- Email: [email protected]
Case report: Brucella osteomyelitis of the pubic bone
Clinical Radiology (1996) 51, 368 370
Case Report: Brucella Osteomyelitis of the Pubic Bone C. H O F F M A N , R. M A R A N * a n d S. T. Z W A S t
Departments of Diagnostic Imaging, *Internal Medicine B, tNuclear Medicine, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel
W e present a p a t i e n t with osteomyelitis o f the p u b i c b o n e caused b y Brucella Melitensis. The p a t i e n t presented with lower a b d o m i n a l p a i n a n d difficulty in walking. P l a i n X - R a y s o f the pelvis a n d a C T scan d e m o n s t r a t e d a lytic lesion s u r r o u n d e d by a n ill defined sclerotic area in the p u b i c b o n e s a d j a c e n t to the symphysis, m o r e pron o u n c e d o n the right side. 99mTc a n d Ga-67 scans showed increased u p t a k e in this area, consistent with a n i n f l a m m a t o r y process. This l o c a t i o n for Brucella osteomyelitis has not, to o u r knowledge, been previously described. Brucella has become a rare disease in most developed countries. I n Israel between 150-250 cases are still diagnosed every year (181 in 1991, 137 in 1992) [1]. Osteoarticular complications of Brucellosis occur in 10% to 20% of cases with spine most often involved. A m u c h higher incidence was reported in a large study, in which 169 (37.4%) out of a total of 452 patients with Brucellosis suffered from arthritis or spondylitis [2]. W e report here a case of Brucellosis osteomyelitis of the pubic bone. This location has to the best of our knowledge n o t previously been reported.
Discussion Osteoarticular c o m p l i c a t i o n s of Brucellosis seem to affect p r e d o m i n a n t l y weight-bearing joints, such as the hip a n d knee j o i n t s [3]. The spine m a y also become involved [4]. The symphysis pubis has n o t previously been m e n t i o n e d as a site of Brucellosis osteomyelitis. All the imaging studies performed showed the characteristic appearance of a non-aggressive infectious process with the b o n e scans being more sensitive, while the C T showed the extent of the lesion in more detail. I n the initial scout film the lesion was clearly visible in the right pubic bone, while C T scans performed 6 m o n t h s later showed lytic a n d sclerotic lesions in the left pubic b o n e as well. This is further evidence of osteomyelitis which has involved the articulation a n d the contralateral pubic joint. D i a g n o s i s i n this p a t i e n t was d e l a y e d for m o r e t h a n 6 m o n t h s , u n t i l the r a d i o n u c l i d e scans were o b t a i n e d , a l t h o u g h she h a d b e e n a d m i t t e d twice with a b d o m i n a l p a i n a n d i n t e r m i t t e n t fever. B l o o d c u l t u r e s h a d b e e n n e g a t i v e i n this period. T h e lesion w h i c h was clearly
CASE R E P O R T A 52-year-old woman was admitted to the hospital with prolonged fever, pain in the lower abdomen and in the right hip joint. Marked limitation in movement of both lower extremities and difficulty in walking were also present• On three earlier admissions for abdominal pain during the previous year, the only positive finding was E. eoliin the urine, and the patient was treated for urinary tract infection. A plain abdominal film taken on one of these admissions showed normal distribution of gas. On examination the patient had fever 38°C and a tender lower abdomen. An X-Ray of the right hip joint was normal, but a small lyric lesion surrounded by an ill defined sclerotic area was seen in the right pubic bone, adjacent to the symphysis pubis (Fig. 1). Review of the earlier abdominal film showed the lesion with less sclerosis around it (Fig. 2). The lesion was compatible with a chronic, non-aggressive infectious process. In addition there was increased sclerosis of the vertebrae on either side of the L4/L5 intervertebral space, with • narrowing of this space (]Fig. 3). A radionuclide scan with 9 9 m Tc showed initially increased uptake in the pubic region, more prominent on the right, as well as in the lumbar spine, while a Ga-67 scan showed increased uptake in the pubic area only, consistent with active inflammation (Figs 4 & 5). The lumbar spine lesions were interpreted as compatible with chronic degenerative changes. Blood cultures proved positive for BrucellaMelitensisand serological examination revealed an IgM titre of 1 : 1280. A CT scan of the pubis showed lytic and sclerotic areas in both pubic bones, but mainly on the right side with destruction of the cortex (Fig. 6). The patient was treated with I.V. gentamicin for 3 weeks and doxycyclinefor 6 weeks. Recovery was rapid with a gradual return of lower limb function. A repeat Ga scan 6 months later was negative. On enquiry the source of the infection proved to be goat cheese from the southern part of the country. Correspondence to: Dr C. Hoffman, Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel. © 1996The RoyalCollegeof Radiologists.
