[Thalassemia today. The radiologic evolution of lesions of the skull and hand with reference to transfusion therapy]

The main abnormalities of the hand and skull in a group of patients who underwent hypertransfusion regimen were reviewed and compared to the lesions observed in a control group of low-transfused patients. The results are reported, and a possible correlation with transfusion regimen is discussed: since bone lesions are explained on the basis of relationship between proliferating bone marrow and bone cortex, hypertransfusion regimen will prevent the development of abnormalities, only if established early in life. For this reason, skeletal lesions in Cooley's anaemia have changed their "classical" radiographic patterns. In the skull, the diploic space may become normal, and the overgrowth of facial bones moderate; the pneumatization of paranasal sinuses may not be completely impeded by the swelling of the jaws, the "hair-brush" pattern may disappear completely. The normalized picture of the hand is and remains a typical differential sign of prepuberal and adult patients.

[Bone marrow scintigraphy in multiple myeloma. A comparison with bone scintigraphy and skeletal radiology]

The radiographic patterns of the skeleton of 73 patients affected by multiple myeloma (MM) were compared to the correspondent scintigraphic findings. Whole body scans were performed using 99m Tc-diphosphonates (bone scintigraphy), and 99m Tc-microcolloids (bone marrow scintigraphy). The results indicate that: a) radiography is more sensitive and accurate than scintigraphy in detecting typical myeloma-related bone lesions; b) bone scintigraphy is useful in detecting alterations in particular locations--i.e., sternum, ribs, scapulae, etc.--which are difficult to demonstrate by plain X-rays; moreover, the recovery of the fractures can be visualized; c) bone marrow scintigraphy is employed to demonstrate the presence of marrow expansion, of cold/hot spots, and relative marrow uptake, related to phagocytic activity. Since in adult men red marrow is confined to the epiphysis of long bones and to the spine, all the diseases affecting bone marrow cause medullary expansion/reduction, which are both easily detected by specific radiopharmaceuticals. The peripheral expansion is clearly documented especially in distal humeri and femora since marrow uptake is included, in healthy adults, in the axial and proximal appendicular skeleton. In spite of its yielding unique information, bone marrow scintigraphy remains an additional technique of bone scan, because of its low diagnostic accuracy.

[Osteoarticular amyloidosis caused by dialysis]

The accumulation of amyloid in the bone and joint system has recently been recognized as a peculiar disease in patients undergoing long-term hemodialysis (5 years at least), especially in those who use cuprophan membranes. The pathology of amyloidosis is characterized by deposits of amyloid (beta 2-microglobulin mainly) in the bone, in the synovia, and in pericapsular soft tissues. The skeleton of 46 long-term hemodialysis patients (19 males and 27 females) was studied by X-ray: bone and joint abnormalities due to amyloid deposition were observed in 45% of cases. The shoulder, hip, and wrist were the most frequently involved joints. Destructive spondyloarthropathy was present in 15% of cases. The radiographic patterns of AOD are generally divided into axial and peripheral lesions. In the appendicular skeleton abnormalities include: well-defined lytic areas (geodes), pathologic fractures, marginal erosions, and periarticular soft tissue swelling. Destructive spondyloarthropathy is frequently present in the cervical spine (85% of our cases), and is characterized by narrowing of the intervertebral space, marginal erosion, and subchondral bone sclerosis of the vertebral body.

Circumscribed lytic lesions of the thalassaemic skull

Solitary or multiple circumscribed osteolytic areas are described in seven patients, selected from 250 patients with homozygous beta-thalassaemia (Cooley's anaemia). On X-ray examinations, these areas appear as purely osteolytic lesions with well-defined margins not associated with sclerosis. The possible mechanisms are discussed.

[Ochronotic arthropathy in alkaptonuria. Radiological manifestations and physiopathological signs]

