Systemic lupus erythematosus x ray: Difference between revisions

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__NOTOC__
__NOTOC__
{{Systemic lupus erythematosus}}
{{Systemic lupus erythematosus}}
{{CMG}}
{{CMG}} {{AE}} {{MIR}}


==Overview==
==Overview==
On X-ray imaging, systemic lupus erythematosus (SLE) may be characterized by different features regarding the present complication. The most common characteristic findings of SLE in X-ray include [[Thumbprinting|thumb printing sign]] in the abdominal X ray, blunting of the [[costophrenic angle]] due to [[pleural effusion]], [[cardiomegaly]], [[hepatomegaly]], [[Osteoporosis|osteoprosis]], tenosinovitis, and other manifestations based on the complications.


==X Ray==
==X Ray==
Shrinking lung (radiograph):  unexplained dyspnoea. restrictive pattern onpulmonary function tests.
Findings on an X ray imaging for systemic lupus erythematosus (SLE) depends on the organ system involvement and may include the following features.<ref name="pmid23812167">{{cite journal |vauthors=Appenzeller S |title=Magnetic resonance imaging in systemic lupus erythematosus: where do we stand? |journal=Cogn Behav Neurol |volume=26 |issue=2 |pages=53–4 |year=2013 |pmid=23812167 |doi=10.1097/WNN.0b013e31829d5b60 |url=}}</ref><ref name="pmid26309728">{{cite journal |vauthors=Thurman JM, Serkova NJ |title=Non-invasive imaging to monitor lupus nephritis and neuropsychiatric systemic lupus erythematosus |journal=F1000Res |volume=4 |issue= |pages=153 |year=2015 |pmid=26309728 |pmc=4536614 |doi=10.12688/f1000research.6587.2 |url=}}</ref><ref name="pmid26038342">{{cite journal |vauthors=Lin K, Lloyd-Jones DM, Li D, Liu Y, Yang J, Markl M, Carr JC |title=Imaging of cardiovascular complications in patients with systemic lupus erythematosus |journal=Lupus |volume=24 |issue=11 |pages=1126–34 |year=2015 |pmid=26038342 |pmc=4567427 |doi=10.1177/0961203315588577 |url=}}</ref><ref name="pmid26236469">{{cite journal |vauthors=Sarbu N, Bargalló N, Cervera R |title=Advanced and Conventional Magnetic Resonance Imaging in Neuropsychiatric Lupus |journal=F1000Res |volume=4 |issue= |pages=162 |year=2015 |pmid=26236469 |pmc=4505788 |doi=10.12688/f1000research.6522.2 |url=}}</ref><ref name="pmid24696368">{{cite journal |vauthors=Qin H, Guo Q, Shen N, Huang X, Wu H, Zhang M, Bao C, Chen S |title=Chest imaging manifestations in lupus nephritis |journal=Clin. Rheumatol. |volume=33 |issue=6 |pages=817–23 |year=2014 |pmid=24696368 |doi=10.1007/s10067-014-2586-2 |url=}}</ref><ref name="pmid22901453">{{cite journal |vauthors=Goh YP, Naidoo P, Ngian GS |title=Imaging of systemic lupus erythematosus. Part II: gastrointestinal, renal, and musculoskeletal manifestations |journal=Clin Radiol |volume=68 |issue=2 |pages=192–202 |year=2013 |pmid=22901453 |doi=10.1016/j.crad.2012.06.109 |url=}}</ref><ref name="pmid23943987">{{cite journal |vauthors=Gal Y, Twig G, Mozes O, Greenberg G, Hoffmann C, Shoenfeld Y |title=Central nervous system involvement in systemic lupus erythematosus: an imaging challenge |journal=Isr. Med. Assoc. J. |volume=15 |issue=7 |pages=382–6 |year=2013 |pmid=23943987 |doi= |url=}}</ref><ref name="pmid1448334">{{cite journal |vauthors=Shirato M, Hisa N, Fujikura Y, Ohkuma K, Kutsuki S, Hiramatsu K |title=[Imaging diagnosis of lupus enteritis--especially about sonographic findings] |language=Japanese |journal=Nihon Igaku Hoshasen Gakkai Zasshi |volume=52 |issue=10 |pages=1394–9 |year=1992 |pmid=1448334 |doi= |url=}}</ref><ref name="pmid25275093">{{cite journal |vauthors=Adachi JD, Lau A |title=Systemic lupus erythematosus, osteoporosis, and fractures |journal=J. Rheumatol. |volume=41 |issue=10 |pages=1913–5 |year=2014 |pmid=25275093 |doi=10.3899/jrheum.140919 |url=}}</ref><ref name="pmid21718325">{{cite journal |vauthors=Curiel R, Akin EA, Beaulieu G, DePalma L, Hashefi M |title=PET/CT imaging in systemic lupus erythematosus |journal=Ann. N. Y. Acad. Sci. |volume=1228 |issue= |pages=71–80 |year=2011 |pmid=21718325 |doi=10.1111/j.1749-6632.2011.06076.x |url=}}</ref><ref name="pmid22901452">{{cite journal |vauthors=Goh YP, Naidoo P, Ngian GS |title=Imaging of systemic lupus erythematosus. Part I: CNS, cardiovascular, and thoracic manifestations |journal=Clin Radiol |volume=68 |issue=2 |pages=181–91 |year=2013 |pmid=22901452 |doi=10.1016/j.crad.2012.06.110 |url=}}</ref><ref name="pmid11571369">{{cite journal |vauthors=Rockall AG, Rickards D, Shaw PJ |title=Imaging of the pulmonary manifestations of systemic disease |journal=Postgrad Med J |volume=77 |issue=912 |pages=621–38 |year=2001 |pmid=11571369 |pmc=1742125 |doi= |url=}}</ref>


