Bilateral Lower Limb Pain Research Articles

Disseminated Peritoneal Leiomyomatosis: An Unusual Complication of Laparoscopic Myomectomy

Disseminated Peritoneal Leiomyomatosis (DPL) is characterised by multiple smooth muscle tissues over the peritoneal surface of the pelvic and abdominal cavity. Possible causes of DPL include hormonal factors, subperitoneal mesenchymal stem cell metaplasia, genetic factors, or iatrogenic factors. Hereby, the authors represents a case of DPL in a 42-year-old female with a history of two Laparoscopic Myomectomies. She presented with complaints of abdominal distension and bilateral lower limb pain lasting eight months. She underwent a robotic hysterectomy with bilateral salpingectomy and the removal of intraperitoneal nodules. Intraoperative findings showed a mass resembling leiomyoma over the uterus, mesentery, spleen, and rectosigmoid. She was discharged on postoperative day 4 and has been asymptomatic for the past two years. Robotic surgery is an emerging surgical modality in the treatment of DPL due to its better precision and ease of accessibility to upper abdominal organs. More importantly, recovery time is enhanced, and it reduces the duration of hospital stay.

Ayurveda Management in Diabetic Neuropathy vis-à-vis Prameha Upadrava–A Case Study

Background- Diabetes mellitus (DM) in India has a higher prevalence (4.3%) than in the west (1-2%) and its complication rate is also high. Diabetic neuropathy symptoms include pain, numbness, reduced sensation of touch or oversensitivity, uncomfortable tingling and burning, skin ulcer and reduced reflexes. Diabetic neuropathies are seen in approximately 50% of individuals with long standing type 1 and type 2 DM and it often goes undiagnosed. This article presents a case study of patient with signs and symptoms of neuropathy who came with the complaint of lower back pain, bilateral lower limb pain, pricking sensation and burning sensation. Diabetic Neuropathy Examination score (DNE) along with other neuropathy screening parameters was more than 60% indicating functional loss. The Nerve conduction study also revealed demyelinating polyneuropathy.
 Observations and Results: The patient was treated with ayurvedic oral medication, Abhyanga (~application of medicated oils), swedana (~fomentation), and basti (~medicated enema). After ayurvedic treatment the patient showed good remission in pain, burning sensation and DNE along with all neuropathy screening were less than 20%. Patient got marked relief in all the symptoms.

Medullary Infarction of Bilateral Tibia - A Rare Presentation of Tuberculosis: A Case Report with Review of Literature

Background: Bony infarction or osteonecrosis is a rare, painful condition, reported in the setting of trauma, chronic steroid exposure, radiation, malignancies, and sickle cell anemia, diagnosed radiologically by its characteristic features in magnetic resonance imaging (MRI). The present case highlights the challenges in the diagnosis and management of an adolescent boy, who presented with medullary infarction of bilateral tibia. Clinical Description: A 15-year-old boy presented with severe pain in bilateral lower limbs, restricting his ability to stand and walk independently. There were no signs of inflammation or restriction of movements at the joints of the lower limb. Routine investigations were largely normal. The MRI of left tibia showed bone infarct in the middle shaft. Further investigations for the known causes of bone infarct were noncontributory. Considering a remote possibility that tuberculous endarteritis may cause such an infarct, tuberculin test was done which was positive. The chest X-ray was normal. Management and Outcome: Therapeutic trial of antitubercular drugs (2HRZE+10HRE) was given. The child showed a significant improvement in leg pain by 2 weeks of the start of therapy. On follow-up, he demonstrated complete resolution of the disease in X-ray and MRI. Conclusion: Tuberculosis endarteritis leading to bony infarction is an extremely rare phenomenon but biologically plausible. By reporting this case, we would like to convey that clinicians may consider bone infarct as a rare cause of unexplained, incapacitating limb pain in children, which, in the absence of known contributory factors, may be due to tuberculosis.

