Prominent Soft Tissue Research Articles

Chronic nonbacterial osteomyelitis in neuroradiology - behavior and evolution of vertebral and mandibular lesions on imaging.

Chronic nonbacterial osteomyelitis (CNO) is a rare non-infectious inflammatory musculoskeletal disease where imaging plays a key diagnostic role. Vertebral and mandibular lesions are frequent manifestations, meaning their awareness is crucial for the neuroradiologist to avoid delays in diagnosis and treatment. Characterize vertebral and mandibular CNO lesions on imaging to assist practicing neuroradiologists in better identifying this disease. Retrospective review of all CNO patients of our pediatric center, including only patients with vertebral or mandibular lesions. All imaging exams were analyzed to record lesion characteristics. We included 13 patients (six male). The mean age of onset was 12.3years. Ten patients had only vertebral lesions, two had only mandibular lesions, and one had both. For patients with vertebral lesions, the median number of levels affected was three, 81.8% had multiple levels affected, 90.0% had dorsal spine lesions, 72.7% had platyspondyly, and 81.8% had inflammatory changes. All vertebral lesions had at least partial resolution of inflammatory findings, the mean time of lesion activity was 2.5years, and recurrence occurred in 27.3%. Three patients had sacral lesions, all with sacroiliitis. In patients with mandibular lesions, all had unilateral lesions involving the mandibular ramus, all had hyperostosis, periosteal reaction, bone edema, and soft tissue inflammation, all had partial resolution on follow-up, and one had recurrence. CNO vertebral lesions are not rare, are often multiple, predominantly affect dorsal levels, and most result in vertebral height loss. Resolution of vertebral inflammatory lesions is frequent, but so is recurrence. Sacral lesions may be present and result in sacroiliitis. The mandible may be a site of unifocal disease, typically affecting the ramus, with prominent bony changes and soft tissue inflammation.

Ultrasound-triggered piezocatalytic composite hydrogels for promoting bacterial-infected wound healing.

Wound healing has become one of the basic issues faced by the medical community because of the susceptibility of skin wounds to bacterial infection. As such, it is highly desired to design a nanocomposite hydrogel with excellent antibacterial activity to achieve high wound closure effectiveness. Here, based on ultrasound-triggered piezocatalytic therapy, a multifunctional hydrogel is designed to promote bacteria-infected wound healing. Under ultrasonic vibration, the surface of barium titanate (BaTiO3, BT) nanoparticles embedded in the hydrogel rapidly generate reactive oxygen species (ROS) owing to the established strong built-in electric field, endowing the hydrogel with superior antibacterial efficacy. This modality shows intriguing advantages over conventional photodynamic therapy, such as prominent soft tissue penetration ability and the avoidance of serious skin phototoxicity after systemic administration of photosensitizers. Moreover, the hydrogel based on N-[tris(hydroxymethyl)methyl]acrylamide (THM), N-(3-aminopropyl)methacrylamide hydrochloride (APMH) and oxidized hyaluronic acid (OHA) exhibits outstanding self-healing and bioadhesive properties able to accelerate full-thickness skin wound healing. Notably, compared with the widely reported mussel-inspired adhesive hydrogels, OHA/THM-APMH hydrogel due to the multiple hydrogen bonds from unique tri-hydroxyl structure overcomes the shortage that catechol groups are easily oxidized, giving it long-term and repeatable adhesion performance. Importantly, this hybrid hydrogel confines BT nanoparticles to wound area and locally induced piezoelectric catalysis under ultrasound to eradicate bacteria, markedly improving the therapeutic biosafety and exhibits great potential for harmless treatment of bacteria-infected tissues.

Management of floating arm: a case report.

This study report a 59-year-old man with a rare humeral fracture and a severe crush injury of the forearm. There is a paucity of evidence regarding the management of concomitant floating arm and soft tissue injuries in the literature.The patient was managed by minimally invasive plate osteosynthesis (MIPO) and vacuum-assisted closure (VAC) followed by a split-thickness skin graft. The concurrent presence of the two pathologies exacerbated the patient's condition and made the management challenging. In this case, the authors have used the MIPO approach to fix both fractures with minimal soft tissue injury. To manage the prominent soft tissue injury, we applied the VAC device. VAC has the advantages of reducing edema, controlling bacterial growth, and promoting granulation tissue formation, leading to faster cellular turnover and healing. In patients with floating arm, especially with concomitant soft tissue damage, the MIPO approach is a safe, minimally invasive, and quick method with minimal bleeding.