Alkaptonuria is a rare autosomal recessive metabolic disease, due to the lack of homogentisic acid oxidase. The following accumulation of homogentisic acid brings about a black discoloration of both the urine (alkaptonuria) and connective tissue (ochronosis). The ochronotic alterations into joint cartilages cause degenerative arthropathy and osteopenia. The radiological features of three unrelated cases of alkaptonuria are reported. Radiographic abnormalities of ochronotic arthropathy are found in both the spine and the extraspinal joints. In the spine, the progressive calcification and "vacuum" phenomenon of disc spaces are the most characteristic findings. Disc space narrowing is associated with calcification and marginal sclerosis of vertebral bodies and is accentuated by osteopenia. Osteophytes are usually absent or of small size; nevertheless progressive formation of marginal intervertebral bridges and obliteration of disc spaces at multiple levels ("pseudoblock vertebrae") may occur. In extraspinal sites, space narrowing, bone sclerosis and fragmentation may also be observed. Diagnosis of ochronotic arthropathy is often suggested by radiographs of the spine, and it is confirmed afterwards by clinical and laboratory findings. The characteristic radiological findings of ochronotic spondylitis, in the final stage, include narrowing of at least four lumbar disc spaces, associated with their calcification and "vacuum" phenomenon, "pseudoblock vertebrae", marginal sclerosis and osteopenia of vertebral bodies.

[Enthesopathies. Radiography and xeroradiography compared]

The term "enthesis" designates the sites of tendon, ligament and articular capsule insertion to bone. Entheses are fundamental to the cybernetic regulation and correlation of postural and motion functions in the body. They also hold a key position in the locomotor system diseases. "Enthesopathy" is a disease occurring at these sites (primary enthesopathy), which can occur alone or together with different disorders, including inflammatory, degenerative, metabolic and traumatic conditions (secondary enthesopathy). Enthesopathy may lead to articular and non-articular manifestations: common sites of involvement include the spine and pelvis, femoral trochanter, humeral tuberosity, patella, olecranon and calcaneus. In acute enthesopathy, all the signs of acute inflammation may be present. In subacute or chronic forms, pain and tenderness localized in the entheses are found. Radiographic patterns include bone erosion, hyperostosis (enthesophytes), bone fragmentation and crystal deposits.

[Radiological picture of the hand and foot in systemic lupus erythematosus]

A detailed examination of the hands and feet was performed in a group of 34 patients affected by systemic lupus erythematosus (SLE), using low-dose mammographic film and Rank Xerox selenium plate, according to current diagnostic techniques. All patients presented articular symptoms (pain and arthralgia). The high incidence (38,8%) of patients with no radiographic evidence of bone damage-even though articular symptoms are present-is emphasized. In such cases, it is very difficult to distinguish SLE from rheumatoid arthritis, especially as far as therapeutic management and prognosis are concerned. The lack of any "pathognomonic" radiological sign of the lupus arthritis, in the hands as well as in the feet, is then stressed. Nevertheless, arthropathy in SLE is defined as a deforming non-erosive arthritis, with a typical symmetric distribution, affecting most commonly-according to incidence-the proximal interphalangeal and metacarpophalangeal joints. In the hand, arthropathy is referred to as Jaccoud's type arthritis, because it is characterized by joint deformities which can be corrected. In the foot, the main abnormalities include hallux valgus, subluxation of the metatarsophalangeal joints and widening of the forefoot.

[The hyperostotic knee]

Diffuse idiopathic skeletal hyperostosis (DISH) is a disorder characterized by bone proliferation of spinal and extraspinal structures. Frequently, extraspinal manifestations may occur before the involvement of the spine. These alterations are so common and characteristic that they should be included in the diagnostic criteria for DISH. The patella is one of the most commonly involved sites. The knee of 48 patients affected by DISH, according to Resnick's diagnostic criteria, were subjected to systematic, radiographic and xerographic studies. The most characteristic radiographic patterns are: thickening of the anterior margin of the patella (81.1%); ossifying enthesopathy of supero-anterior margin of patella (68.7%); periosteal new bone formation on the tibial insertion of the cruciate ligaments (47.8%); presence of fabella (41.%); presence of megafabella (22.9%), which may come near the posterior profile of the femur. Changes are usually symmetrical in DISH: entheseal abnormalities mostly involve the antero-superior margin of the patella, whereas in osteoarthritis, osteophytes are found on the postero-superior margin. In the lateral view enthesophytes at the bone attachment of the cruciate ligaments are oriented inside the joint space; on the contrary, osteophytes are always oriented outside the joint space. Radiographic manifestations of the fabella are similar to those observed in osteoarthritis, and so they cannot be utilized in the differential diagnosis of these diseases.