Tumor-Induced Osteomalacia: A Case Report of Rare Disease and Literature review

Background Oncogenic osteomalacia term used for tumor-induced osteomalacia (TIO) is a paraneoplastic syndrome of abnormal phosphate metabolism secondary to ectopic endocrine tumors. The diagnosis often becomes difficult due to rarity of occurrence and deficient literature. The reconstruction following resection has its own technical difficulties, which are addressed in this article. Presentation of Case A 39-year-old female presented with pain in bilateral lower limbs and difficulty in mobilizing. The patient had unexplained hypophosphatemia which was diagnosed due to tumor (arising ectopically in greater trochanter), inducing osteomalacia. She was managed successfully with excision of tumor and reconstruction. The biochemical parameters improved drastically within 5 days and fracture healed in 6 weeks' time. Conclusion TIO is a debilitating disease with significant morbidity due to prolonged onset to diagnosis interval and difficulty in localizing the causative tumor. So thorough clinico-radiological and laboratory parameter correlation is a necessity. A rapid diagnosis followed by complete surgical excision, which remains the gold standard treatment modality that confers favorable prognosis in most patients, with strict vigilance for recurrence is required.

Urinary Sickle Cells in a Patient with Vaso-Occlusive Crisis: A Case Report

Vaso-occlusive crisis is the most common complication in sickle cell disease and can cause multi organ damage. Here we present a case of sickle cell anemia with vaso- occlusive crisis. The patient is a 39-year-old tribal male, a known case of homozygous sickle cell disease who presented with acute respiratory infection, bilateral lower limb pain and decreased urine output. Peripheral blood smear showed sickled red cells with features of hemolysis and reticulocytosis. Hemoglobin electrophoresis showed prominent HbS band. His symptoms progressed rapidly and he developed hematuria. Urine examination showed sickled erythrocytes. Later the patient went into cardiac arrest and succumbed to the disease. While hematuria is a common symptom in sickle cell disease, sickled RBCs in urine microscopy should be considered a bad prognostic indicator.

Eosinophilic fasciitis: experience with a patient and review of the potential mimics.

Bilateral lower limb swelling is a common clinical scenario with a wide differential diagnosis. We present a young man with gradually worsening bilateral leg swelling, who was diagnosed with eosinophilic fasciitis. A 20 year old Hispanic male presented with a six week history of bilateral lower limb pain and swelling, later involving the upper limbs, but sparing the hands, feet and face. He had initial pitting, followed by non-pitting oedema and had a positive 'groove sign'. With peripheral eosinophilia, a clinical diagnosis of eosinophilic fasciitis was suspected and was later confirmed on histology. He improved with prednisolone initially and is currently maintained on tapering prednisolone alongside methotrexate.

Giant plexiform neurofibroma of thigh in a young woman

A 30-year-old woman presented to orthopaedic clinic with a 5-year history of severe pain and oedema of left lower limb. The patient denied experiencing any other constitutional symptoms and no...

Laminectomy under bilateral paravertebral block in a patient with multiple Co-Morbidities

We report a case of 81 yr old male patient, diagnosed with spinal canal stenosis with bilateral lower limb pain, posted for Laminectomy. Patient had multiple co-morbidities including Hypertension, Diabetes mellitus type 2, obesity, sarcoidosis and COPD. Laminectomy was performed under bilateral paravertebral block using 0.25% Bupivacaine. Regional anaesthesia techniques have played a pivotal role in decreasing morbidity and mortality in high risk cases by providing both intraoperative anaesthesia and postoperative analgesia, without any major side effects. In this case, paravertebral block was helpful, not only in conducting surgery successfully, but also helps in providing post-operative analgesia without using any sedative drugs or NSAIDS which may exacerbate symptoms related to any of above co-morbidities.

Cauda Equina Syndrome Post Epidural Steroid Injection

We report a case of a 62-year-old lady who developed cauda equina syndrome post- epidural steroid injection. She undergone an epidural injection to relieve her radiculopathy pain caused by underlying lumbar spinal canal stenosis L4/L5 and L5/S1. Post epidural injection she developed an acute bowel and bladder dysfunction, worsening pain and weakness over her bilateral lower limbs with saddle anesthesia which did not resolve after 6 days. Her repeated magnetic resonance imaging (MRI) post- epidural injection shows no evidence of extradural hemorrhage/ collection and is unremarkable as compared to her pre- epidural magnetic resonance images. She undergone emergency laminectomy of L4/ L5 and L5/S1. Post laminectomy, her bilateral lower limb pain resolved, power restored, and she regained her bowel and bladder functions. The development of cauda equina syndrome post epidural injection have been reported as a rare complication and is commonly associated with local anesthetic toxicity, direct trauma of the needle to the spinal cord or the development epidural hematoma post injection. However, in this case there was no evidence of epidural hematoma both on magnetic resonance imaging and intraoperatively. Complete neurological recovery occurs following laminectomy suggesting the likely cause of cauda equina syndrome in this case is more to a mechanical compression.