Chest x-ray often shows small but clear lungs with diaphragmatic elevation. Occasional basal atelectasis may be present. 
=== More common findings ===
 
Pleural fibrosis: Pleural thickening
 
====== Pulmonary infarct ======
* wedge-shaped (less often rounded) juxtapleural opacification (Hampton hump) without air bronchograms
* more often in the lower lobes
 
*
 
==== Plumonary alveolar hemorrhage: ====
 
===== Mesentric vascuitis: =====
* Plain radiographic studies:
** Thumb-printing sign: Due to bowel wall edema or intramural hemorrhage
** Segmental bowel dilatation
** Air-fluid levels, pneumatosis
** Narrowing of the lumen
** Pseudo-obstruction
** Portal venous gas
 
===== Arthritis =====
* Pericapsular soft-tissue edema
* Synovitis around small joints
* Juxtaarticular osteoporosis
 
===== Carpal instability =====
* Radioulnar deviation: An static deformity
{| class="wikitable"
{| class="wikitable"
!Organ
! style="background: #4479BA; color: #FFFFFF; " |Organ
!Disease
! style="background: #4479BA; color: #FFFFFF; " |Disease
!Description
! style="background: #4479BA; color: #FFFFFF; " |Description
!CT
! style="background: #4479BA; color: #FFFFFF; " |Preview
!MRI
!SONO
|-
| rowspan="8" |Gastrointestinal system
|[[Dysphagia]]
|
*Barium swallow/esophagography
**Oesophageal stricture
*** Peptic strictures that appear as smooth, tapered narrowing in the distal esophagus
** Esophageal dilatation 
|
|
|
|-
|[[Intestinal pseudo-obstruction]]
|
*dilated bowel loops with or without the presence of fluid levels
*Erect chest radiographs for perforation evaluating
|
* dilated bowel loops with or without the presence of fluid levels
** a distinct transition point where bowel calibre changes from normal to abnormal
** dilated bowel loops proximal to the transition point
*** small bowel >3.5 cm
*** large bowel >5 cm
** collapsed or normal calibre bowel distal to the transitional point
** bowel wall thickening
** Obstruction:
*** pneumoperitoneum indicating perforation
*** bowel ischaemia
|
|
|-
|[[Hepatitis]]
|
**
|
* Hepatic granulomas
* Nonspecific, ranging from normal to hepatomegaly and cirrhosis.
 
