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<v ->Well, I will show you in this part of the section,

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two cases again.

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The first one...

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is a 57 year-old man

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with gradual onset of swelling and pain in the right wrist,

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about three months.

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No leukocytosis.

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HIV negative.

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Mild C-reactive protein elevation.

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And... this is the x-ray.

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The x-ray...

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In the x-ray,

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we can see just...

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a mild soft tissue swelling

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in the posterior aspect of the hand.

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Maybe you can see...

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an erosion in the posterior aspect of the distal radius.

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And the small ossification.

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We performed an ultrasound...

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of the wrists.

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Show you in here the images.

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In the ultrasound,

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we can see... tenosynovitis of the 12 compartments.

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With thickened tendons sheath.

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Hyperemia, both within and around tendon sheath.

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Inter sheath hyperemia confirms tenosynovial proliferation.

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Tendon thickening and edema, confirms chronic inflammation.

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We performed also an MRI.

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That I'll show you next.

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I will show some images and I will talk some.

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Well, you can see the same findings

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of the ultrasound in the MRI.

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The thickening of the tendons.

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The... tenosynovial tissue.

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Around the tendons and within the tendons.

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And...

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we can see also...

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focal cortical erosion

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of the posterior aspect of the distal radius.

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And bone edema.

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In the axio plane,

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we can see also the formation of the bone.

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Suggesting it's a chronic process.

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Well, he has three months of pain.

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He has no fever.

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Our first thoughts were,

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"Is it a rheumatoid arthritis,

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or microcrystalline deposition disease,

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or chronic infection?"

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For rheumatoid arthritis,

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I think it's...

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unilateral.

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Only in this area of the body, on this articulation joint.

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And...

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there's a lot of edema in the subcutaneous tissue.

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We can think the same for gout

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or other microcrystalline disease.

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It's unilateral.

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And we have the hypothesis of infection.

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Well, few minutes ago,

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I said, "Well, the tenosynovitis of tuberculosis

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is pretty more common in the wrists and hands, it could be."

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It was a good idea.

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We have these areas that suggests chronic tenosynovitis.

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And...

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it could be...

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becoming...

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rice bodies.

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Well, that was my best shot.

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At that time.

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And...

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They decided to make a blood test.

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And...

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They found the serological test...

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for secondary syphilis.

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So, it's tenosynovitis,

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and osteomyelitis,

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and secondary syphilis.

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Syphilis can mimic lots of lesions and lots of disease.

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And...

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Don and I used to change cases

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of patients with of syphilis.

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He showed me, in '93,

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dactylitis with syphilis.

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And few years ago, I sent him

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a numerous osteomyelitis with syphilis.

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And now we get another.

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And in this one I missed the diagnosis.

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I thought about tuberculosis more than syphilis.

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But the symptoms resolved after intravenous antibiotics.

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And no other cause was identified for these findings.

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Don, any comments?

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<v ->Well, (laughs) my first comment is,

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I wish I had remembered,

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you know, those prior cases

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because I didn't even consider that as a diagnosis

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in this case.

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I thought most likely, this was going to be

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a granulomas infection.

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So probably, tuberculosis or atypical mycobacteria.

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I think, if you continue sending me cases of syphilis,

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at some point I will be better

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at diagnosing that.

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<v ->Well, I thought it was tuberculosis too.

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I'd seen, a few years ago, mycobacteria marinum...

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<v ->Yeah.

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<v ->And I thought it could be tuberculosis or it.