Clinical Images: Magnetic resonance imaging changes of bone marrow edema in the hands in Raynaud phenomenon

The patient, a 39-year-old woman with a long-standing history of symptoms suggestive of Raynaud phenomenon, presented to the rheumatology outpatient clinic with a three-month atypical history of bilateral, asymmetric, intermittent swelling and pain of her fingers. These episodes affected one or multiple fingers. She had three episodes in total, each lasting for one week, and thereafter all symptoms resolved spontaneously. On physical examination, there was transient mild erythema noted on the nail bed of the third finger in the right hand. There was no clinical evidence of synovitis or dactylitis appreciated on clinical examination of the hand joints, nor was there any clinical evidence of chronic deforming arthropathy, skin sclerosis, or telangiectasia. Her complete blood cell count, C-reactive protein level, and erythrocyte sedimentation rate were within the normal range. Relevant serologic findings, including rheumatoid factor, anti–cyclic citrullinated peptide, antinuclear antibodies, and anticentromere antibodies, were all negative, and plain radiography of both hands demonstrated normal findings. Magnetic resonance imaging (MRI) of the right hand demonstrated an abnormal bone marrow signal at multiple sites on the phalanges, consistent with bone marrow edema (A–C). The findings were identical to previously described MRI findings on the feet of patients with Raynaud phenomenon.1 Raynaud phenomenon is an episodic and recurrent disorder that involves microvascular vasospasm of digital arteries and subcutaneous arterioles typically resulting in hand and/or foot pain, numbness, paresthesia, and changes in skin color in response to stimuli, including cold temperatures and/or upset emotions.2 It can occur as a primary condition, but it may also be associated with autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, and CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias).3 Since 2016, a number of observational case reports and series have described abnormal MRI findings in the pedal phalangeal bones in patients with Raynaud phenomenon.4 This patient had an atypical presentation to the clinic, with symptoms predominantly affecting her hands. The presence of MRI changes similar to those described in the pedal bones of patients with Raynaud phenomenon in the absence of clinical or serologic evidence of associated rheumatologic conditions lent support to a diagnosis of primary Raynaud phenomenon. The frequency of MRI bone marrow abnormalities in the hands of affected patients is unclear. Lifestyle changes aimed at minimizing the symptoms of Raynaud phenomenon, and to which this patient adhered strictly, have resulted in her being almost asymptomatic for more than a year.