** Discrete, sharply defined nodular lesions within the liver
|
* nodules ranging around 0.5-4.5 cm in diameter 
** '''T2:''' nonspecific, increased periportal oedema 4
** '''MRCP:''' primary sclerosing cholangitis (PSC) should be excluded
|
|-
|[[Acute pancreatitis]]
|
*
|Abnormalities that may be seen in the pancreas include:
* typical findings
** focal or diffuse parenchymal enlargement
** changes in density because of oedema
** indistinct pancreatic margins owing to inflammation
** surrounding retroperitoneal fat stranding
* liquefactive necrosis of pancreatic parenchyma
** lack of parenchymal enhancement
** often multifocal
* infected necrosis
** difficult to distinguish from aseptic liquefactive necrosis
** the presence of gas is helpful
** FNA helpful
* abscess formation
** circumscribed fluid collection
** little or no necrotic tissues (thus distinguishing it from infected necrosis)
* haemorrhage
** high-attenuation fluid in the retroperitoneum or peripancreatic tissues
|Contrast-enhanced MR is equivalent to CT in the assessment of pancreatitis.
 
Abnormalities that may be seen in the pancreas include:
* typical findings
** focal or diffuse parenchymal enlargement
** changes in density because of oedema
** indistinct pancreatic margins owing to inflammation
** surrounding retroperitoneal fat stranding
* liquefactive necrosis of pancreatic parenchyma
** lack of parenchymal enhancement
** often multifocal
* infected necrosis
** difficult to distinguish from aseptic liquefactive necrosis
** the presence of gas is helpful
** FNA helpful
* abscess formation
** circumscribed fluid collection
** little or no necrotic tissues (thus distinguishing it from infected necrosis)
* haemorrhage
** high-attenuation fluid in the retroperitoneum or peripancreatic tissues
|
* to identify gallstones as a possible cause
* diagnosis of vascular complications, e.g. thrombosis
* identify areas of necrosis which appear as hypoechoic regions
|-
|Aotpsplenectomy
|If heavily calcified, the splenic remnant may be visible in the left upper quadrant.
|CT easily identifies the abnormally small and irregular splenic remnant, which is usually calcified.
|
|Ultrasound will either not be able to demonstrate a spleen at all, or identify a small irregular and shadowing nodule in the splenic bed.
|-
|-
|Enteritis
| style="background: #DCDCDC; " |<small><small>[[Gastrointestinal system]]</small></small>
|The main feature of enteritis is '''small bowel wall thickening'''. Low density submucosal edema can usually be differentiated from higher density mural haemorrhage or infiltration. Dilatation or strictures may or may not be present, the later if chronic.
![[Enteritis]]
|
|
|
|-
|[[Mesenteric vascular occlusion|Mesenteric vasculitis]]
|
*
|
* The '''comb sign''' refers to the hypervascular appearance of the mesentery 
* This forms linear densities on the mesenteric side of the affected segments of small bowel, which give the appearance of the teeth of a comb. 
|
* The '''comb sign''' refers to the hypervascular appearance of the mesentery 
* This forms linear densities on the mesenteric side of the affected segments of small bowel, which give the appearance of the teeth of a comb. 
|
|-
|[[Acute cholecystitis]]
|
*
|
|
* gallbladder distension
* [[Small bowel]] wall thickening
* gallbladder wall thickening
** [[Thumbprinting|Thumbprinting sign]]
* mural or mucosal hyperenhancement
* pericholecystic fluid and inflammatory fat stranding
* enhancement of the adjacent liver parenchyma due to reactive hyperaemia
* tensile gallbladder fundus sign 7
** fundus bulging the anterior abdominal wall
|MR cholangiopancreatography (MRCP) may show an impacted stone in the gallbladder neck or cystic duct as a rounded filling defect.
|
|
* gallbladder wall thickening (>3 mm) and pericholecystic fluid 
[[File:Thumbpronting.gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
* Positive Murphy sign
* gallbladder distension
*
|-
|-
| rowspan="7" |Pulmonary involvement
| rowspan="4" style="background: #DCDCDC; " |<small><small>[[Pulmonary|Pulmonary involvement]]</small></small>
|Pleural effusion
![[Pleural effusion]]
|
|
* A lateral decubitus film can visualise small amounts of fluid layering against the dependent parietal pleura.
* Lateral decubitus view:
** Visible small amounts of fluid layering against the dependent [[parietal pleura]]
* PA and AP CXR:
* PA and AP CXR:
** blunting of the costophrenic angle
** Blunting of the [[costophrenic angle]]
** blunting of the cardiophrenic angle
** Blunting of the cardiophrenic angle
** fluid within the horizontal or oblique fissures
** Fluid within the [[Horizontal fissure of right lung|horizontal]] or [[Oblique fissure|oblique fissures]]
** mediastinal shifts with large amounts of fluid
** [[Mediastinal]] shifts with large amounts of fluid
|
* May be associated with thickening of the pleura
* Fluid density
|
|
|echo-free space between the visceral and parietal pleura
[[File:Pleural effusion.gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|Respiratory muscle dysfunction
![[Pulmonary fibrosis]]
|elevated hemidiaphragms at chest radiography
 
linear atelectasis and an ill-defined juxtadiaphragmatic areas of increased opacity 
 
