Behcets Syndrome

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Behcet's syndrome is a chronic relapsing disease, basically manifesting as painful oral ulceration, genital ulceration, and uveitis. Peculiarly, the prevalence is not uniform in global distribution: the majority of cases have been reported from the eastern Mediterranean countries, Korea, and Japan. The mean age of onset is between 25 and 30 years with men be

Old Man Knee Syndrome

Fig. 12.5A, B Radiographic and scintigraphic features of acute Behcet's disease. A Lateral radiograph of the right knee in a 22-year-old woman with acute Behcet's disease shows diffuse articular distension denoting synovitis and periarticular soft-tissue swelling (arrows). B Lateral pinhole scintigraph reveals periarticular tracer uptake (arrows) with extremely subtle uptake in inflamed tendons (arrowheads). Note particularly intense uptake at the suprapatellar (left upper arrow) and infrapatellar (lower arrow) tendon insertions, the characteristic sign of enthesitis

Fig. 12.5A, B Radiographic and scintigraphic features of acute Behcet's disease. A Lateral radiograph of the right knee in a 22-year-old woman with acute Behcet's disease shows diffuse articular distension denoting synovitis and periarticular soft-tissue swelling (arrows). B Lateral pinhole scintigraph reveals periarticular tracer uptake (arrows) with extremely subtle uptake in inflamed tendons (arrowheads). Note particularly intense uptake at the suprapatellar (left upper arrow) and infrapatellar (lower arrow) tendon insertions, the characteristic sign of enthesitis ing affected more commonly than women. A number of immunological abnormalities have been detected in patients with Behcet's disease, including antibodies to human mucosal cells, lymphotoxicity to heterologous oral epithelial cells, and blast transformation of patient's lymphocytes by human oral epithelial cells. HLA-B5 has been found to be increased fourfold in this disease in Korean, Japanese, and Turkish, but not in northern European, patients. Joints

Dactylitis

Fig. 12.6A, B The "sausage digit" in acute Behcet's dactylitis. A Dorsoplantar radiograph of the right foot shows diffuse periarticular soft-tissue swelling around the third toe metatarsophalangeal and proximal interphalangeal joints (arrows). B Dorsal pinhole scintigraph reveals diffuse sausage-like tracer uptake (large arrow). Note that dubious radiographic changes in the second and fourth toes are distinctly shown on the scintigraph (small arrows)

Fig. 12.6A, B The "sausage digit" in acute Behcet's dactylitis. A Dorsoplantar radiograph of the right foot shows diffuse periarticular soft-tissue swelling around the third toe metatarsophalangeal and proximal interphalangeal joints (arrows). B Dorsal pinhole scintigraph reveals diffuse sausage-like tracer uptake (large arrow). Note that dubious radiographic changes in the second and fourth toes are distinctly shown on the scintigraph (small arrows)

are involved in more than 50% of patients, and the involvement is mostly monoarticular or oligoarticular (Yurdakul et al. 1983). The knees, ankles, and wrists are the most common sites of affliction. The feet are occasionally involved and may produce the "sausage digit" sign and pseudopodagra (Giacomello et al. 1981).

Radiographic features in the acute stage include diffuse articular distension, denoting synovitis and periarticular soft-tissue swelling

Sausage Digit

Fig. 12.8A, B Early changes of SLE. A Anteroposterior radiograph of the right knee in a 22-year-old woman shows articular widening and periarticular soft-tissue swelling (arrows). B Anterior pinhole scintigraph reveals diffusely increased tracer uptake in periarticular bones and soft-tissue structures (arrowheads). Note peculiar accentuated uptake in the distal femoral metaphysis that is sharply demarcated by the physeal line (arrow)

Fig. 12.7A, B Iatrogenic osteonecrosis in Behcet's disease treated with corticosteroid. A Anteroposterior radiograph of the right hip in a 29-year-old woman receiving corticosteroid shows mottled areas of increased bone density and osteopenia in the femoral head due to bone reaction and necrosis (arrow). B Anterior pinhole scinti-graph reveals a small photon defect at the center of the femoral head with increased tracer uptake, respectively reflecting osteonecrosis (open arrow) and reactive and new bone formation (solid arrow)

Fig. 12.8A, B Early changes of SLE. A Anteroposterior radiograph of the right knee in a 22-year-old woman shows articular widening and periarticular soft-tissue swelling (arrows). B Anterior pinhole scintigraph reveals diffusely increased tracer uptake in periarticular bones and soft-tissue structures (arrowheads). Note peculiar accentuated uptake in the distal femoral metaphysis that is sharply demarcated by the physeal line (arrow)

Metaphysis

Fig. 12.9A-C Peculiar metaphyseal tracer uptake in SLE. A Whole-body scintigraphy in a 31-year-old woman with steroid-treated SLE shows symmetrical polyarthritis-like tracer uptake in the shoulders, elbows, hips, knees, and spine, strongly resembling classic rheumatoid arthritis (arrows). B, C However, anterior pinhole scintigraphs of the right knee and hip, respectively, reveal tracer uptake peculiarly localized not to the joint proper but to the phy-ses and metaphyses (arrows). The clinical implications of such a phenomenon are unknown

Osteopenia The Spine

(Fig. 12.5A). Osteopenia, articular narrowing, and bone erosions are usually inconspicuous, and, if conspicuous, they resemble rheumatoid arthritis. The "sausage digit" sign is another important feature, denoting soft-tissue swel ling in and around the metatarsophalangeal joint (Fig. 12.6A). Whole-body bone scintigra-phy reveals monoarticular or oligoarticular arthritis, and pinhole scintigraphy demonstrates diffuse periarticular tracer uptake occasionally with subtle uptake in inflamed tendons (Fig. 12.5B). The "sausage digit" sign and other articular changes are efficiently diagnosed using this method (Fig. 12.6B). It is probably the best available means to accurately diagnose plantar fasciitis of Behçet's disease in its early phase (Fig. 12.3) and also iatrogenic oste-onecrosis that frequently develop in patients with this disease under glucocorticoid treatment (Fig. 12.7).

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