOS, PGC-1. Results The db/db mice showed sensorimotor impairment, nerve fibrosis and inflammation, apoptosis, disorganized myelin with axonal shrinkage and degeneration, and fewer unmyelinated fibers in the sciatic nerve compared to db/m mice. Cinacalcet administration, without causing any changes in blood glucose and Ca++ concentrations, significantly increased the paw withdrawal mechanical threshold and decreased the motor conduction latency, and ameliorated the deterioration of sciatic nerve pathology, accompanied by increases in the expressions of calcium-sensing receptor-CaMKK and phosphorylation of AMPK-eNOS in diabetic mice. Conclusion Cinacalcet may play an important role in the prevention and amelioration of DPN by amplifying AMPK signaling.

The purpose of this article is to correlate MRI arthrographic findings with range of shoulder motions in patients with frozen shoulder.Shoulder MRI studies of 40 patients (22 women and 18 men; mean age, 52.8 years) with frozen shoulder were retrospectively compared with MRI studies of 40 age- and sex-matched control subjects without frozen shoulder. The thickness of the coracohumeral ligament and the capsule in axillary recess were measured retrospectively. The range of shoulder motions, including external rotation (ER), internal rotation (IR), lateral abduction, and forward flexion (FF), were prospectively evaluated by one experienced orthopedic surgeon.The mean (±SD) thickness of the coracohumeral ligament (4.13±1.04 vs 2.51±0.59 mm; p=0.000) and the capsule in axillary recess (3.97±1.45 vs 2.33±0.87 mm; p=0.000) were significantly greater in the patient group than in the control group. Multiple linear regression showed that only coracohumeral ligament thickness was significantly associated with ER (R2=0.418; p=0.000) and IR (R2=0.346; p=0.001), but not with lateral abduction and FF. Capsular thickness in axillary recess was not significantly correlated with any shoulder motion.Coracohumeral ligament thickness on MR arthrography correlates with the range limitation of ER and IR in patients with frozen shoulder.

Epidural injection of cyclooxygenase-2 inhibitors has been suggested as a useful therapeutic modality in pain management in animal studies and clinical settings. Direct epidural administration of parecoxib, a highly selective cyclooxygenase-2 inhibitor, may have advantages over its parenteral administration regarding required dose, side effects, and efficacy. However, no animal studies have been performed to investigate the possible neurotoxicity of epidurally injected parecoxib. Therefore, the present study was performed to assess the neurotoxicity of epidurally injected parecoxib in rats. Rats ( n = 45) were randomly divided into three groups: normal saline group (group N, n = 15), ethanol group (group E, n = 15), and parecoxib group (group P, n = 15). 0.3 mL of epidural parecoxib (6 mg) and the same volume of epidural ethanol or normal saline were injected into the epidural space. Neurologic assessment was performed 3, 7 and 21 days after the injection by pinch toe testing. Histologic changes were evaluated for vacuolation of the dorsal funiculus, chromatolytic changes of the motor neurons, neuritis, and meningeal inflammation. All rats in groups N and P showed normal response to pinch-toe testing and had a normal gait at each observation point. Histological examination showed no evidence suggestive of neuronal body or axonal lesions, gliosis, or myelin sheet damage in group N or P at any time. However, all rats in group E showed sensory-motor dysfunction, behavioral change, or histopathological abnormalities. No neurotoxicity on the spinal cord or abnormalities in sensorimotor function or behavior was noted in rats that received epidural parecoxib.

The aim of this study was to evaluate the imaging findings of invasive lobular carcinoma (ILC) compared to those of invasive ductal carcinoma (IDC). The study included ILCs (n = 27) and IDCs (n = 85). Imaging findings were retrospectively evaluated, according to the BI-RADS lexicon. We compared the imaging findings, multiplicity, and magnetic resonance imaging (MRI) detection accuracy of ILC with those of IDC. At mammography, normal findings and mass lesions were more frequent with ILCs (14.8% and 59.2%, respectively) than with IDCs (1.2% and 44.7%, respectively) (P = 0.009). With ultrasonography (US), posterior acoustic shadowing was more frequently seen in ILCs (59.2%) than in IDCs (15.8%) (P < 0.001). With MRI, both ILCs and IDCs most commonly appeared as a heterogeneously enhancing, irregular mass with a spiculated border. Multifocality was more frequently associated with ILCs (40.7%) than with IDCs (14.1% 1% 0.002). However, multicentricity and bilaterality were not different between the two groups. The sensitivity and specificity of MRI for the detection of multiplicity were 91.6% and 73.3%, respectively, for ILCs and 83.3% and 80.3%, respectively, for IDCs. Normal findings, mass lesions on mammography, and posterior acoustic shadowing on US were more frequently associated with ILCs than with IDCs. Multifocality was more prevalent with ILCs than with IDCs.

Granulocytic sarcoma is a form of extramedullary involvement of primitive myeloid cells. A 69-year-old male patient, with history of acute myeloid leukemia (AML) in remission state for 4 years, presented numbness, radiating pain and progressive motor weakness in left leg. MRI showed perineural thickening of the left sciatic nerve with increased signal intensity on fat-saturated T2-weighted image. The patient underwent surgical excision and the pathology was confirmed as granulocytic sarcoma. Its involvement of the peripheral nerve is extremely rare and also unusual to be the only evidence of AML relapse. In this case, we figured out the MRI feature of granulocytic sarcoma involving sciatic nerve, emerged as a sole manifestation of AML relapse.