Wiedemann HP, Matthay RA. ''Pulmonary manifestations of collagen vascular diseases.Clin Chest Med'' 1989; 10:677-696
|
|
|
* Diffuse increased interstitial markings
* Reduce in lung volume
* [[Pulmonary nodule|Pulmonary nodularity]] may be seen
* Shaggy outline to the heart
** Due to adjacenet [[Pulmonary Fibrosis|lung fibrosis]] so the outline of the heart is less well delineated
* Tracheomegaly
|
|
[[File:Pulmonary fibrosis.gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|[[Pneumonitis|Acute pneumonitis]]
![[Pulmonary hypertension]]
|
*A rare and fulminant form of diffuse lung injury that generally occurs in previously healthy individuals and has a rapid onset with [[fever]], [[cough]], and [[Dyspnea|shortness of breath]].
|
|
|
*Elevated [[cardiac apex]] due to [[right ventricular hypertrophy]]
* [[Enlarged right atrium]]
* Prominent pulmonary outflow tract
* Enlarged [[pulmonary arteries]]
|
|
[[File:PHTN.gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|[[Pulmonary hemorrhage]]
![[Pneumonitis|Acute pneumonitis]]
|
*Patchy bilateral and acinar areas of increased opacity, predominantly in the lower lungs
**
|
|
|
*[[Bilateral]] patchy airspace opacification
|
|
[[File:Webp.net-gifmaker (2).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|[[Pulmonary hypertension]]
| rowspan="2" style="background: #DCDCDC; " |<small><small>[[Cardiac|Cardiac involvement]]</small></small>
|
![[Cardiomegaly]]
*Elevated cardiac apex due to right ventricular hypertrophy
* enlarged right atrium
* prominent pulmonary outflow tract
* enlarged pulmonary arteries
* pruning of peripheral pulmonary vessels
|
|
|
|
*[[Cardiac enlargement]]
| rowspan="2" |
[[File:270780927951f0155ba941fe2264d1 big gallery.jpg|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|Pulmonary emboli
![[Mitral stenosis]]
|
** Fleishner sign: enlarged pulmonary artery (20%)
** Hampton hump: peripheral wedge of airspace opacity and implies lung infarction (20%)
** Westermark sign: regional oligaemia and highest positive predictive value (10%)
** pleural effusion (35%)
** knuckle sign 11
** Palla's sign17: enlarged right descending pulmonary artery
|
* filling defects within the pulmonary vasculature with acute pulmonary emboli
* vascular CT signs include
** direct pulmonary artery signs
*** complete obstruction
*** partial obstruction
*** eccentric thrombus
*** calcified thrombus - calcific pulmonary emboli
*** pulmonary arterial bands/pulmonary arterial webs 1,4-5
*** post stenotic dilatation
** signs related to pulmonary hypertension
*** enlargement of main pulmonary arteries
*** the peripheral pulmonary arteries in affected segments may be narrowed ref required
*** pulmonary arterial calcification
*** tortuous pulmonary vessels
*** right ventricular enlargement/hypertrophy
** signs of systemic collateral supply
*** enlargement of bronchial and nonbronchial systemic arteries
* Signs of chronic obstruction: webs or bands, intimal irregularities 3/ abrupt narrowing or complete obstruction of the pulmonary arteries 3 / “pouching defects” which are defined as chronic thromboembolism organised in a concave shape that “points” toward the vessel lumen
*
* parenchymal signs (often non-specific on their own):
** scars
** mosaic perfusion pattern
** focal ground-glass opacities
** bronchial anomalies
* The central filling defect from the thrombus is surrounded by a thin rim of contrast, appearing like the popular sweet, the polo mint 
|
|
|
*[[Cardiomegaly]]
*Double right heart border (enlarged [[left atrium]] and normal [[right atrium]])
*Prominent [[left atrial]] appendage
*Splaying of the subcarinal angle (>120 degrees)
|-
|-
|Shrinking lung syndrome
| rowspan="2" style="background: #DCDCDC; " |<small><small>[[Musculoskeletal system|Musculoskeletal]] involvement</small></small>
|
![[Arthritis]]
*small but clear lungs with diaphragmatic elevation
*basal atelectasis 
|
* reduced lung volumes with diaphragmatic elevation +/- occasional basal atelectasis but without any major parenchymal lung or pleural disease 
|
|
*Soft tissue swelling of the involved joints
*Normal joint spaces
*Symmetric involvement of [[interphalangeal joints]]
**[[Swan neck deformity]]
**[[Boutonniere deformity|Boutonniere deformities]]
**[[Subluxation]] with [[ulnar deviation]] at [[MCP joints]]
**[[Subluxation]] of the 1st [[Metacarpophalangeal joints|metacarpophalangeal joint]]
*Widened forefoot
*[[Hallux valgus]]
|
|
[[File:Webp.net-gifmaker (3).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
| rowspan="7" |Cardiac involvement
![[Osteoporosis]]
|[[Cardiomegaly]]
|
**Cardiac enlargement
|
|
|
*Periarticular [[osteoporosis]]