Hard and Soft Tissue Asymmetry in Patients with Skeletal Class III Malocclusion: A Cone-Beam Computed Tomography Study.

This study aims to investigate hard and soft tissue asymmetry in skeletal Class III patients to elucidate how soft tissue thickness alters overall asymmetry and whether menton deviation is correlated with bilateral differences in hard and soft tissue prominence and soft tissue thickness. The cone-beam computed tomography data of 50 skeletal Class III adults were divided based on menton deviation into symmetric (n = 25; deviation ≤ 2.0 mm) and asymmetric (n = 25; deviation > 2.0 mm) groups. Forty-four corresponding hard and soft tissue points were identified. Bilateral hard and soft tissue prominence and soft tissue thickness were compared using paired t-tests. The correlations between bilateral differences in these variables and menton deviation were examined using Pearson's correlation analysis. In the symmetric group, no significant bilateral differences in soft and hard tissue prominence and soft tissue thickness were observed. In the asymmetric group, both hard and soft tissue prominence were significantly greater on the deviated side than the non-deviated side at most of the points; however, no significant differences in soft tissue thickness were detected except at point 9 (ST9/ST'9, p = 0.011). The difference of hard and soft tissue prominence at point 8 (H8/H'8 and S8/S'8) was positively correlated with menton deviation, whereas the soft tissue thickness at point 5 (ST5/ST'5) and point 9 (ST9/ST'9) was negatively correlated with menton deviation (p = 0.05). Soft tissue thickness does not affect overall asymmetry in the presence of underlying hard tissue asymmetry. Soft tissue thickness at the centre of the ramus may be correlated with the degree of menton deviation in patients with asymmetry; however, this correlation needs to be confirmed by further studies.

Complete pachydermoperiostosis with diffuse keratoderma mimicking thyroid Acropachy: A case report and review of literature

Pachydermoperiostosis (PDP) is a rare genodermatosis with prominent cutaneous, soft tissue and skeletal manifestations. It can mimic secondary causes of hypertrophic osteoarthropathy such as thyroid acropachy. Cutaneous manifestations can be debilitating and constitute critical clues to formulating an accurate diagnosis. Palmoplantar keratoderma is a seldom reported manifestation of the disease hence, its significance as a phenotypic variant of pachydermoperiostosis is unknown. We describe a rare case of complete pachydermoperiostosis with diffuse palmoplantar keratoderma in a young African man presenting with hyperhidrosis, hyper-defecation and weight loss who had been previously misdiagnosed with thyroid acropachy. The aim is to provide a detailed clinical description of both common and unconventional features of this rare disease. Pachydermoperiostosis manifests with diverse genotypic and phenotypic characteristics that can mimic treatable, secondary causes of hypertrophic osteoarthropathy. Keratoderma and hyper-defecation are seldom reported manifestations that may represent unique variants of PDP. Awareness of characteristic dermatological manifestations of the disease can enhance early and accurate clinical diagnosis and prevent needless investigations.

LBODP102 A Case of Unexpected Thyroid Storm Due To Acute Suppurative Thyroiditis From Klebsiella Pneumoniae

