Faint Tracer In L2 Vertebra

Fig. 11.8 Spotty asymmetrical polyarthritis and spondylitis in Reiter's syndrome. Composite whole-body spot scintigraph in a 26-year-old man with Reiter's syndrome panoramically delineates the lesions in the lower lumbar spin, both proximal tibiae, the right forefoot, and the left hind- and midfoot (arrows)

with diarrheal disorder or a postvenereal complication. The prevalence of Reiter's syndrome is not easy to assess because of the difficulty in making a definite diagnosis. This is due mainly to the lack of absolute diagnostic criteria, the mobile community of young adults that constitutes the majority of patients, and the frequently suppressed history of venereal disease and forgotten features of diarrheal disorder. The

Left And Right Hindfoot
Fig. 11.9 Early pinhole scintigraphic diagnosis of Reiter's enthesopathy in the calcaneus. Medial pinhole scan of the right hindfoot in a 30-year-old man with focal osteoen-thesopathy shows a small spotty tracer uptake in the upper posterior aspect of the calcaneus (arrowhead)
Enthesopathy Calcaneus

Fig. 11.10 Preradiographic diagnosis of early Reiter's enthesopathy in the knee. Anterior pinhole scintigraph of the left knee in a 48-year-old man with fibular head pain shows faint tracer uptake in the fibular ligament insertion site (arrowhead). The anatomical location was confirmed by radiography, which did not reveal comparable alteration (not shown). An ordinary scintigraph also failed to reveal abnormality even in retrospective observation

Fig. 11.10 Preradiographic diagnosis of early Reiter's enthesopathy in the knee. Anterior pinhole scintigraph of the left knee in a 48-year-old man with fibular head pain shows faint tracer uptake in the fibular ligament insertion site (arrowhead). The anatomical location was confirmed by radiography, which did not reveal comparable alteration (not shown). An ordinary scintigraph also failed to reveal abnormality even in retrospective observation

Calcaneal Enthesopathy Achilles

Fig. 11.11A, B Progression of scintigraphic change of upper retrocalcaneal enthesitis in Reiter's syndrome. A Lateral radiograph of the right calcaneus in a 26-year-old man shows thickening of the distal Achilles tendon at the calcaneal insertion (arrow). B Lateral pinhole scintigraph reveals intense reactive uptake at the Achilles insertion (arrow)

Fig. 11.11A, B Progression of scintigraphic change of upper retrocalcaneal enthesitis in Reiter's syndrome. A Lateral radiograph of the right calcaneus in a 26-year-old man shows thickening of the distal Achilles tendon at the calcaneal insertion (arrow). B Lateral pinhole scintigraph reveals intense reactive uptake at the Achilles insertion (arrow)

gender distribution has been reported as an overwhelming male preponderance, but a study by Fox et al. (1979) indicated a high prevalence of 15% in women. The highest incidence of the syndrome occurs in the third decade of life, but no age is immune.

Important clinical features are persistent or recurrent joint pain and pauciarticular involvement of the weight-bearing joints. Dactylitis, popularly known as the "sausage digit", is a characteristic digital manifestation. Tendinitis and fasciitis with extrasynovial swelling and enthesopathic spinal inflammation are other diagnostic stigmata. Urethritis or cervicitis and ocular lesions including conjunctivitis, iritis,

Old Man Knee Syndrome

Fig. 11.12 (154). Progression of scintigraphic change of Reiter's osteoenthesopathy in the knee. Anterior pinhole scintigraph of the left knee in 26-year-old man with well-established Reiter's syndrome (the same patient as in Fig. 11.8) demonstrates extremely intense, triangular tracer uptake in the lateral aspect of the proximal tibia at the fibular ligament insertion site and the proximal tibiofibular articulation (arrowheads)

Fig. 11.12 (154). Progression of scintigraphic change of Reiter's osteoenthesopathy in the knee. Anterior pinhole scintigraph of the left knee in 26-year-old man with well-established Reiter's syndrome (the same patient as in Fig. 11.8) demonstrates extremely intense, triangular tracer uptake in the lateral aspect of the proximal tibia at the fibular ligament insertion site and the proximal tibiofibular articulation (arrowheads)

and uveitis may constitute important extraske-letal clinical manifestations.