*Insufficiency fracture:
**[[Periosteal reaction]] progressing to callus formation in diaphyseal fractures
**Linear [[sclerosis]] and cortical thickening more frequent in [[metaphyseal]] and [[epiphyseal]] [[fractures]]
*Decrease
|
|
[[File:Webp.net-gifmaker (4).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|}
=== Less common findings ===
{| class="wikitable"
! style="background: #4479BA; color: #FFFFFF; " |Organ
! style="background: #4479BA; color: #FFFFFF; " |Disease
! style="background: #4479BA; color: #FFFFFF; " |Description
! style="background: #4479BA; color: #FFFFFF; " |Preview
|-
|-
|Mitral stenosis
| rowspan="3" style="background: #DCDCDC; " |<small><small>[[Gastrointestinal]] system</small></small>
![[Intestinal pseudo-obstruction]]
|
|
** cardiomegaly
*Dilated [[bowel]] loops with or without the presence of fluid levels
** double right heart border (enlarged left atrium and normal right atrium)
*Upright [[chest]] radiographs for [[perforation]] evaluating
** prominent left atrial appendage
** splaying of the subcarinal angle (>120 degrees)
|valve thickening or leaflet fixation
|
* mitral leaflet thickening
* reduced diastolic opening
* abnormal valve motion toward the left ventricular outflow tract
|
|
[[File:Webp.net-gifmaker (5).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|Mitral regurgitation
![[Autosplenectomy]]
|frontal projection
* left atrial enlargement
** convexity or straightening of the left atrial appendage just below the main pulmonary artery (along left heart border)
** double density sign: the right side of the enlarged left atrium pushes into the adjacent lung and creates an addition contour superimposed over the right heart
** elevation of the left main bronchus and splaying of the carina
* upper zone venous enlargement due to pulmonary venous hypertension
* left ventricular enlargement is also eventually present due to volume overload
|
|
|
* Calcified [[spleen]] may be visible in the left upper quadrant
|
|
|-
|-
|Acute pericarditis
![[Hepatomegaly]]
|
*
|enhancement of the thickened pericardium generally indicates inflammation 
|The normal pericardial thickness is considered 2 mm while a thickness of over 4 mm suggests a pericarditis 
|
|
|-
* Enlargement of liver silhouette
|Pericardial effuson
* Medially displaced bowel loops
|
|
* globular enlargement of the cardiac shadow giving a water bottle configuration
[[File:Webp.net-gifmaker (6).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
* Lateral CXR may show a vertical opaque line (pericardial fluid) separating a vertical lucent line directly behind sternum (epicardial fat) anteriorly from a similar lucent vertical lucent line (pericardial fat) posteriorly; this is known as the Oreo cookie sign
*
|Fluid density material is seen surrounding the heart
|Fluid density material is seen surrounding the heart
|Echocardiography is the method of choice to confirm the diagnosis, estimate the volume of fluid and most importantly assess the haemodynamic impact of the effusion
|-
|-
|[[Myocarditis]]
| rowspan="4" style="background: #DCDCDC; " |<small><small>[[Pulmonary]] involvement</small></small>
|
![[Respiratory failure|Respiratory muscle dysfunction]]
*
|
|
|
* regional or global wall motion abnormalities are common, but nonspecific (biventricular wall motion abnormality, however, is the main predictor of death or transplantation)
*Elevated hemidiaphragms at [[CXR]]
* pericardial effusion is reported in ~45% (range 32-57%) of patients with myocarditis
*Linear [[atelectasis]] and an ill-defined juxtadiaphragmatic areas of increased opacity
** regional vasodilatation and increased blood volume due to the inflammation in myocarditis causes early postcontrast enhancement
|
|
[[File:Webp.net-gifmaker (7).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|[[Coronary heart disease|Coronary artery disease]]
![[Pulmonary hemorrhage]]
|
*
|
* coronary CT angiography (cCTA)
* can show the amount of stenosis
|
|
*Patchy bilateral and acinar areas of increased opacity, predominantly in the lower lungs
|
|
[[File:Webp.net-gifmaker (8).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
| rowspan="3" |Neurological involvement
![[Pulmonary emboli]]
|[[Cognitive-shifting|Cognitive dysfunction]]
|
*The mental status of SLE patients can be temporarily affected by multiple, transient metabolic and systemic processes
|
|
|
*[[Fleischner sign|Fleishner sign]]: Enlarged [[pulmonary artery]]
*[[Hampton's hump|Hampton hump]]: Peripheral wedge of airspace opacity and implied [[lung infarction]]
*[[Westermark sign]]: Regional oligoemia
*[[Pleural effusion]]
|
|