Efficacy of mustadi yapana basti in Diabetic neuropathy –A case study

Diabetic Mellitus (DM) is a silent killer, which is spreading as an epidemic all over the world. Peripheral neuropathy is nerve damage caused by chronically high blood sugar and diabetes. It is the most common complication of diabetes. Incidences of diabetic neuropathy are more common in patients with poor diabetes control, overweight, have higher levels of blood fat and blood pressure, and are over the age of 40. In this study, patient’s main complaint was numbness and burning pain in bilateral lower limbs especially in sole. Patient was diagnosed as a case of Diabetic neuropathy (DN) in which according to Ayurvedic principles, there is involvement of Vata and Pitta dosha. Ayurvedic treatment for diabetic neuropathy is one of the most underrated yet powerful treatments because in modern science there is no any proper medicine invented for DN. Ayurveda is beneficial in managing symptoms of diabetic neuropathy without side effects. Panchakarma therapies like Virechana (therapeutic purgation),Basti (therapeutic enema) etc. can be found effective in this disease as according to Ayurveda, there is vitiation of vata and pitta doshas as Basti for vata dosha as well tridosha according to Acharya Sushruta. So in this study, Mustadi yapana basti has been taken as the primary treatment. This case shows the efficacy of Panchakarma specially Mustadi yapana Basti in DN with good follow up results and without any adverse effects. Thus we can say that, Mustadi yapana basti can be used as effective management in case of DN.

Percutaneous Endoscopic Interlaminar Unilateral Ventral Dural Approach for Symptomatic Bilateral L5-S1 Herniated Nucleus Pulposus: Technical Note.

Percutaneous endoscopic lumbar diskectomy is a good treatment modality for lumbar disk herniation. However, when a patient complains of bilateral lower limb radicular pain with severe disk protrusion at the L5-S1 level, the transforaminal approach is often unable to resolve both lesions owing to anatomical limitations. It is also very difficult to resolve both lesions in an ipsilateral direction using the percutaneous interlaminar approach. We report our surgical technique and clinical results using a ventral dural approach of percutaneous endoscopic interlaminar lumbar diskectomy for L5-S1 herniated nucleus pulposus (HNP) in patients with bilateral radiculopathy due to a severe disk protrusion. Twenty-seven patients with severe L5-S1 HNP complaining of back pain and bilateral lower limb pain were included in the study. The unilateral ventral dural approach of percutaneous full endoscopic interlaminar lumbar diskectomy technique was used. The visual analog scale (VAS) and Macnab criteria were used for clinical evaluation. All assessments were completed 1 day before surgery, 1 week after surgery, 6 months after surgery, and at final follow-up after surgery. The mean preoperative back and leg pain VAS scores decreased from 5.67 ± 0.78 and 7.81 ± 0.83 to 2.44 ± 0.58 and 2.26 ± 0.53 at 1 week, 1.78 ± 0.51 and 1.52 ± 0.58 at 6 months, and 1.56 ± 0.70 and 1.67 ± 0.96, respectively, at the final follow-up after surgery. With respect to the Macnab criteria, 51.85% of the results were excellent, 44.44% were good, and 3.70% were fair. Four cases recurred: three patients underwent conservative treatment and one patient operated with percutaneous endoscopic interlaminar lumbar diskectomy. According to the results of this study, the ventral dural approach of percutaneous full endoscopic interlaminar lumbar diskectomy in patients with L5-S1 HNP associated with bilateral lower limb pain due to a severely protruded HNP is a good option for a minimally invasive surgical approach.