Abstract Introduction Thyroid storm is a life-threatening endocrinological emergency. It creates a hypermetabolic state caused by excessive release of thyroid hormones, causing adrenergic hyperactivity following a precipitant(s). An uncommon precipitant of thyroid storm is a thyroid abscess. Clinical Case A 48-year-old man with a PMHx of COPD on home oxygen, OSA, HTN, left thyroid lobe nodule and recent treatment for community-acquired pneumonia the prior week presented to the ED with complaints of right neck pain and swelling of 5 days duration. Patient had associated diarrhea, fever, nausea, vomiting and palpitations. VS: Temp 101.9 F, BP 164/120, RR 20 and HR 160. Physical examination revealed a right non-mobile tender neck mass, rales on the lower lobe of the left lung, and drenching sweats. CT of the neck showed a prominent soft tissue mass on the right side of the neck with irregular margins abutting the right thyroid lobe, suggesting possible abscess. A subsequent thyroid US revealed a large heterogeneous nonvascular right thyroid mass measuring approximately 12×7×7 cm. Initial labs: TSH < 0. 005 mU/L (normal range 0.45-5. 0 mU/L), FT4 2.54 mU/L (normal range 0.9 to 2.3 mU/L); TSHrAB, TSI and TPO were negative. Thyroid storm was diagnosed using the Burch Wartofsky score (45 points). He was treated with propythiouracil, hydrocortisone, propranolol and antibiotics. FT4 normalized after 2 days on admission at which time he was taken for surgical drainage of his right thyroid abscess. 80 cc of pus was aspirated and cultured with isolation of Klebsiella Pneumoniae. Blood cultures also revealed K. Pneumoniae. Repeat Thyroid US showed resolution of abscess. Patient remained in hospital for ongoing treatment of his pneumonia. Clinical Lesson: Acute suppurative thyroiditis (AST) is a rare, life-threatening infection of the thyroid gland. Thyroid gland is rich in iodine, blood supply and lymphatics with a thick capsule which is relatively resistant to infection from neighboring sites. AST is more common in women and affects the left lobe of thyroid. Our patient is a man and his thyroid abscess was on the right lobe. The most common route of infection in AST is a congenital pyriform sinus fistula which was ruled out in our patient with direct laryngoscopy. Common presenting symptoms include fever, neck pain, and dysphagia. Pathogens commonly found to cause AST include Streptococcus and Staphylococcus. Our patient presents as an interesting case of AST from K. Pneumoniae with hematogenous spread that precipitated a thyroid storm. Thyroid storm incidence is noted to be <10%; however, to our knowledge AST is a rare cause of thyroid storm resulting from a thyroid abscess. For patients presenting with thyroid storm and a neck abscess, AST should be kept in mind as a possible etiology. Reference: https://www.ncbi. nlm. nih.gov/pmc/articles/PMC5667251, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587896/ Presentation: No date and time listed

Imaging Characterization of Non-Rheumatoid Retro-Odontoid Pseudotumors: Comparison with Atlantoaxial Manifestation of Rheumatoid Arthritis.

Backgroundand Objectives: To date, imaging characterization of non-rheumatic retro-odontoid pseudotumors (NRROPs) has been lacking; therefore, NRROPs have been confused with atlantoaxial joint involvement of rheumatoid arthritis (RA). It is important to differentiate these two disease because the treatment strategies may differ. The purpose of this study is to characterize imaging findings of NRROPs and compare them with those of RA. Material and Methods: From January 2015 to December 2019, 27 patients (14 women and 13 men) with NRROPs and 19 patients (15 women and 4 men) with RA were enrolled in this study. We evaluated various imaging findings, including atlantoaxial instability (AAI), and measured the maximum diameter of preodontoid and retro-odontoid spaces with magnetic resonance imaging (MRI) and computed tomography (CT). Results: Statistical significance was considered for p < 0.05. AAI was detected in eight patients with NRROPs and in all patients with RA (p < 0.0001). Seventeen patients with NRROPs and six patients with RA showed spinal cord compression (p = 0.047). Compressive myelopathy was observed in 14 patients with NRROPs and in 4 patients with RA (p = 0.048). Subaxial degeneration was observed in 25 patients with NRROPs and in 9 patients with RA (p = 0.001). Moreover, C2-3 disc abnormalities were observed in 11 patients with NRROPs and in 2 patients with RA (p = 0.02). Axial and longitudinal diameter of retro-odontoid soft tissue and preodontoid and retro-odontoid spaces showed significant differences between NRROP and RA patients (p < 0.0001). Furthermore, CT AAI measurements were differed significantly between NRROP and RA patients (p < 0.05). Conclusions: NRROPs showed prominent retro-odontoid soft tissue thickening, causing compressive myelopathy and a high frequency of subaxial and C2-3 degeneration without AAI.

Localized Bilateral Midclavicular Mass in Response to Repetitive Direct Pressure

A 25-year-old male consulted his physical therapist for bilateral clavicular pain and midclavicular masses that began after performing repetitive power clean lifts approximately 3 years prior. Clinical assessment of muscles, nerves, and joints did not reproduce the patient’s pain. Due to the patient’s dissatisfaction with the aesthetic appearance of the midclavicular masses and inability to perform his desired workouts, the patient was referred to a sports medicine physician for further workup. Magnetic resonance imaging findings characterized the swelling as a benign abnormality. A surgical procedure to excise the prominent soft tissue was performed. JOSPT Cases 2022;2(3):130–131. doi:10.2519/josptcases.2022.11185

Aggressive Osteoblastoma in adolescents: Radiological case report

In this article we represent an 18-year-old female with progressive back pain and neurologic symptoms due to a large heterogenous mass centered in posterior elements of lower thoracic vertebrae with prominent soft tissue extension into paravertebral and epidural space and subsequent central cord compression along with severe adjacent inflammatory changes. Considering patient age, lesion location and characteristics, aggressive Osteoblastoma, eosinophilic granuloma, and with lower probability of Ewing sarcoma were included in the differential list, which aggressive Osteoblastoma was confirmed after pathologic examination.

