0:01

<v ->Okay. And the last case is,

0:11

just one second,

0:18

a 55 year old man with mild pain and swelling

0:23

in the third finger of the left hand

0:25

and the second finger of the right hand

0:28

for one month.

0:30

He has family history of psoriatic arthritis.

0:36

This is the MRI.

0:40

Well, I use the technique to make both together,

0:43

both hands and wrists.

0:46

We can lose some details,

0:49

but I think it's pretty good.

0:52

I show you why.

1:06

We can see tenosynovitis

1:12

of flexors of the third finger

1:16

in the left hand

1:19

and the second finger of the right hand.

1:23

But in the second hand,

1:25

we can see that the digit is larger.

1:29

And we have edema around in the soft tissue.

1:32

All the finger has edema.

1:44

Post contrast.

1:48

You can see exactly the same findings.

1:52

Tenosynovitis, both flexors.

1:56

But in the left hand,

1:58

we have enhancements,

2:03

not only around the tendon,

2:06

but in all the soft tissue of the finger.

2:11

Looks like a sausage.

2:18

We made a post contrast

2:23

with IDO

2:24

to have a good (indistinct)

2:31

I'm sorry. It's (indistinct)

2:39

And we made a TRIX technician,

2:48

I'm try to invert here,

2:53

but I can't,

2:57

I don't know why,

2:59

to see the vascularization of this finger.

3:04

And we can see clearly

3:07

that we have more vessels here in this finger

3:11

than the other.

3:12

I'll try to invert the images.

3:14

Just a second.

3:19

Okay.

3:22

We can see in the TRIX technique

3:28

that this third finger has more vessels.

3:33

And the pattern of the enhancement is different.

3:40

So, we made the diagnosis of the dactylitis.

3:52

That's a global

3:53

and relatively uniform swelling of the finger or toe.

3:59

Infection must be the first diagnosis

4:02

because of the consequences.

4:06

So we must think about infection every time.

4:11

The second hypothesis should be spondyloarthritis arthritis.

4:17

And this guy has family with psoriatic arthritis.

4:25

So I think it's the best diagnosis.

4:29

And we have other possible diagnosis

4:31

like sarcoidosis as Don said

4:34

and inflammatory reaction of micro crystal in deposition

4:39

and osteoid osteoma and sickle cell dactylitis and others.

4:44

But this one,

4:48

we think that was a first finding

4:54

of a psoriatic arthritis.

4:57

Don, have any comments?

5:00

<v ->I agree with that.

5:00

At first,

5:01

I thought you were showing another case of syphilis,

5:07

but I agree that this is probably psoriasis.

5:10

I have a few cases of osteoid osteomas

5:15

involving the phalanges

5:17

and that it produced extensive swelling

5:19

of almost the entire digit.

5:22

And the reason they're diagnostically difficult

5:25

is that the imaging findings are not classic osteoid osteoma

5:31

in that location.

5:33

And even the pain symptoms,

5:35

they're different.

5:35

And so, I always include osteoid osteoma

5:39

when I'm dealing with that.

5:41

But I think from what you've presented here by far,

5:44

I mean this...

5:45

It should be the dactylitis

5:47

associated with the psoriasis.

5:51

So that would've been my preferred diagnosis here.

5:54

That's a very nice case of that.