Pathologically, the most characteristic change is observed in the entheses in the form of inflammatory enthesopathies that sharply contrasts with overwhelming involvement of the synovia in rheumatoid arthritis. Typical enthe-sopathies include Achilles tendinitis, calcanean plantar fasciitis, sausage digit, and the whiske-ring of the iliac crest, ischiopubic bone, tro-chanter, and spine. No radiographic change is present in the early stage. The first signs to manifest in the joints include periarticular soft-tissue swelling, articular narrowing, and bone erosions in the absence of significant osteope-nia. Tendinitis, fasciitis, periosteal thickening, and whiskering follow. Spurs in the plantar and posterior portions of the calcaneus and sausage-like deformity of the toes are important features. Not infrequently unilateral or bilateral sacroiliitis occurs mimicking ankylosing spon-

Sacroiliitis Erosion Unilateral

Fig. 11.13A, B Para-articular enthesitis of the sternoclavicular joint in Reiter's syndrome. A Conventional tomogram of the left sternoclavicular joint in a 43-year-old man shows erosions in the undersurface of the medial part of the clavicle and upper border of the subjacent ossified first rib cartilage (arrows). Note that the pathology is not in the joint but in the enthesis. B Anterior pinhole scintigraph reveals tracer uptake specifically localized to enthesis (arrows)

Fig. 11.13A, B Para-articular enthesitis of the sternoclavicular joint in Reiter's syndrome. A Conventional tomogram of the left sternoclavicular joint in a 43-year-old man shows erosions in the undersurface of the medial part of the clavicle and upper border of the subjacent ossified first rib cartilage (arrows). Note that the pathology is not in the joint but in the enthesis. B Anterior pinhole scintigraph reveals tracer uptake specifically localized to enthesis (arrows)

dylitis, and when the spine is involved radiographic findings become indistinguishable.

Bone scintigraphy is the method of choice for the panoramic mapping of asymmetrical foci of polyarthritis and spondylopathy of Reiter's syndrome (Fig. 11.8). When augmented with the pinhole technique, bone scintigra-phy is more sensitive and often more specific than radiography, revealing early enthesopa-thies in the heel and knee (Kim et al. 1999). During the very early stage of the disease painful enthesopathies in the heel or knee may not be detected by radiography, but pinhole scintigraphy can portray subtle uptake as early as at

Reiter Syndrome

Fig. 11.14A, B Apophyseal joint involvement in spinal Reiter's syndrome. A Lateral radiograph of the lumbar spine in a 16-year-old male shows blurring and narrowing of the apophyseal joints of L2-3 (upper arrow) and L3-4 (lower arrow). B Lateral pinhole scintigraph reveals increased tracer uptake in the affected apophyseal joints and also in L3 lower and L4 upper endplates denoting diskovertebral joint involvement, which is not shown on the radiograph

Fig. 11.14A, B Apophyseal joint involvement in spinal Reiter's syndrome. A Lateral radiograph of the lumbar spine in a 16-year-old male shows blurring and narrowing of the apophyseal joints of L2-3 (upper arrow) and L3-4 (lower arrow). B Lateral pinhole scintigraph reveals increased tracer uptake in the affected apophyseal joints and also in L3 lower and L4 upper endplates denoting diskovertebral joint involvement, which is not shown on the radiograph

Apophyseal Joint

Fig. 11.15A, B The "sausage digit" sign. A Dorsal pinhole scan of the metatarsophalangeal joint of the right middle toe in a 30-year-old man with Reiter's syndrome shows fusiform tracer uptake resembling a sausage (arrows). B CT reveals edematous obliteration of the bone marrow with soft-tissue thickening or enthesitis (arrows)

Fig. 11.15A, B The "sausage digit" sign. A Dorsal pinhole scan of the metatarsophalangeal joint of the right middle toe in a 30-year-old man with Reiter's syndrome shows fusiform tracer uptake resembling a sausage (arrows). B CT reveals edematous obliteration of the bone marrow with soft-tissue thickening or enthesitis (arrows)

this stage of the disease (Figs. 11.9 and 11.10). Even more importantly, many such extremely subtle yet significant tracer uptakes may pass undetected by ordinary bone scintigraphy. To be specific, the subtle uptake occurs in the superior posterior edge or the plantar aspect of the calcaneus in the heel (Figs. 11.2 and 11.9) and the fibular ligament insertion at the proximal tibia (Fig. 11.10). No corresponding radiographic change can be observed in many of these early cases. With progress of disease, the calcaneal tendon becomes involved, showing prominent tracer uptake in the upper and middle retrocalcaneal surface, whereas radio-graphically the enthesic or tendinous lesion is barely discernible (Fig. 11.11). Progressive change of enthesitis can also be observed in the proximal tibiofibular lesions (Fig. 11.12).

Pinhole scintigraphy provides unique information on the specific anatomical sites of involvement, the enthesis and synovial joint, by Reiter's disease in the hip, knee, hindfoot, finger, spine, and sternum. For example, in sternal Reiter's disease, characteristic tracer uptake occurs at the insertion of the costoclavicular ligament (Fig. 11.13) or both the anterior sternoclavicular ligament and the costoclavicular ligament, but usually not in the sternoclavicu-lar joint. In the spine, the disease affects the apophyseal joints, manifesting characteristic tracer uptake that is localized to the joints (Fig. 11.14). On the other hand, the whole-body scan is indispensable for obtaining information on systemic distribution of SNSA.