Haemorrhagic intramedullary spinal cord lesion: Answer

1.AnswerC. Intramedullary spinal cord metastasis2.Discussion Intramedullary spinal tumours are uncommon, representing about 4% of spinal tumours [[1]Balmaceda C. Chemotherapy for intramedullary spinal cord tumors.J Neuro-Oncol. 2000; 47: 293-307Crossref PubMed Scopus (72) Google Scholar]. The most common are astrocytoma and ependymoma [[2]Samartzis D. et al.Intramedullary spinal cord tumors: part I – epidemiology, pathophysiology, and diagnosis.Global Spine J. 2015; 5: 425-435Crossref PubMed Scopus (101) Google Scholar]. Intramedullary spinal cord metastases (ISCM) are rarer, accounting for about 2% of intramedullary tumours [2Samartzis D. et al.Intramedullary spinal cord tumors: part I – epidemiology, pathophysiology, and diagnosis.Global Spine J. 2015; 5: 425-435Crossref PubMed Scopus (101) Google Scholar, 3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar]. Disease spread is thought to be commonly haematogenous, and symptoms can develop rapidly prior to diagnosis [[4]Grem J.L. et al.Clinical features and natural history of intramedullary spinal cord metastasis.Cancer. 1985; 56: 2305-2314Crossref PubMed Scopus (169) Google Scholar]. Primary tumours are commonly lung, breast, melanoma, lymphoma and renal cell carcinoma [[5]Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Common symptoms include weakness, pain, with sensory loss, bladder or bowel dysfunction [3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar, 5Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Frequently these can be the only presenting symptoms [3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar, 5Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. MRI is the imaging modality of choice [[2]Samartzis D. et al.Intramedullary spinal cord tumors: part I – epidemiology, pathophysiology, and diagnosis.Global Spine J. 2015; 5: 425-435Crossref PubMed Scopus (101) Google Scholar], and most lesions are contrast-enhancing [3Rykken J.B. et al.Intramedullary spinal cord metastases: MRI and relevant clinical features from a 13-year institutional case series.Am J Neuroradiol. 2013; 34: 2043-2049Crossref PubMed Scopus (45) Google Scholar, 5Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Although not well supported by evidence, treatment often consists of resection (where appropriate), chemotherapy and stereotactic radiotherapy [[5]Kalayci M. et al.Intramedullary spinal cord metastasis: diagnosis and treatment – an illustrated review.Acta Neurochir. 2004; 146: 1347-1354Crossref PubMed Scopus (142) Google Scholar]. Treatment aims to preserve neurological function and minimise symptoms. Prognosis is poor for ISCM, with median survival less than three months [[4]Grem J.L. et al.Clinical features and natural history of intramedullary spinal cord metastasis.Cancer. 1985; 56: 2305-2314Crossref PubMed Scopus (169) Google Scholar]. In this patient, we performed formal catheter angiography, because of the prominent vasculature seen dorsal to the lesion, thus excluding arteriovenous malformation. A repeat MRI demonstrated a low-enhancing intramedullary mass at T3-4 with development of syrinx (Fig. 2B). The lesion was biopsied and histopathology demonstrated adenocarcinoma, likely of oesophageal origin. A CT abdomen revealed a concentric oesophageal mass, proven as adenocarcinoma on endoscopic biopsy. This case represents one of possibly three cases of oesophageal adenocarcinoma ISCM reported in the literature. Unfortunately, this patient’s only preceding symptom of oesophageal cancer was abdominal pain. He had no history of gastro-oesophageal reflux, nor dysphagia. Given his severe neurological injury, there was no role for palliative radiotherapy and he declined chemotherapy. Haemorrhagic intramedullary spinal cord lesionJournal of Clinical NeuroscienceVol. 48PreviewA 59 year-old man was referred with acute bilateral lower limb weakness, altered sensation and urinary retention. He also described having three months of abdominal and bilateral lower limb pain, and unsteady gait. He had a medical history of ischaemic heart disease treated by coronary artery bypass, and was on aspirin. He had no history of malignancy and was a non-smoker. Examination demonstrated bilateral profound lower limb weakness, decreased sensation up to the level of T4 with decreased anal tone. Full-Text PDF

Efficacy of color doppler imaging over CT angiography in peripheral arterial disease

Introduction : PAD is an atherosclerotic occlusive condition in which plaque builds up in the distal arteries. Until 10 years ago, conventional angiography and digital subtraction angiography were the only angiographic techniques used in peripheral vascular disease and are considered gold standard. However, the complications and patient discomfort associated with these techniques have prompted the need of less invasive means of assessing the peripheral arterial system. Aim of the study was to compare efficacy of USG and MDCT angiography for investigating the lower limb arterial disease. Method: 40 patients suspected of lower limb PAD were included. Patients with previous amputation surgery were excluded. In all patients color Doppler sonography and multi-detector CT angiography was done. A comparative study of multi-detector CT angiography and color Doppler sonography was undertaken. Result: 50% patients had complaints in left lower limb and 25% in right lower limb. 22% had bilateral lower limb pain which was more on the left side (12%). Three patients examined by angiography showed irregularity of arterial wall on both sides, which appeared as calcifications on CT angiography (sensitivity 100%) while only 2 of them appeared on color coded Doppler examination (sensitivity 75%). Conclusions: Color Doppler USG is the initial modality of choice in PAD. CT Angiography is a better for segmental length assessment, collateral circulation along with a road map reproduction of the arterial system. USG is better than CT angiography in diagnosis of Grade 1 &2 cases, with better assessment of soft plaques, segmental flow and recanalization in PAD.