Technical Note on Placement of Low-Profile Triangular Osteosynthesis for Unstable Posterior Pelvic Ring Injuries.

Triangular osteosynthesis is a technique used to stabilize posterior pelvic ring injuries. Conventional triangular fixation can be problematic for several reasons, including the need for advanced skill sets to place instrumentation, difficulty with pelvic reduction and placing the connecting construct, and prominent instrumentation. The purpose of this study is 2-fold: (1) to describe in detail a technique for lumbopelvic fixation using implants that are easy to connect, allow distraction for complex lumbosacral displacements, and are placed in a location minimizing soft tissue prominence and (2) to present our initial case series using this technique. We present a retrospective review of 18 consecutively treated patients with this technique. Inclusion criteria were patients with complete disruption through the sacrum or sacroiliac joint from blunt trauma (OTA/AO type C injuries). Outcomes included pelvic reduction/malreduction, wound healing, and complications. Fourteen patients underwent unilateral fixation (81%), and 4 patients underwent bilateral fixation (19%). All patients (18 of the 18) had a well-reduced pelvis after fixation. No patient (0%) required a return trip to the operating room for loss of reduction/malreduction, wound breakdown, or implant failure. This study presents an updated technique for a low-profile triangular osteosynthesis construct with straightforward application for unstable posterior pelvic ring injuries. This technique does not require rod bending, results in a consistently more recessed iliac screw and connecting rod, and can be used in a wide variety of unstable posterior pelvic ring injuries, including comminuted sacral fractures, L5/S1 facet fractures, and vertical shear injuries.

Malignancy in giant cell tumor of bone in the extremities

BackgroundMalignancy in giant cell tumor of bone (GCTB) is a rare tumor with relevant literature being sparse. In primary malignant GCTB, distinct areas of benign GCTB are juxtaposed with high-grade sarcoma, while in secondary malignant GCTB sarcoma occurs at the site of previously managed GCTB. This study assesses the distinguishing characteristics of patients with this condition, the time interval for development of secondary malignant GCTB, the outcome of treatment, and explores factors associated with oncologic outcomes. MethodsThis is a retrospective case series of patients from a prospectively collected institutional musculoskeletal oncology database. From January 1998 to December 2016, 1365 patients were managed for extremity GCTBs. 32 (2.3%) patients had malignant GCTB, including 12 with primary malignant GCTB and 20 with secondary malignant GCTB. The study population comprised 18 males and 14 females presenting at a mean age of 33.7 years (±13.0) and followed for a mean of 9.5 years (±7.4). Data were collected on patient and treatment-related factors, and the occurrence of local recurrence, metastasis, and death. The time from the diagnosis of GCTB to the secondary malignant GCTB was defined as the latent period. ResultsMalignant GCTB most commonly presents in the distal femur and proximal tibia with pain and swelling. Radiologically, they are aggressive Campanacci Grade III tumors with prominent bony destruction and soft tissue extension. In the 20 patients with secondary malignant GCTB, the tumors were osteosarcoma in 15, undifferentiated pleomorphic sarcoma in 4 patients and fibrosarcoma in one patient. The mean latent period in patients with secondary malignant GCTB was 7.9 year (±7.3). The median recurrence-free survival (RFS) of secondary malignant GCTB (latent period) and benign GCTB were 61.5 and 19 months respectively (p < 0.001), receiver operating curve analysis found 49.5 months to be the critical threshold, with a longer interval to recurrence being seen in malignant recurrence. The 5 and 10-year overall survival rate of malignant GCTB were 45.8% and 36.1% respectively. The 5-year survival rates of primary malignant GCTB and secondary malignant GCTB were 56.2% and 40.0% respectively (p = 0.188). Adequate surgical margins decreased the local recurrence (LR) rate (P = 0.006). Pulmonary metastasis developed in 69% of patients. The median distant metastasis-free survival between malignant GCTB and benign GCTB were 9 and 21 months (p = 0.002). Chemotherapy was associated with a longer pulmonary metastasis free survival (13 months Vs 6 months, P = 0.002), but not with increased overall survival (57.0% Vs 33.3%, P = 0.167). ConclusionsMalignant GCTB carries a poor prognosis. Accurate diagnosis is critical to avoid inadequate surgical margins when treating primary malignant GCTB. Aggressive tumors and pulmonary metastasis should raise suspicion for malignant GCTB. Secondary malignant transformation should be suspected in patients presenting with recurrence especially after 4 years. Adjuvant chemotherapy use did not benefit survival, but was associated with increased pulmonary progression-free survival.