[[File:Webp.net-gifmaker (9).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
|[[Stroke]]
!Shrinking lung syndrome
|
|
*
*Small but clear [[lungs]] with [[diaphragmatic elevation]]
|
*Basal [[atelectasis]] 
* Early sign: a hyperdense segment of a vessel, representing direct visualisation of the intravascular thrombus / embolus and as such is visible immediately
* Early hyperacute: loss of grey-white matter differentiation, and hypoattenuation of deep nuclei
* cortical hypodensity with associated parenchymal swelling with resultant gyral effacement
* elevation of the attenuation of the cortex. This is known as the CT fogging phenomenon
* a region of low density with negative mass effect. Cortical mineralisation can also sometimes be seen appearing hyperdense.
*
|
* the affected parenchyma appears normal on other sequences, although changes in flow will be detected (occlusion on MRA) and the thromboembolism may be detected (e.g. on SWI). Slow or stagnant flow in vessels may also be detected as a loss of normal flow void and high signal 
* after 6 hours, high T2 signal will be detected
|
|
|-
|-
|[[Neuropathies]]
| rowspan="2" style="background: #DCDCDC; " |<small><small>[[Cardiac]] involvement</small></small>
|
![[Mitral regurgitation]]
*
|
|
|
* Optic neuritis:
*[[Left atrial enlargement]]
** Typically findings are most easily identified in the retrobulbar intra-orbital segment of the optic nerve, which appears swollen, with high T2 signal. High T2 signal persists and may be permanent; chronically the nerve will appear atrophied rather than swollen.  Contrast enhancement of the nerve, best seen with fat-suppressed T1 coronal images, is seen in >90% of patients if scanned within 20 days of visual loss
**Convexity or straightening of the [[left atrial appendage]] just below the main [[pulmonary artery]] (along with left heart border)
**Double density sign: An addition contour superimposed over the [[right heart]] due to [[Left atrial enlargement|left atrium enlargement]]
**Elevation of the left main [[bronchus]] and splaying of the [[carina]]
*Upper zone venous enlargement due to [[pulmonary hypertension]]
*Left [[ventricular]] enlargement is also eventually present due to volume overload
|
|
[[File:Webp.net-gifmaker (10).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
![[Pericardial effusion]]
|
|
|Autoimmune encephalitis
*Globular enlargement of the cardiac shadow giving a water bottle configuration
|
*Anteroposterior [[CXR]]:
|
**Enlarged cardiac silhouette
|mesial temporal lobes and limbic systems, typically manifested by cortical thickening and increased T2/FLAIR signal intensity of these regions. Bilateral involvement is most common (60%), although often asymmetric
*Lateral [[CXR]]:
Patchy areas of enhancement
**Vertical opaque line ([[pericardial fluid]]) separating a vertical lucent line directly behind [[sternum]] ([[Epicardial fat pad|epicardial fat]]) anteriorly
|
|
[[File:Webp.net-gifmaker (11).gif|thumb|300px|<SMALL><SMALL>''[https://radiopaedia.org/ Adapted from Radiopaedia]''</SMALL></SMALL>]]
|-
|-
| style="background: #DCDCDC; " |<small><small>[[Musculoskeletal system|Musculoskeletal involvement]]</small></small>
![[Osteonecrosis]] ([[Avascular necrosis]])
|
|
|Raynaud phenomen
*Initial minor [[osteopenia]], followed by variable density
|
*Gradually micro-fractures of the subchondral bone accumulate in the dead bone
|
*Collapse of the [[articular]] surface
|contrast-enhanced MR angiography may also reveal characteristic narrowing and tapering of digital vessels 
*Crescent sign of [[AVN]]
|Doppler sonography:
flow volume and vessel size irregularities 
|-
|
|Myositis
|
|
|'''Intramuscular oedema''' (increased high T2/STIR signal)
|
|-
| rowspan="4" |Musculoskeletal involvement
|[[Arthritis]]
|
*Mostly symmetrical and non-erosive
*Arthralgias
*Effusions
*Decreased range of motion of both small and large joints
*Morning stiffness
|
|
|
|-
|[[Osteonecrosis]] ([[Avascular necrosis]])
|
*Most common in the femoral head
*Can involve humeral head, tibial plateau, and scaphoid navicular
*Usually bilateral and is often asymptomatic
*Glucocorticoids treatment is associated with the greatest risk of developing the disease
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|Subcutaneous nodules
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*In association with active disease
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|Osteoporosis
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*Mostly due to [[glucocorticoid]] usage
*Loss of height
*Sudden back pain
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Latest revision as of 16:19, 1 February 2018