Severe rhabdomyolysis after recreational training

A 26-year-old woman presented at the emergency department with 4 days’ bilateral lower limb pain and swollen upper legs. Serum creatine kinase was elevated to 33 736 mmol. A diagnosis...

Case 148

HomeRadiologyVol. 251, No. 1 PreviousNext Diagnosis PleaseFree AccessCase 148Nanda Venkatanarasimha, Richard W. ParrishNanda Venkatanarasimha, Richard W. ParrishAuthor Affiliations1From the Department of Neuroradiology, Derriford Hospital, Derriford Road, Level 6, Plymouth PL6 8DH, England. Received March 3, 2008; revision requested April 9; final revision received April 19; accepted April 23; final version accepted May 13.Address correspondence to N.V. (e-mail: [email protected]).Nanda VenkatanarasimhaRichard W. ParrishPublished Online:Apr 1 2009https://doi.org/10.1148/radiol.2511080364MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked InEmail HISTORYA 61-year-old man presented to the emergency department with sudden onset of inability to walk, worsening of long-standing back pain, and bilateral lower limb weakness. There were no bowel or bladder problems. He had an 18-month history of progressive back and bilateral lower limb pain and difficulty walking. (He required rest after walking 100 yards.) He did not have a history of peripheral vascular disease. Relevant medical history included diet-controlled diabetes mellitus and chronic obstructive pulmonary disease, for which he had received high-dose inhaled steroids for 4 years prior to admission. He had received oral steroids occasionally but for no more than a few days at a time. Neurologic examination revealed spastic paraparesis and decreased sensation below the T9 vertebra. Magnetic resonance (MR) imaging of the thoracolumbar spine was performed (,Figs 1,, ,2,).Submit the most likely diagnosis to http://rsna.org/dxplease (use only for submission of diagnosis). Select the case from the Active Case List for which you are submitting a diagnosis. Only one case, one name, and one diagnosis per e-mail submission. Multiple diagnoses and multiple submissions will not be considered. Deadline: Midnight U.S. Central Time, June 10, 2009. Answer will appear in the August issue. Authors wishing to submit cases for Diagnosis Please should first write to the Editor to obtain approval for the case and further information.Figure 1a: Fast spin-echo sagittal (a) T1-weighted (repetition time msec/echo time msec, 400/10.5; 4-mm section thickness) and (b) T2-weighted (3500/120, 4-mm section thickness) MR images of the thoracic spine.Figure 1a:Download as PowerPointOpen in Image Viewer Figure 1b: Fast spin-echo sagittal (a) T1-weighted (repetition time msec/echo time msec, 400/10.5; 4-mm section thickness) and (b) T2-weighted (3500/120, 4-mm section thickness) MR images of the thoracic spine.Figure 1b:Download as PowerPointOpen in Image Viewer Figure 2a: Fast spin-echo axial (a) T1-weighted (400/11, 4.5-mm section thickness) MR image at the T7 vertebral body level and (b) T2-weighted (4478/120, 4-mm section thickness) MR image at the T6-T7 dorsal intervertebral disk level.Figure 2a:Download as PowerPointOpen in Image Viewer Figure 2b: Fast spin-echo axial (a) T1-weighted (400/11, 4.5-mm section thickness) MR image at the T7 vertebral body level and (b) T2-weighted (4478/120, 4-mm section thickness) MR image at the T6-T7 dorsal intervertebral disk level.Figure 2b:Download as PowerPointOpen in Image Viewer Authors stated no financial relationship to disclose.Article HistoryPublished in print: 2009 FiguresReferencesRelatedDetailsRecommended Articles Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department RadiologistsRadioGraphics2019Volume: 39Issue: 6pp. 1862-1880Injuries to the Rigid Spine: What the Spine Surgeon Wants to KnowRadioGraphics2019Volume: 39Issue: 2pp. 449-466CT Myelography: Clinical Indications and Imaging FindingsRadioGraphics2020Volume: 40Issue: 2pp. 470-484Case 234: Neuropathic SpondyloarthropathyRadiology2016Volume: 281Issue: 1pp. 314-319Multimodality Imaging Evaluation of Fetal Spine Anomalies with Postnatal CorrelationRadioGraphics2021Volume: 41Issue: 7pp. 2176-2192See More RSNA Education Exhibits Acuity and Etiology of Vertebral Compression Fractures on Plain RadiographyDigital Posters2018The Fault of Being Laid Back? Intraspinal Fat Containing LesionsDigital Posters2018The Whole Spine Yards: A Review of Pediatric Spine TraumaDigital Posters2019 RSNA Case Collection Diffuse idiopathic skeletal hyperostosis RSNA Case Collection2020Spinal canal cement leakRSNA Case Collection2021Pediatric Idiopathic Intervertebral Disc CalcificationRSNA Case Collection2020 Vol. 251, No. 1 Metrics Downloaded 287 times Altmetric Score