Langerhans cell histiocytosis of the shoulder girdle, pelvis and extremities: a review of radiographic and MRI features in 85 cases.

To describe the radiographic and MRI features of histologically proven Langerhans cell histiocytosis (LCH) of the bone. A retrospective review of the radiographic and MRI features of 85 histologically proven cases of skeletal LCH over a 12-year period. Clinical data recorded included age, gender and location. Radiographic features evaluated included Lodwick grading, cortical/periosteal response and matrix mineralisation. MRI features assessed included lesion size and T1-weighted signal intensity (T1W SI), nature of margin, hypointense rim, enhancement pattern, bone marrow and soft tissue oedema, soft tissue mass, fluid-fluid levels, the penumbra sign and the budding and bulging signs. The study included 85 patients, 54 males and 31 females with mean age of 13years (range 1-76years). The femur was the commonest bone involved (38.8%), followed by the scapula (9.4%), clavicle (8.2%), ilium (8.2%) and ischium (8.2%). The mean maximal lesion size was 40mm (range 16-85mm). The commonest radiographic appearance was of a lytic lesion with no appreciable sclerotic rim, an intact expanded cortex and either absent or laminated periosteal response. MRI demonstrated a hypointense rim (41.5%), the budding (31.7%) and bulging (36.6%) signs, eccentric extra-osseous mass (42.7%), prominent bone marrow (95.3%) and soft tissue oedema (84.1%). Rarer features included haemorrhage (2.4%), the penumbra sign (3.5%) and fluid-fluid levels (2.4%). Thirteen of 25 post-contrast studies showed peripheral/rim enhancement with central necrosis. LCH classically presents as a moderately aggressive lytic bone lesion on radiography, with prominent reactive bone and soft tissue oedema being a characteristic feature on MRI.

SUN-LB12 Prenatal Trenbolone Exposure and External Genital Malformation: A Case Report

Background Trenbolone is a synthetic anabolic steroid used for muscle growth in livestock. Human use is not FDA approved. The active metabolite, 17β trenbolone is 3 times more potent an androgen than testosterone propionate. Prenatal trenbolone exposure in rats results in female offspring with external genital malformations including an increased anogenital distance (AGD). We now report a case of prenatal trenbolone exposure in humans. Clinical Case A 10 hour old baby delivered vaginally at 37 6/7 weeks of gestation with a birth weight of 3615 grams was admitted to the NICU for concern of ambiguous genitalia. Baby was born to 30 year old G6P3 mother who was HIV positive and adequately treated with Triumeq. She had irregular cycles prior to conception and pregnancy recognized at 14 weeks. Unlike her previous pregnancies, during this pregnancy she had acne and mildly increased facial hair. Prenatal cell-free DNA screening was 46XX and ultrasound showed female genitalia. The 9 year old half-sister and 5 year old brother are healthy. No family history of early neonatal deaths. On arrival blood glucose was 55 mg/dL (45-90). On exam baby had no obvious facial dysmorphic features or midline defects. Hand creases were normal and no extremity edema was noted. Genitalia appeared symmetrical and, showed prominent soft tissue of clitoris without corpus enlargement. No gonads were palpable in the groin or labioscrotal folds. Significant posterior labioscrotal fusion was noted. Anogenital ratio was 0.8 (normal <0.5). A single orifice at the base of the clitoral hood was noted, consistent with likely urogenital sinus. Additional history provided by mother included her disclosure of use of 200 mg of IM trenbolone weekly for 5 weeks, for muscle building, prior to her knowledge of being pregnant. Multidisciplinary care included pediatric endocrinology, genetics, pediatric urology, and pediatric infectious disease. Labs at 24 hours of life: Sodium - 139 mmol/L (131-144), Potassium - 5.3 mmol/L (3.2-5.7), Serum glucose - 75 mg/dL (45-90), Random cortisol - 34.1 mcg/dL (1.0-10.0), 17 hydroxyprogesterone - 124 ng/dL (<460), CAH diagnostic panel - normal with exception of elevation in Progesterone - 3400 ng/dL (5-53), Newborn screening - normal, Chromosomal analysis - 46,XX and absent SRY, Ultrasound pelvis - normal Müllerian structures and bilateral intra-abdominal gonads present. Baby was hemodynamically stable, voided well, gained weight by discharge on DOL 4. Baby was stable on follow-up in endocrinology clinic on DOL 10. Surgical repair of anatomic malformation to be performed at 6 months of age by urology team. Conclusion To our knowledge, this is the first report of virilization of female offspring following human prenatal exposure to trenbolone. Women must be cautioned that trenbolone poses risks of external genital malformation to the developing fetus.

