0:01

<v ->I'm going to show you some typical cases

0:04

of bone osteonecrosis.

0:08

The first,

0:11

let me put the cases.

0:14

The first case is a seven-year-old female patient

0:20

with malaria.

0:22

I don't know if you know what is malaria.

0:24

Malaria is a specific disease we have in some countries

0:28

and it's caused by Plasmodium parasite

0:31

transmitted by bite of infected mosquitoes.

0:36

She started with low back pain

0:39

and discomfort in the left hip

0:43

with difficulty walking long distance.

0:46

Let me put the images here.

0:50

This is after gadolinium.

0:58

That's good.

1:00

This is the images from the spine column.

1:05

We can see the same pattern

1:07

of the osteonecrosis is the same that you spoke,

1:13

you talked all about osteonecrosis.

1:16

In the spine it's a little bit different.

1:18

When we see this kind of necrosis,

1:20

it comes, in this case, in all of the vertebras,

1:25

this case the patient had the symptoms

1:28

because we can see two disc herniation

1:33

touching the neural roots inside the vertebral canal,

1:36

which determined the symptoms presented by the patient.

1:39

But we can observe the geographic

1:44

and subscribed area of infraction, of necrosis,

1:50

surrounded by a halo of hyper signal

1:54

that corresponds to the new vascularization

1:57

next to the focus of necrosis.

2:00

What is interesting to observe in these areas,

2:05

usually the infract affect the central portion

2:10

of the vertebra, as you can see,

2:13

in the middle of the vertebra,

2:15

which corresponds exactly to the final vascularization

2:18

of the vertebra,

2:19

generating this kind of elongate aspect

2:25

of the, between the superior plate and the inferior plate.

2:31

In this case, we can see there is a chronic,

2:35

and after gadolinium we don't see any enhancement

2:39

inside of the necrosis.

2:41

Necrosis is filled by fat and fibrous tissue.

2:46

But we can see some fractures, chronic fractures

2:51

and substantial fractures in T1

2:53

in L1

2:55

and L3

2:57

secondary to this necrosis, the old necrosis.

3:04

We performed pelvis imaging,

3:09

and the pelvis imaging is almost the same.

3:13

Let me try to divide here in different way.

3:17

We have T1, T2 fat suppression

3:20

in coronal and axial planes.

3:23

We will see,

3:27

a huge infract,

3:29

a huge osteonecrosis

3:31

affecting all,

3:34

all bones in the hip.

3:37

We have chronic necrosis

3:40

in the left head

3:44

with fracture with arthrosis,

3:46

we can see synovitis and arthrosis, well, define arthrosis.

3:51

It's very rare to see one case like this.

3:54

The image of the necrosis is the same.

3:59

There's no difference

4:01

between the other places, but in this case

4:05

probably there's two possibilities in the malaria.

4:09

The first one is the belief

4:12

that the disease itself caused in coagulation disorders,

4:17

and the other one is the chronic use of hydroxychloroquine,

4:23

which can determine bone infraction as an adverse reaction.

4:28

Very uncommon, it's the only case that I have

4:33

in patient with malaria, with this kind of osteonecrosis.

4:37

We have a lot of malaria here in Brazil.

4:41

In Amazon area we have so many cases,

4:45

but this is the only case that I have

4:47

with this kind of image.

4:51

You have cases of malaria, Don, with this kind of necrosis?

4:56

<v ->No, you know, you had showed me this case before,

5:00

and I said, first of all,

5:01

I didn't even know the relationship

5:04

between malaria and osteonecrosis.

5:06

And you know, in my lecture, I said

5:09

whenever I see widespread osteonecrosis,

5:12

I think of lupus and vasculitis and steroids,

5:16

but now I have to add malaria to that list

5:19

because this is the most impressive widespread osteonecrosis

5:24

that I have seen, and no, we don't see much malaria.

5:28

So this is a, I don't know, in a review,

5:32

have you come across many articles that have described this?

5:36

<v ->Yes, I will look a lot of articles to see

5:39

what is the relation about this.

5:41

We didn't find, we find only one article from Brazil

5:44

in rheumatology, people from university here in Brazil.

5:47

And it's really rare, but if you look,

5:51

the hydroxychloroquine,

5:53

one of the adverse reaction of hydroxychloroquine

5:57

in chronic users is the calculation disturbs.

6:02

And probably could be the hydroxychloroquine.

6:06

I'm not sure.

6:07

<v ->Well I think you should consider writing it up.

6:10

So I'm gonna talk to you about that.

6:12

<v ->Okay, let's go.

6:13

(both laughing)