A 41-year-old female presented with complaint of left hip and buttock pain. Magnetic resonance imaging (MRI) showed multi-focal bone marrow signal intensity changes in left iliac bone, sacrum and femur with an area of necrosis. The primary radiological differential diagnosis was multi-focal tuberculous osteomyelitis. Subsequent pelvic bone biopsy and bone marrow biopsy confirmed the diagnosis of B-cell precursor acute lymphoblastic leukemia with extensive necrosis, which is infrequent in leukemia. When musculoskeletal symptoms precede peripheral blood abnormalities and MRI scanning reveals multi-focal necrotic lesions rather than diffuse signal change, it can be difficult to identify and/or advance leukemia as differential diagnosis.

Multicentric reticulohistiocytosis (MRH) is a rare non-Langerhans histiocytosis of unknown etiology with a predilection for joint and skin. The characteristic clinical features are papulonodular skin eruptions and inflammatory polyarthritis, sometimes progressive to arthritis mutilans, a severe destructive arthropathy. Although these manifestations can present at the same time, it is more common that one feature precedes the others. Notably, these features are similar to those found in some rheumatic diseases, such as rheumatoid arthritis or dermatomyositis, and this can lead to a misdiagnosis, especially during periods where only one feature is present. Herein, we report a female patient with polyarthralgia and subsequent skin eruptions, who was eventually diagnosed with MRH. Her symptoms seemed to resemble those of some rheumatic diseases, but several features such as affected joints and the characteristic shape of the skin lesions did not correspond to that. The histological result of infiltration of histiocytes and multinucleated giant cells in the skin ultimately facilitated the correct diagnosis. In this paper, we review MRH briefly and highlight several differential points which enable us to increase the likelihood of correctly diagnosing MRH.

To document the imaging characteristics of subcutaneous and musculoskeletal sparganosis.Ten patients with musculoskeletal sparganosis were examined, with a variety of imaging modalities including MRI (n=6), ultrasonography (n=8), plain radiography (n=7) and CT (n=1). Pathologic correlation was carried out in all cases.Nine lesions involved soft tissues, of which seven were in the thigh, two in the trunk and one involved a vertebral body. The majority of the lesions in soft tissue were confined to the subcutaneous layer but two extended deep into underlying muscles. Sonography revealed low-echoic serpiginous tubular tracts (8/8), and an intraluminal echogenic structure (4/8). MRI revealed multiple serpiginous tubular tracts and peripheral rim enhancement. Two patients showed perilesional soft tissue edema. Pathologically, the lesion consisted of a larva surrounded by three layers of inflammation: an inner epithelioid granulomatous cell layer, middle chronic inflammatory cell layers, and an outer fibrous layer.The study suggests that if serpiginous tubular tracts are seen at imaging studies, musculoskeletal sparganosis should be included in the differential diagnosis.

This chapter describes the some common disorders of the bone marrow and immune systems with an emphasis on the elderly. Advancing age comes bundled with increased cancer incidence and mortality. The hematopoietic disorders of the elderly which can be diagnosed by radiologic studies include anemia, amyloidosis, myelofibrosis, and malignancies such as multiple myeloma, plasmacytoma, leukemia, and lymphoma. In this chapter, we discuss various imaging characteristics of hematological disorders and malignancies in the geriatric population. Imaging modalities include radiography, computed tomography (CT), positron emission tomography (PET), PET-CT, and magnetic resonance imaging (MRI).

Granulocytic sarcoma is a tumor formed by myeloid precursors at an extramedullary site. The purpose of this study was to evaluate the MRI findings and clinical manifestations in 32 cases of granulocytic sarcoma of the spine.Thirty-two patients (21 males, 11 females; mean age, 32 years) with myeloid leukemia and spinal granulocytic sarcoma were included in this study. All of the patients underwent radiotherapy with chemotherapy, and four patients underwent surgical decompression or excisional biopsy. All 32 patients underwent MRI of the spine; 21 patients underwent follow-up MRI.Nine patients had spinal granulocytic sarcoma in the initial manifestation of leukemia. The other 23 diagnoses were made during a remission or relapse period. The lumbosacral and thoracic portions of the spine were commonly involved. Twenty-seven patients had multiple or contiguous multilevel involvement. According to location, spinal granulocytic sarcoma was classified as epidural in the central spinal canal, epidural along the nerve course, thickening of the nerve root itself, or prevertebral. Lesions were seen as isointense on T1-weighted images and had intermediate signal intensity with homogeneous enhancement on T2-weighted images. Nine patients had complete reduction of the tumor volume, and 12 patients had partial reduction. The median survival period was 9 months, and the 1-year survival rate was 41%.Knowledge of the imaging findings of spinal granulocytic sarcoma, which consists of multiple extramedullary masses with diffuse leukemic bone marrow infiltration, can lead to early diagnosis and appropriate treatment to reduce neurologic symptoms.