Mechanics of Psoas Tendon Snapping. A Virtual Population Study

Internal snapping of the psoas tendon is a frequently reported condition, especially in young adolescents involved in sports. It is defined as an increased tendon excursion over bony or soft tissue prominence causing local irritation and inflammation of the tendon leading to groin pain and often is accompanied by an audible snap. Due to the lack of detailed dynamic visualization means, the exact mechanism of the condition remains poorly understood and different theories have been postulated related to the etiology and its location about the hip. In the present study we simulated psoas tendon behavior in a virtual population of 40,000 anatomies and compared tendon movement during combined abduction, flexion and external rotation and back to neutral extension and adduction. At risk phenotyopes for tendon snapping were defined as the morphologies presenting with excess tendon movement. There were little differences in tendon movement between the male and female models. In both populations, abnormal tendon excursion correlated with changes in mainly the femoral anatomy (male r = 0.72, p < 0.001, female r = 0.66, p < 0.001): increased anteversion and valgus as well as a decreasing femoral offset and ischiofemoral distance. The observed combination of shape components correlating with excess tendon movement in essence presented with a medial positioning of the minor trochanter. This finding suggest that psoas snapping and ischiofemoral impingement are possibly two presentations of a similar underlying rotational dysplasia of the femur.

Angiosarcoma arising in massive localized lymphedema

We report a case of a 70-year-old woman with a BMI of 58 who developed cellulitis refractory to treatment, within an area of massive localized lymphedema. Biopsy showed angiosarcoma. MRI showed multiple lobulated, low T1, high T2 masses within a background of prominent soft tissue septal stranding, dilated lymphatic channels, and skin thickening. CT also showed the mass well, within the background lymphedema. Massive localized lymphedema is increasing in prevalence due to the worsening obesity epidemic. Radiologists should be aware that the presence of a nodule within an area of massive localized lymphedema is suspicious for sarcoma.

Concurrent musculoskeletal and soft tissue pain in the upper extremity can affect the treatment and prognosis of carpal tunnel syndrome: redefining a common condition.

ObjectiveTo demonstrate the importance of recognizing and separating nonmedian nerve-related symptoms from those related to median nerve compression at the carpal tunnel.MethodsThe records of 80 patients, aged 31–82 years (39 males and 41 females), who had undergone median nerve decompression using open and endoscopic release surgery, were reviewed. Peripheral electrodiagnostic studies were performed in all patients prior to surgery. Those whose nonmedian nerve-related symptoms, also known as musculoskeletal and soft tissue pain and tenderness, persisted postoperatively, were referred to another electrodiagnostic study to reassess the median nerve function at the carpal tunnel. Peripheral electrodiagnostic studies were deemed unnecessary for patients with exclusively median nerve-related symptoms who improved dramatically following surgery. Included from the study were cases whose presenting symptoms were primarily referrable to median nerve dysfunction with or without associated musculoskeletal pain. Cases that were excluded were those whose symptoms were related to various primary conditions. Outcome of surgery was reviewed and correlated with symptoms related to median nerve compression and musculoskeletal irritation, and with electrodiagnostic abnormalities.ResultsComplete resolution of symptoms, following surgery, occurred in patients with clinical and electrophysiologic signs of median nerve compression but without significant symptoms of musculoskeletal irritation. Those with concurrent and prominent musculoskeletal and soft tissue pain had variable results, both favorable and unfavorable, including three who developed signs and symptoms of complex regional pain syndrome.ConclusionThe symptoms related to median nerve compression at the carpal tunnel and the symptoms related to musculoskeletal and soft tissue irritation are two different symptom complexes that have important diagnostic and therapeutic considerations. We would like to propose that “true carpal tunnel syndrome” symptoms, those that are exclusively median nerve related, should be considered a distinct entity. When musculoskeletal and soft tissue pain is more prominent and dominates the overall clinical presentation, the term “mechanical stress syndrome” is more appropriate.

