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<v ->The second case.

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Load the images here.

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It's a 52-years-old male with chronic rheumatoid arthritis.

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He used corticoids for many, many years.

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And started, this is important, he started his treatment

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with biological medication infliximab.

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I don't know if it's the same name,

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the commercial name, infliximab.

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About two years ago, he presented pain in the distal region

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of the right side with an evolution of three months

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associated with local heat.

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An MRI was requested.

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This is an image from the MRI, the bilateral.

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As we can see, appearance of extensive bone infraction

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in the left and the right side, this is a classical image.

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Let me divide in different way here

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to put the images after gadolinium.

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Now we have images before and after gadolinium.

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Let me enlarge these images.

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This is the left side.

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The left side is the typical infract.

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But when we look for the right side,

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there is something different.

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On the right side, which is possible to see,

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the signal change in the region of the epiphysis

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with areas of increased low signal,

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as you can see in T1, and hyper signal on T2,

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and intense bone enhancement in post-contrast phase.

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In addition, we can observe significant edema

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and inflammation of the entire musculature

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surrounding the bone alteration.

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You can see all this inflammatory process at the muscle.

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And when you see the images in the posterior portion,

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in the diaphysis, it is possible to see something different.

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Probably show you in the axial plane.

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It will be better to see in the axial plane.

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You can see if you follow the images,

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we can have T1 after gadolinium,

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T2 fat suppression,

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and T1, and we can see this kind of image.

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There is that C continent in this part

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who came from,

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from inside the bone.

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Came out of the rupture of the cortical as you can see here,

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I think that you can see.

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And what is interesting here,

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we see the vessels leaving the bone and going to this area.

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This area is called cold abscess,

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and this cold abscess usually we see in the tuberculosis

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we need to remember that tuberculosis or infection

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associated with osteonecrosis is not rare.

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More in patient with sickle cell anemia.

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The osteonecrosis in this kind of disease

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is 50 times more common than osteomyelitis.

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But this case, the patient had tuberculosis

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associated with osteonecrosis.

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And this is the, we call the cold abscess.

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Usually we see this kind of cold abscess

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in patients in the spine, even in thoracic spine,

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in paravertebral areas, we see this cold.

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It's cold because there's no very,

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there's more granulomatous infection

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and not liquid abscess.

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It's very thickening, the content of this area.

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This is a very interesting case

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to show the association of osteomyelitis and osteonecrosis.