A 41-year-old Caucasian female patient presented with diffuse pustulous skin lesions and polyarthralgias. The patient had no other relevant past medical history. The histological study of the skin lesions revealed a polymorphonuclear infiltrate in the dermis. Other laboratory tests were unremarkable. 

CT AXIAL PELVIS

CT AXIAL CLAVICLE

CT CORONAL LOWER LUMBAR

Tc-99m methylene diphosphonate bone scintigraphy
What is the likely diagnosis?

ANSWER


SAPHO syndrome

The main findings in the CT study were sclerosis, irregularities, and hyperostosis of the manubrium and medial ends of both clavicles; asymmetric sacroiliitis (Fig. 2) and sclerosis and erosion of the superior-lateral corner of L4 vertebral body .
Bone scintingraphy revealed intense radiotracer uptake in both clavicle medial ends and sternoclavicular joints. There was also radiotracer uptake in the sacroiliac joints (more pronounced on the right).

SAPHO is an acronym that refers to an uncommon syndrome, composed of the combination of synovitis, acne, pustulosis, hyperostosis and osteitis. It affects more often young adults, with a female preponderance.
The causes are unknown, although some authors support its integration in seronegative spondyloarthtropaties which is supported by the increasead prevalence of the HLA B27 allele, occasional presence of sacroiliitis, inflammatory bowel disease and psoriasis.The most common dermatologic manifestations are palmoplantar pustulosis, severe acne, and psoriasis.
Characteristic radiographic findings include hyperostosis, which includes endosteal and periosteal proliferation and enthesopatic ossification. In association there are mixed areas of osteolysis. Adjacent joints show manifestations of arthritis, namely erosions and joint space narrowing. CT can depict these alterations in greater detail.

An 11-year-old boy was referred with acute paraplegia and local tenderness over the left costovertebral angle. He had also history of left side insidious back pain, low grade fever and malaise. Chest X-ray also showed a calcified focus probably a calcified lymph node at the left hilar region however no evidence of parenchymal infiltration was found.Helical abdominal CT was performed after taking the Plain radiograph of the thoracolumbar region.
Image of Helical abdominal CT was given here.


Identify the lesion and what is the most likely diagnosis?

Woman with Acute abdomen

Saturday, September 10, 2011 10 comments

A 22-year old woman was admitted for acute pain in the right lower abdominal quadrant. Laboratory analysis showed mild leukocytosis and slight elevation of C-reactive protein. Transvaginal sonography revealed a complex right adnexal mass and a moderate amount of fluid in the Douglas pouch. A pelvic MR study was indicated.





T2-weighted MR Images are shown here.What is the most likely diagnosis?

ANSWER

Adnexal torsion with haemorrhagic infarction

Transverse T2-weighted image. Tube thickening (arrow) is detected as an amorphous solid masslike structure. A small amount of fluid (long arrow) in the Douglas space is seen.

Sagittal T2-weighted image depicts a few small cystic structures (small arrows) in the periphery of the enlarged adnexa, probably related to transudation of fluid into the ovarian follicles due to ovarian congestion.
Imaging findings were strongly suggestive of hemorrhagic necrosis of the adnexa following torsion and were confirmed surgically.

Adnexal torsion is a rare cause of lower abdominal pain, often presenting as a diagnostic problem due to the nonspecific clinical, laboratory and sonographic findings, as it was seen also in this patient.It is associated with an ipsilateral ovarian tumour or cyst in 50-81% of cases, which is almost always benign.
The sonographic findings of adnexal torsion are usually nonspecific and include the presence of a cystic, solid or complex adnexal mass, as it was seen in this patient.Free intraperitoneal fluid is found in one to two thirds of patients. CT and MR imaging is usually recommended in subacute or chronic cases to confirm the diagnosis of adnexal torsion and to differentiate haemorrhagic from nonhaemorrhagic infarction.Common CT and MR imaging findings of adnexal torsion include fallopian tube thickening, ascites and uterus deviation to the twisted side.Imaging findings suggestive of haemorrhagic infarction include eccentric smooth wall thickening exceeding 10 mm in a cystic ovarian mass, lack of contrast enhancement of the internal solid component or the thickened wall of a twisted adnexal mass, haemorrhage within the tube or adnexal mass, or haemoperitoneum.

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