Benign or Malignant: A Case Report of Multifocal Epithelioid Hemangioma of Fibula

Case Presentations: A 63-year-old female with no significant prior trauma and relevant past medical history presented with a 2-month history of severe, persistent, gradually worsening, sharp and non-radiating pain over her left distal fibula. Physical examination revealed extreme tenderness to palpation over the lateral distal fibula. There was soft tissue prominence over the mid to lower third of the fibula. Results: Left lower leg radiographs depicted two ill-defined osteolytic destructive lesions measuring 29 and 37 mm in length in the fibular diaphysis. A pathologic fracture was present through the distal lesion. A laboratory test, including serum protein electrophoresis, alkaline phosphatase and basic metabolic profile, was ordered to evaluate for multiple myeloma. CT scans of the chest and abdomen were obtained to evaluate for primary malignancy or any evidence of metastatic disease. The results of these tests were unremarkable. Image-guided biopsy of the lesions was performed and revealed epithelioid hemangioma (EH). The patient was initially managed with a walker boot. At the 2-month follow-up, an additional third smaller lesion was detected along with an interval increase in size of the two previously seen lesions. The patient proceed with preoperative embolization followed by surgical curettage and open reduction and internal fixation. Angiogram was done and tumor feeding artery was identified but tumor embolization was unsuccessful. The patient underwent fibular bone lesion curettage, PRO-DENSE bone grafting and open reduction and internal fixation with the left fibular diaphyseal plate. Radiographs revealed continued healing with bone graft incorporation at 1.5-, 3- and 7-month follow-ups. The patient was permitted to return to all activities without restriction 1.5 months after the surgery. Conclusions: EH is an uncommon, slow-growing vascular tumor that generally presents on the skin and the subcutaneous soft tissues of the head, with osseous EHs being rare. Although osseous EHs can present as multifocal lesions, the majority of bony EHs are solitary and arise in the diaphysis or metaphysis of long tubular bones, with a predilection for the lower extremity. Radiographically, EH may present as well-defined lytic lesions with sclerotic margins or mixed lytic and sclerotic lesions. These lesions are often located eccentrically and may demonstrate a disrupted or intact cortex.

The imaging characteristics of hemophilic pseudotumor

Objective To investigate the imaging characteristics of hemophilic pseudotumor. Methods Twelve cases of type A hemophilic pseudotumor proved by clinic and laboratory examination were included in the study. The X-ray, CT and MRI examination were performed in 6, 9 and 5 cases, respectively. The imaging appearances of 12 cases were retrospectively analyzed regarding the pseudo-tumor location, size, density, bone destruction, enhancement and the change of adjacent tissue. Results In 12 cases of hemophilic pseudo-tumors, there were 4 cases in femur, 3 cases in ilium, 3 cases in skull and 2 cases in calcaneus. There were intra-muscular type (n=1), subperiosteal type (n=2) and intra-osteal type (n=9).The size of pseudo-tumor was 5.0-60.0 cm, mean (19.1±6.0) cm, and more than 10.0 cm in 7 cases. X-ray and CT demonstrated expansive bone destruction(n=6), expansive and lytic bone destruction(n=3), erosive bone destruction(n=2), cystic and lytic bone destruction(n=1); bone destruction with edge sclerosis(n=10), thick bone crest residue within bone destruction(n=2), bone destruction with pathologic fracture(n=2), pseudo Codman's triangle(n=1), and soft tissue mass(n=10) with higher density (CT value 45-68 HU) than normal muscle. CT showed no enhancement in bone destruction and soft tissue mass in 5 cases of contrast agent enhancement and CT angiography demonstrated compression and displacement of pseudo-tumor and adjacent vessels. MRI examination (n=5) showed soft tissue masses and bone destruction with high, low and mixed signals on T2WI, T1WI, SPAIR and DWI sequences, as well as multiple cystic and separate change in pseudo-tumors(n=2, respectively). Conclusions Hemophilic pseudo-tumor has some imaging characteristics, such as expansive, cystic and erosive bone destruction, thinning or disappearance of bone cortex, bone destruction with edge sclerosis, prominent soft tissue mass, mixed density or signal on CT or MRI, and no contrast enhancement, et al. It can be clearly diagnosed on imaging together with clinic andlaboratory information. Key words: Tomography, X-Ray computed; Magnetic resonance imaging; Hemophilia pseudotumor

Rare Case of Patient with HIV Related Plasmablastic Lymphoma Presenting with Bilateral Parotid Involvement and Hypergammalobulemia

