Usefulness of magnetic resonance imaging in eosinophilic fasciitis

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Dear Editor, Eosinophilic fasciitis is a rare scleroderma-like disorder of unknown etiology characterized by symmetrical painful swelling and skin induration of the extremities accompanied by peripheral eosinophilia [1]. The diagnosis of this disease is challenging when the patient shows atypical clinical and laboratory manifestations. A 35-year-old Japanese man was referred because of progressive stiVness of his right Wngers and myalgia of his extremities. He had initially noticed a painful swelling in the right forearm 3 months previously. One month prior to his visit, he had noted limited joint motion in the right Wngers and wrist and also noted severe myalgia in the upper and lower extremities. He had no history of Raynaud’s phenomenon. Physical examination showed induration of the skin and subcutaneous tissues from the right wrist to the forearm, Xexion contractures of the right Wngers, and marked tenderness of his left forearm and bilateral calves, but there was no apparent muscle atrophy, weakness, joint swelling or tenderness, or sclerodactyly. Laboratory examination revealed no remarkable abnormalities, such as eosinophilia, inXammatory signs, liver function tests, creatine kinase, hypergammaglobulinemia, or thyroid function tests, and his serum was negative for rheumatoid factor, anti-nuclear antibodies, anti-topoisomerase-I antibody, or anti-centromere antibody. Magnetic resonance imaging (MRI) examination at a local hospital showed hyperintense areas situated within the deep fascia in the right forearm, compared in the left forearm (Fig. 1). As he had the progressive right Wnger contractures, he was started on prednisolone, 30 mg per day, without pathological examination. His clinical manifestations dramatically improved, and the dose of prednisolone was reduced. The follow-up MRI scan revealed a marked reduction in the fascial signal intensity in his right forearm (Fig. 2). We have encountered a patient with eosinophilic fasciitis presenting no typical clinical and laboratory Wndings, such as symmetrical skin induration of the extremities, peripheral blood eosinophilia, inXammatory signs, or hypergammaglobulinemia [1]. Although we could not obtain the pathological evidence of eosinophilic fasciitis, our patient presented no Raynaud’s phenomenon and visceral involvement; further, he showed the abnormal Wndings of deep fascia in the MRI scan, myalgia in the extremities, and the dramatic clinical improvement with corticosteroid therapy, indicating he might have eosinophilic fasciitis [1]. Eosinophilic fasciitis might often be overlooked because this illness is thought to be rare and is sometimes self-limited with spontaneous improvement, the patients do not always show typical clinical and laboratory features [1, 2], and it is diYcult to obtain a suitable deep tissue, skin to skeletal muscle, for pathological diagnosis [3]. If untreated, fascial inXammation will lead to joint contractures; thus correct and early diagnosis is required. Although data on clinical utility are still limited, there are anecdotal reports indicating that the MRI scan can T. Sugimoto (&) · A. Kashiwagi Department of Internal Medicine, Shiga University of Medical Science, Seta, Otsu, Shiga 520-2192, Japan e-mail: toshiro@belle.shiga-med.ac.jp