Fig. 11.16A, B Anatomical and metabolic alterations of the "sausage digit" in Reiter's syndrome. A Dorsoventral radiograph of the diffusely thickened right middle finger in a 25-year-old man with Reiter's syndrome shows fusiform soft-tissue swelling about the metacarpophalangeal (arrowheads) and proximal interphalangeal (arrow) joints with periarticular erosions and articular narrowing. B Dorsal pinhole scintigraph shows very intense tracer uptake sharply localized in the periarticular bones of the metacarpophalangeal (arrowheads) and proximal inter-phalangeal joint (open arrow). Note that the abnormal tracer uptake is confined to the knuckled regions of the heads and bases of the digital bones with preserved articular spaces, producing a "knuckle bone" appearance

In addition, both the enthesopathy and arthropathy in Reiter's syndrome strongly tend to affect the lumbar spine and lower limb joints (Fig. 11.8), helping distinguish it from ankylo-sing spondylitis and psoriasis in which the lower limb joints are rather sparingly affected.

With regard to specific signs, pinhole scinti-graphy can demonstrate both the anatomical

Enesopathy The NeckEnthesopathy The Hip

Fig. 11.17A, B Osteophytes or "whiskers" in the hip joint in Reiter's syndrome. A Anteroposterior radiograph of the right hip in a 28-year-old man with Reiter's syndrome shows shaggy bone excrescences in the femoral neck and the acetabular margin (arrowheads). Bone trabeculae appear coarsened and the joint space is moderately narrowed. B Anterior pinhole scintigraph shows necklacelike tracer uptake in the femoral neck and the acetabular margin (arrowheads)

Fig. 11.17A, B Osteophytes or "whiskers" in the hip joint in Reiter's syndrome. A Anteroposterior radiograph of the right hip in a 28-year-old man with Reiter's syndrome shows shaggy bone excrescences in the femoral neck and the acetabular margin (arrowheads). Bone trabeculae appear coarsened and the joint space is moderately narrowed. B Anterior pinhole scintigraph shows necklacelike tracer uptake in the femoral neck and the acetabular margin (arrowheads)

and metabolic profiles of the sausage digit of Reiter's syndrome (Willkens et al. 1981). The sausage digit uptake reflects soft-tissue swelling resulting from effusion, periarticular edema, and bursal and tendinous inflammation or enthesopathy (Fig. 11.15). It may also be associated with erosions, periostitis, and whiske-ring (Fig. 11.16). Thus, pinhole scintigraphy shows expansive tracer uptake that is confined to the periarticular bones, especially the hallu-cis and digital muscles in the foot and the pol-licis and digital muscles in the hand. The bones involved in this process consist of the base of the distally placed phalanx and the head of the proximally placed phalanx or metatarsal or metacarpal. When uptake is discrete it may be termed the "knuckle bone" appearance (Fig. 11.16B). To distinguish from rheumatoid arthritis, it appears helpful to observe that, except in rare early cases (Fig. 10.5), the tracer uptake in rheumatoid arthritis is diffuse and concentric, and not eccentric as in Reiter's syndrome. Such differences may reflect generalized synovitis in rheumatoid joints and eccentric enthesopathy in Reiter's syndrome (Fig. 11.16). The whiskers in the femoral head are indicated by spiky uptake and those in the neck by necklace-like uptake (Fig. 11.17).

Another sign is the asymmetrical, paravertebral "tear-drop" ossification that bridges the disk space in the thoracolumbar spine (Sundar-am and Patton 1975). It is seen in 14% of cases, and antedates more widely recognized sacroi-liac and peripheral articular involvement. Pinhole scintigraphically, this peculiar ossification is represented by roundish tracer uptake, bulging laterally from the margin of the disk space (Fig. 11.18). Occasionally, the uptake is exaggerated and larger in size than the radiographic "tear-drop" when apophysitis of the neighboring joint is superimposed (Fig. 11.19).