[The skull in renal osteodystrophy]

Skull X-rays of 60 patients with chronic renal failure were examined. Alterations included diminished or increased bone density, radiolucent areas, pepper pot skull and the disappearance of vascular grooves and sutures. It is suggested that the radiological aspect of the skull is of very little diagnostic use in the assessment of uremic osteopathy since specific alterations are rare and tardive and show no correlation with clinical and laboratory findings. Skull X-rays can be useful in assessing the effects of treatment (vitamin D derivatives, parathyroidectomy) and for the identification of focal lesions (brown tumors).

[The shoulder in basic calcium phosphate microcrystal deposit disease]

Basic calcium phosphate (BCP) crystal deposition can lead to periarticular collections associated with typical radiographic findings, most frequently observed in the shoulder. Moreover, these deposits may be revealed in other articular sites (i.e., wrist, hand, foot, elbow, hip, etc.). Initially, the calcium deposits may appear poorly defined (cloudlike); afterwards, they may reveal different patterns (linear, triangular or circular areas), changing in size, configuration and site. Adjacent bone may be normal, although osteoporosis, cystic lesions and reactive sclerosis are reported. The radiographic appearance of calcifications will depend upon the exact location of the deposits in the specific tendon of the rotator cuff, the adjacent bursae and the soft tissues.

Aseptic necrosis of femoral head complicating thalassemia

Aseptic necrosis of the femoral head is described in 4 patients, selected from 280 patients with homozygous beta-thalassemia (Cooley anemia). The incidence of the complication appears to be very high (14.5%) in thalassemia, compared to the general population. The possible mechanism are discussed.

[Radiology of the hand in progressive systemic sclerosis]

Radiographs and xerographs of the hands of 35 patients with progressive systemic sclerosis (PSS), as defined by the ARA, were reviewed. Patients with "overlap" syndromes (i.e., mixed connective tissue disease, systemic lupus erythematosus or rheumatoid arthritis) have been excluded. Soft tissue changes included atrophy (hide-bound skin), and dystrophic calcifications, particularly in CREST patients (calcinosis, Raynaud phenomenon, esophageal dysmobility, sclerodactily and telangectasia). The most common bony change is resorption of distal phalanges; diffuse osteoporosis is also frequent; the distal interphalangeal and first carpometacarpal joints involvement appear as a distinctive feature of this erosive arthritis.

[Direct radiographic magnification of the hand: study of erosions in rheumatoid arthritis]

Plain films and direct magnification radiographs of the hands were performed in 34 patients affected by rheumatoid arthritis, using mammographic x-ray tube, achieved with 0.1 mm microfocus, and 1.85 X magnification factor. Direct magnification radiography has provided essential or useful diagnostic data in 44% of cases, particularly in recognizing early skeletal erosions. Nevertheless direct magnification radiography must be used only in those cases in which traditional mammographic techniques do not supply satisfactory results.

[Aseptic necrosis of the head of the femur in Cooley's disease]

The incidence of aseptic necrosis of femoral head in homozygous beta-thalassaemia (Cooley's anaemia)--which is indeed significantly high--is not satisfactorily referred in late literature regarding haemolytic syndromes. Therefore, 4 cases of osteonecrosis of femoral head, recently recognized in a series of 280 patients affected by Cooley's anaemia (14.5 0/00) are presented, and a review of hypotheses about the pathogenesis of the lesions is considered. In Cooley's anaemia, the skeletal lesion (osteoporosis) must be believed as a propitious state, in which some other pathogenetic events (i.e. local ischemia, bony age, etc.) and microtraumas overlap. In any case, characteristic blood circulation of the femoral head is the "conditio sine qua non" in developing osteonecrosis.

[Value and limitations of scintigraphy of the hand in rheumatoid arthritis]

99mTc-polyphosphate joint imaging of the hand has been performed in 18 patients, with evidence of inflammatory joint disease, but without any significant radiographic lesions, which might be related to rheumatoid arthritis. The hand scans were compared to clinical and radiographic data. An year after, the same subjects were re-examined, with both the radionuclide imaging and radiography. Scintigraphy has been shown to be significantly more sensitive for detecting inflammatory joint disease than x-ray, especially in the early stage of rheumatoid arthritis. Although radionuclide imaging is non specific (activity is increased also in osteoarthritis, trauma, metabolic bone disease, infarction, etc.). Radiography is highly specific but relatively non sensitive.