Post-transplant plasmacytoma without Epstein–Barr virus infection occurring rapidly after unrelated allogeneic bone marrow transplantation

Post-transplant lymphoproliferative disorders (PTLD) represent a heterogenous group of lymphoid proliferations that develop as a consequence of immunosuppressive therapy in recipients of solid organ or bone marrow (BM) transplantation (BMT). PTLD range from benign hyperplastic lesions to lymphoid neoplasm including plasma cell tumors, and they are mostly Epstein–Barr virus-related [1, 2]. In contrast to the high incidence of post-transplant lymphomas, PTLD manifesting as plasma cell tumors such as multiple myeloma and extranodal plasmacytoma are extremely rare [3]. We report a case of plasmacytoma without evidence of Epstein–Barr virus (EBV) infection which developed rapidly after bone marrow transplantation. A 45-year-old Japanese male with myelodysplastic syndrome (MDS, RAEB-1) received myeloablative allogeneic bone marrow transplantation due to progressive pancytopenia and episodes of recurrent infection. Pretransplant evaluation did not detect plasma cell proliferation in bone marrow aspirate and clot sections, monoclonal gammopathy on serum protein electrophoresis, or splenomegaly on the computed tomography (CT) scan (Fig. 1a). The serum IgG, IgA and IgM values were 1,160, 188, and 123 mg/dl, respectively. These were within the normal range. The conditioning regimen comprised conventional TBI and CY. He had no available HLA-identical family donors. He received an infusion of unmanipulated bone marrow containing 3.6 9 10/kg nucleated cells from a minor ABO-incompatible, one allele-mismatched (HLA DRB1) (disparities in the rejection direction), unrelated male donor. Tacrolimus and short-term MTX were administered for GVHD prophylaxis. Treatment with G-CSF was initiated on day ?5. On day ?7, severe stomatitis and febrile neutropenia (FN) developed. Immediate treatment was started with broad-spectrum antibiotics and an anti-fungal agent. The patient engrafted (ANC[500/mm) on day ?18 after the transplant. However, a platelet count above 5 9 10/mm was not observed. Along with recovery of the neutrophil count, stomatitis and FN improved. Cytomegalovirus (CMV) antigenemia developed on day ?28. Treatment with ganciclovir was started and CMV antigenemia disappeared. The patient did not develop acute graft-versus-host disease (GVHD). On day ?36, a fever of unknown origin and bilateral lower limb pain developed. Radiograph of bilateral lower limb did not show any abnormality including osteolytic lesion. These symptoms did not resolve despite the administration of broad-spectrum antibiotics and an anti-fungal agent. The neutrophil count began to decrease on day ?42. On day ?49, the serum IgG was 1,028 mg/dl, which was within the normal range. K. Kawakami (&) H. Mitani M. Nakao Division of Hematology, Suzuka General Hospital, Yasuzuka-cho, Suzuka, Mie 1275-53, Japan e-mail: Kawakei@cocoa.ocn.ne.jp

Bilateral lower limb pain and swelling in a young girl with type 1 diabetes mellitus

The patient was a 20-year-old female with poorly controlled type 1 diabetes mellitus of 7 years' duration complicated by nephropathy, background diabetic retinopathy, dense peripheral neuropathy and symptomatic cardiac and gastrointestinal autonomic neuropathy.