RotReuma Clinical cases 2012 . No 1

1. Clinical Case 1
RotReuma
Presentado por:
Eduardo M. Rodelo, MD
Residente de Medicina Interna; Fundacion Hospital
Universidad del Norte
Barranquilla, (ATL) COL
Para:
Carlo V. Caballero. Medicina Interna-Reumatología

2. Resumen de Historia Clínica
42 years. 12 years with lower back pain and bilateral sacroileitis. Infliximab since 2006.
before Metrotexate up to 15 mg-day and Sulfazalacine up to 1.5 grs-day.
Clinical response with infliximab.(see outcome) for several years. PCR and VSG between
normal range or ocasionally a little up.
Rx ray twice in 2006 and 2010 with bilateral sacroileitis GIII-IV
Very Ocasionally low back pain , or peripheral pain and enthesitis (chest, heel) because
delayed treatment.
I ordered a MRI to check those sacroiliac joints by this method and because he was with
some low back pain last 3 month. See slides. Imagenologist said residual lesions?
Pain dolor 6/10 Global VAS 4/10
BASDAI: 4.4 BASFI : 2.1
Distancia occipucio-pared: 9.5 cm
Distancia punta de dedo–pie: 13 cm
Schober test: Variación a la flexión 2.5 cm

3. Outcome

4. RMN Patient Nov 2011

5. RMN Nov 2011

6. RMN Edema óseo
T1 T2
Gd

7. RMN Nov 2011
T2

9. Paraclinicos

10. Paraclinicos

11. ASDAS

17. Discussion
• How are you usin MRI in yopur practice?
• What do you thin about clinical, paraclinic and
Imagenologic responses in this patient?
• What would be your next step? Therapy