["Cupid's bow" contour of the lumbar vertebrae]

The cortical margin of the inferior end plate of lumbar vertebral bodies, in the frontal projection, frequently simulates the curvature of a bow, aimed cephalad. On lateral view, the two concavities are superimposed and lie in the posterior portion of the vertebral body. The aspect, called "Cupid's bow" must be considered a normal anatomic variant and should not be confused with diseases affecting the spine. The incidence and degree of the finding are discussed.

[Changes in thyroid hormone status after injections of iodinated contrast media]

Administration of four different contrast media exerted slight but significant and prolonged effects on the hormonal thyroid status, in 53 euthyroid subjects (four subgroups), without any clinical expression of dysthyroidism. Changes in serum T3, rT3 and T4 demonstrated different trends for each iodinated compound, probably depending on the regulatory thyroid mechanisms, and CM pharmacokinetics. Plasma profiles of free fractions (FT3, FT4) slightly reflected consensual changes with circulating iodothyronines, at various time periods of study, demonstrating high correlation indexes with total fractions. The five hormones profiles correlation study suggest that different mechanisms could be responsible for some features encountered of "low T3 syndrome". These effects may be not only equivalent to giving various sources of iodide, but suggest more complex mechanisms. It is apparent that man has a remarkable and possibly unique system of homeostatic thyroid hormone regulation.

[Secondary non-Hodgkin's lymphoma of the small intestine. Double-contrast radiological study using oral enema]

The small bowel double contrast enema was performed in 44 patients with diffuse non-Hodgkin lymphoma. "Secondary" involvement of small bowel is detected in 14 subjects (31.8%), but radiographic features are not specific for the disease. Really, lymphoma and regional enteritis may demonstrate strikingly similar patterns. The signs we have considered are: intraluminal involvement, with narrowing or dilated segments; diffuse or localized polypoid lesions; large extraluminal masses. The roentgenographic pattern of the mucosal folds consists of thick, straight or tortuous folds, with "cogwheel" appearance and moderate dilatation of the lumen.

[Abdominal ultrasonography in the staging and follow-up of malignant lymphomas]

During the period September 1980-June 1984, abdominal US was performed by the authors on 103 patients with confirmed malignant lymphomas. The results indicate US has accuracy comparable to that of lymphography for lymph node enlargement; furthermore, US has the added advantages of being able to demonstrate mesenteric, renal hilar and other abdominal lymph nodes that are not commonly filled with contrast medium during lymphography. For these reasons, US is now frequently used in the diagnosis and staging of malignant lymphomas as well as for following up the results of therapy.(US = ultrasonography)

[Erosive arthrosis of the hand. Criteria of the differential diagnosis]

Erosive osteoarthritis (EOA) is a peculiar form of osteoarthritis, characterized by inflammatory destructive changes (erosions) in the interphalangeal joints, with relative sparing of the metacarpophalangeal joints, and frequent involvement of the trapeziometacarpal joint. Linear periosteal bone apposition is also commonly reported. In EOA, erosions tend to occur exclusively in the subchondral cortex of joints, causing in DIP joints a typical "gull wings" configuration of bones of distal phalanges, whereas in psoriatic arthritis (PA) and in rheumatoid arthritis (RA) the "bare areas" are primarily affected. However, such "gull wings" erosions are nonspecific, and may be observed in the late stage of PA in the IP joints, or RA in the PIP joints.

[Crystalline calcium pyrophosphate dehydrate deposit disease]

Radiographic features of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease are outlined in an investigation of 32 patients, with definite or probable disease (according to the diagnostic criteria previously utilized by McCarty). The crystal deposits within fibro- and hyaline cartilage (chondrocalcinosis) may produce an acute synovitis (pseudogout syndrome), and in some patients a radiographically distinctive degenerative arthropathy (pyrophosphate arthropathy). These abnormalities are most frequent in the knee, wrist and symphysis pubis, but often other joints may be affected. Although the alterations superficially resemble osteoarthritis, they are more severe and progressive (Charcot-like joint).

Xeroradiography in beta-thalassaemia

Xeroradiographic investigations of the skull, hand, and elbow were performed on 27 patients with homozygous beta-thalassaemia. The results were compared with plain radiographic examinations. Xeroradiography, because of its technical properties (i.e. edge contrast enhancement and wide latitude), was shown to demonstrate cortical thinning of long bones, swelling of the diploic space in the skull, and reticulated patterns in the elbow better than standard radiography. Moreover, the use of "positive" mode imaging was shown to have advantages in the study of the skull and extremities.