What's the Diagnosis - Case 25

History 19 year old man with long standing elbow pain.

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Findings MRI demonstrates synovial thickening with blooming artifact or phenomenon, prominent subchondral cystic change, subchondral bony irregularities/erosisons, advanced cartilage loss, and moderate edema pattern of the distal humerus.

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Diagnosis: Hemophilia Hemophilia is a classically X-linked recessive disease affecting men where there is deficiency of a clotting factor (Factor VIII or IX) that leads to repetitive episodes of bleeding into the joint or hemarthrosis with subsequent hemosiderin deposition and synovial proliferation. This in turn leads to erosion of the cartilage, subchondral cystic change, and hemophilic arthropathy. Secondary degenerative changes are frequently seen as well.

This underlying pathology accounts for the findings on the MRI of the thickened synovium, subchondral cysts, and bony erosions. The extensive cartilage loss is seen well particularly on the axial images of the current case. The blooming artifact or exaggerated low signal within the synovium relates to the physics in the acquisition of the gradient echo sequence and is seen in the presence of particularly pigment or hemosiderin and to a lesser degree calcification. Hemophilia has a proclivity to affect the hinge joints (elbow, ankle, and knee) secondary to the tendency for hemarthrosis in these joints.

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Resources

• MR Imaging of Pediatric Arthritis. Daldrup-Link HE, Steinbach L. Magn Reson Imaging Clin N Am. 2009 Aug;17(3):451-67, vi. Review.

• Imaging of Musculoskeletal Complications of Hemophilia. Kerr R. Semin Musculoskelet Radiol. 2003 Jun;7(2):127-36. Review.

• Resnick. Diagnosis of Bone and Joint Disorders. 4th Ed. 2002.

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