44 year old male with no past medical history presents with rapidly enlarging neck mass over past two months. He denied B-symptoms. Clinical examination revealed bulky midline neck mass with bilateral cervical and left supraclavicular adenopathy. 6/29/16 excisional lymph node biopsy of neck lymph node showed a monomorphic proliferation of malignant cells with large immunoblastic tumor cells with prominent nucleoli (Figure1). Neoplastic cells expressed MUM-1, CD138 (Figure 2), and were lambda light chain restricted. Neoplastic cells were negative for CD20, CD79, CD3, CD5, CD7, and BCL-2. Additionally, Cyclin D1, BCL-6, CD30, ALK-1, S100, CD56 was negative. Ki-67 was 99%. EBER by ISH was positive (Figure 3). Karyotype was normal. PET CT 7/1/16 Showed small hypermetabolic lymph nodes in the right neck, bilateral parotid gland with additional hypermetabolic activity in the left supraclavicular fossa and central neck base along with activity in the tongue base with maximum SUV 16.1. CT neck chest abdomen and pelvis 7/1/16 showed bilateral enhancing parotid lesions, large central midline neck mass with right strap muscle involvement. Also, there was soft tissue prominence of the adenoids, tonsil pillars, lingual tonsils, laryngeal ventricle. Last there was bilateral deep cervical, supraclavicular, & posterior cervical lymphadenopathy. Lumbar puncture, bone marrow biopsy, & MRI brain were negative for involvement. Labs 6/27/16: Platelet 126 10x3/µL, hemoglobin 15.7 g/dL, white blood cell 5.2 with variant lymphocytes. Uric acid 4.3 m/dL, total protein 9.3 g/dL, creatinine 1.23 m/dL, alanine aminotransferase 83 U/L, aspartate aminotransferase 83 U/L and complete metabolic panel otherwise normal. LDH 228 U/L, beta 2 microglobulin 4.5 mg/L. HIV-1 test was positive with 94316 copies/mL by PCR. CD4 count 65 cells/mcl. EBV VCA IgM <0.2 AI, EBV VCA IgG > 8.0 AI. IgG 3023 mg/dL, IgE 207IU/ML, IgA 581 m/dL, IgM 286 mg/dL, free kappa 117 mg/L, free lambda 97.94 mg/L and normal kappa/lambda ratio. SPEP with immunofixation consistent with inflammatory response. Peripheral blood flow cytometry revealed a minimal kappa predominant monoclonal B-cell population. Patient started on DA-EPOCH with prophylactic intrathecal methotrexate with excellent clinical response after first cycle. Plan for 4-6 cycles with prophylactic intrathecal chemotherapy followed by autologous stem cell transplantation. For supportive care, the patient was started on HAART therapy, acyclovir, fluconazole, Levaquin, azithromycin. To our knowledge this is the first case of bilateral parotid gland involvement in PBL. Furthermore it is unclear if the hypergammaglobulinemia is related to HIV infection vs. directly PBL related. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Localized acral hypertrophy.

A 35-year-old male presented with complaints of a progressive increase in the size of his right thumb. There was a significant increase in subcutaneous tissue, which was most prominent on the palmar aspect. He was experiencing difficulty in his day-to-day work due to restricted movement. There was no history of trauma, infection, or a family history suggestive of neurofibromatosis or any similar disease. He had undergone surgery two years prior for similar complaints in the index finger. Plain radiograph of the hand [Figure 1] was advised following this magnetic resonance imaging (MRI) of the right hand was performed to confirm the diagnosis and assess the disease status [Figure 2]. Figure 1 (a) Clinical photograph showing localized enlargement of thumb with postoperative changes in index finger. (b) X-ray imaging of the hand shows hypertrophy of soft tissue and bone with mushroom shaped terminal phalanx. Secondary degenerative changes are ... Figure 2 Magnetic resonance imaging of the fingers. (a) T1-weighted imaging shows proliferation of the fibro-fatty tissue of the thumb. (b and d) Proton Density fat saturated image confirms the fatty nature. (c) T2-weighted imaging shows osteophyte formation with ... A plain X-ray of the hand of another patient with similar complaints in the middle finger showed increased lengths of metacarpals and phalanges of the middle finger with prominent soft tissue and is shown in Figure 3. Figure 3 X-ray imaging of the hand of another patient shows hypertrophy of soft tissue and bone of middle finger with advanced degenerative changes in the involved digits.