Bone scintigraphy is useful for the observation and follow-up of the inflammatory process in Reiter's disease after the initial diagnosis has been made and treatment instituted. Follow-up pinhole scanning performed 6 months after NSAID treatment with apparent amelioration of symptoms in one of our patients showed the spread of the inflammatory lesion from an initial single toe to three toes (Fig. 11.20). As an adjunct, nuclear angiography may be performed in Reiter's disease for the assessment of inflammatory change in terms of vascularity

Paravertebral Inflammation

Fig. 11.19A, B Scintigraphic version of the "tear-drop" sign of the paravertebral ossification in Reiter's syndrome. A Anteroposterior radiograph of the lumbar spine in a 42-year-old woman with Reiter's syndrome reveals two small paravertebral ossifications in the upper right lateral aspects of L2 and L3 vertebrae (arrows). B Anterior pinhole scan of the L3 vertebra shows "tear-drop" shaped intense tracer uptake in the right paravertebral region, bridging the L2 and L3 vertebrae (arrowheads). The lesion in the L2 vertebra was not included because of the closest approximation of the collimator to the spine (contact imaging)

Fig. 11.18A, B The "tear-drop" sign in Reiter's syndrome. A Posteroanterior radiograph of the lumbar spine shows a vertically aligned ovoid bone bulging out at the L2-3 disk space level (open arrow). Apophyseal joints are narrowed due to apophysitis (arrowheads). B Posterior pinhole scintigraph reveals increased uptake in the "teardrop" (open arrow) and apophysitis (arrowheads)

Fig. 11.19A, B Scintigraphic version of the "tear-drop" sign of the paravertebral ossification in Reiter's syndrome. A Anteroposterior radiograph of the lumbar spine in a 42-year-old woman with Reiter's syndrome reveals two small paravertebral ossifications in the upper right lateral aspects of L2 and L3 vertebrae (arrows). B Anterior pinhole scan of the L3 vertebra shows "tear-drop" shaped intense tracer uptake in the right paravertebral region, bridging the L2 and L3 vertebrae (arrowheads). The lesion in the L2 vertebra was not included because of the closest approximation of the collimator to the spine (contact imaging)

Drop Toe Syndrome
Fig. 11.20A-C Serial bone scans in Reiter's disease in the toes. A Initial dorsoplantar radiograph of the second through fourth toes of the left foot in a 29-year-old male with Reiter's syndrome shows minimal erosion in the head of the third metatarsal bone (arrows). B Initial bone

scan reveals fusiform tracer uptake (3). C Follow-up scan 6 months after NSAID treatment shows spread of the lesion to two neighboring toes. This occurred with apparent amelioration of symptoms

Nuclear Angiogram

Fig. 11.21A, B Nuclear angiography in Reiter's syndrome. A Nuclear angiogram of the left ankle and foot in a 29-year-old male with Reiter's syndrome shows in

Reiter Syndrome Pictures

Fig. 11.21A, B Nuclear angiography in Reiter's syndrome. A Nuclear angiogram of the left ankle and foot in a 29-year-old male with Reiter's syndrome shows in creased blood flow and blood pool (arrowheads). B Equilibrium scintigraph reveals bone uptake denoting both enthesopathy and bone reaction (arrowheads)

Arrowhead Bone

Fig. 11.22A-C Early changes of Reiter's syndrome in the temporomandibular joint. A Lateral radiograph of the right temporomandibular joint in a 38-year-old female shows articular widening (arrowhead). B Measure-set (W=264, C=115) CT reveals lysis of the joint disk with widened space (leftpair of arrows). Note clearly visualized disk in the normal temporomandibular joint (rightpair of arrows). C Lateral pinhole scintigraph shows patchy uptake (arrowhead)

Fig. 11.22A-C Early changes of Reiter's syndrome in the temporomandibular joint. A Lateral radiograph of the right temporomandibular joint in a 38-year-old female shows articular widening (arrowhead). B Measure-set (W=264, C=115) CT reveals lysis of the joint disk with widened space (leftpair of arrows). Note clearly visualized disk in the normal temporomandibular joint (rightpair of arrows). C Lateral pinhole scintigraph shows patchy uptake (arrowhead)

that may increase in the active florid phase of the disease (Fig. 11.21). Reiter's syndrome of the temporomandibular joint radiographically manifests as articular widening and scintigra-

Polyarthritis Joints

Fig. 11.23A, B Symmetrical polyarthritis in psoriasis. A Dorsoventral scintigraphs of hands and wrists show multiple joint involvement on both sides of the body strongly simulating rheumatoid arthritis (arrows). Note distal interphalangeal joint involvement. B Lateral scinti-graphs of ankles and feet of the same patient reveal a similar polyarthritic manifestation of psoriatic arthritis (arrows)

Fig. 11.23A, B Symmetrical polyarthritis in psoriasis. A Dorsoventral scintigraphs of hands and wrists show multiple joint involvement on both sides of the body strongly simulating rheumatoid arthritis (arrows). Note distal interphalangeal joint involvement. B Lateral scinti-graphs of ankles and feet of the same patient reveal a similar polyarthritic manifestation of psoriatic arthritis (arrows)

phically as patchy uptake in the early phase (Fig. 11.22). The differentiation between Reiter's syndrome and rheumatoid arthritis of the temporomandibular joint is impracticable simply because basically the same inflammatory process underlies both conditions.

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