Systemic lupus erythematosus Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mahshid Mir, M.D. [2]

Overview

On X-ray imaging, systemic lupus erythematosus (SLE) may be characterized by different features regarding the present complication. The most common characteristic findings of SLE in X-ray include thumb printing sign in the abdominal X ray, blunting of the costophrenic angle due to pleural effusion, cardiomegaly, hepatomegaly, osteoprosis, tenosinovitis, and other manifestations based on the complications.

X Ray

Findings on an X ray imaging for systemic lupus erythematosus (SLE) depends on the organ system involvement and may include the following features.[1][2][3][4][5][6][7][8][9][10][11][12]

More common findings

Organ Disease Description Preview
Gastrointestinal system Enteritis
Adapted from Radiopaedia
Pulmonary involvement Pleural effusion
Adapted from Radiopaedia
Pulmonary fibrosis
  • Diffuse increased interstitial markings
  • Reduce in lung volume
  • Pulmonary nodularity may be seen
  • Shaggy outline to the heart
    • Due to adjacenet lung fibrosis so the outline of the heart is less well delineated
  • Tracheomegaly
Adapted from Radiopaedia
Pulmonary hypertension
Adapted from Radiopaedia
Acute pneumonitis
Adapted from Radiopaedia
Cardiac involvement Cardiomegaly
Adapted from Radiopaedia
Mitral stenosis
Musculoskeletal involvement Arthritis
Adapted from Radiopaedia
Osteoporosis
Adapted from Radiopaedia

Less common findings

Organ Disease Description Preview
Gastrointestinal system Intestinal pseudo-obstruction
  • Dilated bowel loops with or without the presence of fluid levels
  • Upright chest radiographs for perforation evaluating
Adapted from Radiopaedia
Autosplenectomy
  • Calcified spleen may be visible in the left upper quadrant
Hepatomegaly
  • Enlargement of liver silhouette
  • Medially displaced bowel loops
Adapted from Radiopaedia
Pulmonary involvement Respiratory muscle dysfunction
  • Elevated hemidiaphragms at CXR
  • Linear atelectasis and an ill-defined juxtadiaphragmatic areas of increased opacity
Adapted from Radiopaedia
Pulmonary hemorrhage
  • Patchy bilateral and acinar areas of increased opacity, predominantly in the lower lungs
Adapted from Radiopaedia
Pulmonary emboli
Adapted from Radiopaedia
Shrinking lung syndrome
Cardiac involvement Mitral regurgitation
Adapted from Radiopaedia
Pericardial effusion
  • Globular enlargement of the cardiac shadow giving a water bottle configuration
  • Anteroposterior CXR:
    • Enlarged cardiac silhouette
  • Lateral CXR:
Adapted from Radiopaedia
Musculoskeletal involvement Osteonecrosis (Avascular necrosis)
  • Initial minor osteopenia, followed by variable density
  • Gradually micro-fractures of the subchondral bone accumulate in the dead bone
  • Collapse of the articular surface
  • Crescent sign of AVN
Adapted from Radiopaedia

References

  1. ↑ Appenzeller S (2013). "Magnetic resonance imaging in systemic lupus erythematosus: where do we stand?". Cogn Behav Neurol. 26 (2): 53–4. doi:10.1097/WNN.0b013e31829d5b60. PMID 23812167.
  2. ↑ Thurman JM, Serkova NJ (2015). "Non-invasive imaging to monitor lupus nephritis and neuropsychiatric systemic lupus erythematosus". F1000Res. 4: 153. doi:10.12688/f1000research.6587.2. PMC 4536614. PMID 26309728.
  3. ↑ Lin K, Lloyd-Jones DM, Li D, Liu Y, Yang J, Markl M, Carr JC (2015). "Imaging of cardiovascular complications in patients with systemic lupus erythematosus". Lupus. 24 (11): 1126–34. doi:10.1177/0961203315588577. PMC 4567427. PMID 26038342.
  4. ↑ Sarbu N, Bargalló N, Cervera R (2015). "Advanced and Conventional Magnetic Resonance Imaging in Neuropsychiatric Lupus". F1000Res. 4: 162. doi:10.12688/f1000research.6522.2. PMC 4505788. PMID 26236469.
  5. ↑ Qin H, Guo Q, Shen N, Huang X, Wu H, Zhang M, Bao C, Chen S (2014). "Chest imaging manifestations in lupus nephritis". Clin. Rheumatol. 33 (6): 817–23. doi:10.1007/s10067-014-2586-2. PMID 24696368.
  6. ↑ Goh YP, Naidoo P, Ngian GS (2013). "Imaging of systemic lupus erythematosus. Part II: gastrointestinal, renal, and musculoskeletal manifestations". Clin Radiol. 68 (2): 192–202. doi:10.1016/j.crad.2012.06.109. PMID 22901453.
  7. ↑ Gal Y, Twig G, Mozes O, Greenberg G, Hoffmann C, Shoenfeld Y (2013). "Central nervous system involvement in systemic lupus erythematosus: an imaging challenge". Isr. Med. Assoc. J. 15 (7): 382–6. PMID 23943987.
  8. ↑ Shirato M, Hisa N, Fujikura Y, Ohkuma K, Kutsuki S, Hiramatsu K (1992). "[Imaging diagnosis of lupus enteritis--especially about sonographic findings]". Nihon Igaku Hoshasen Gakkai Zasshi (in Japanese). 52 (10): 1394–9. PMID 1448334.
  9. ↑ Adachi JD, Lau A (2014). "Systemic lupus erythematosus, osteoporosis, and fractures". J. Rheumatol. 41 (10): 1913–5. doi:10.3899/jrheum.140919. PMID 25275093.
  10. ↑ Curiel R, Akin EA, Beaulieu G, DePalma L, Hashefi M (2011). "PET/CT imaging in systemic lupus erythematosus". Ann. N. Y. Acad. Sci. 1228: 71–80. doi:10.1111/j.1749-6632.2011.06076.x. PMID 21718325.
  11. ↑ Goh YP, Naidoo P, Ngian GS (2013). "Imaging of systemic lupus erythematosus. Part I: CNS, cardiovascular, and thoracic manifestations". Clin Radiol. 68 (2): 181–91. doi:10.1016/j.crad.2012.06.110. PMID 22901452.
  12. ↑ Rockall AG, Rickards D, Shaw PJ (2001). "Imaging of the pulmonary manifestations of systemic disease". Postgrad Med J. 77 (912): 621–38. PMC 1742125. PMID 11571369.

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