Fig. 1 - X-ray of the right hip joint shows that the joint is normal but a small lytic lesion surrounded by an ill defined sclerotic area is present in the right pubic bone adjacent to the symphysis.
CASE REPORTS
369
Fig. 4 - 24 h 99mTC bone scan. Anterior and posterior views demonstrate markedly increased tracer uptake in the pubic region bilaterally, more extensive on the right side consistent with a pubic lesion. In addition increased uptake is shown in the 5th lumbar vertebra.
Fig. 2 - Detail of a plain abdominal film taken 6 months previously, shows essentially the same lesion with less sclerosis.
visible on the plain film of the abdomen taken 6 months prior to the present admission had not been appreciated at that time. In 38 patients with Brucellosis seen at our hospital, the time between onset of symptoms and diagnosis ranged between 1 to 12 weeks [5]. The radiographic appearance of lytic and sclerotic lesions in the pubic bones can occur in patients with osteitis pubis, in men after surgery of the bladder and prostate and in women following pelvic operations or delivery [6]. This 52year-old female patient had not undergone pelvic surgery. It
Fig. 5 - 48 h gallium scan anterior pelvic view shows increased gallium accumulation in the pubic region only, compatible with an active pubic inflammatory process and probably degenerative bone changes in Ls.
Fig. 3 Lateral film of the lower lumbar spine shows narrowing o f the joint space anterior osteophytes and sclerosis of the adjoining margins of L 4 and Ls. © 1996 The Royal College of Radiologists, Clinical Radiology, 51, 368 370.
Fig. 6 CT of the symphysis pubis area shows partial destruction of hoth pubic bones near the midline, more pronounced on the right.
370
CLINICAL RADIOLOGY
may also rarely be seen in athletes due to an avulsive injury of one of the muscles attached to the pubic bones [7]. Regarding Brucellosis infection involving bones and joints, partial or complete obliteration of the joint space in sacroileitis and destruction of the medial end of the clavicle in sternoclavicular arthritis have been reported [2]. In our patient, a lytic lesion surrounded by an illdefined area of sclerosis and localized destruction of the cortex adjacent to the symphysis pubis were demonstrated. The joint space itself was not affected and the soft tissues were normal. This relatively indolent process is consistent with other reports mentioning that Brucellosis infection usually does not cause joint destruction [3]. Plain X-rays, CT scans and radiosotope studies all contributed to the diagnosis of osteomyelitis with the CT scan giving a more detailed demonstration of the lesion. Although Brucellosis is not a c o m m o n disease nowadays it should be included in the differential diagnosis of patients with fever and arthralgia, and it may present
as low grade osteomyelitis seen in flat bones such as in the pelvis.
REFERENCES
1 State of Israel Ministry of Health. Monthly Epidemiological Bulletin 1992;27:1-3. 2 Mousa ARM, Muhtaseb SA, Ahnudallal DS et al. Osteoarticular complications of Brucellosis: A study of 169 cases. Review of Infectious Diseases 1987;9:531-543. 3 A1-Eissa YA, Kambal AM, Alrabeeah A A et al. Osteoarticular Brucellosis in children. Annals of the Rheumatic Diseases 1990;49:896 900. 4 Samra Y, Shaked Y, Hertz M e t al. Brucellosis: difficulties in diagnosis and a report of 38 cases. Injection 1983;11:310-312. 5 Samra Y, Hertz M, Shaked Y e t al. Brucellosis of the spine. Journal of Bone and Joint Surgery 1982;64:429-431. 6 Resnick D, Niwayama G. Diagnosis of bone and joint disorders. Philadelphia: WB Saunders, 1981:1875 1879. 7 Schneider L, Kaye JJ, Gelman B. Adductor avulsive injuries near the symphysis pubis. Radiology 1976;120:567 569.
Clinical Radiology (1996) 51, 370-372
Case Report: Fibroma of Tendon Sheath in the Distal Forearm With Associated Median Nerve Neuropathy: US, CT and MR Appearances M: B E R T O L O T T O , I. R O S E N B E R G * , R. C. PARODI~, R. P E R R O N E , S. G E N T I L E S, G. A. R O L L A N D I * and S. S U C C I t
Servizio di Ecografia, *Servizio di Tomografia Computerizzata, tServizio di Risonanza Magnetica, Istituto di Radiologia and ~.Clinica Neurochirurgica, Universith di Genova, Genova, Italy A fibroma of tendon sheath has been identified in the distal forearm in a patient presenting with pain and sensory impairment in the distribution of the median nerve. The sonographic CT and M R appearances are reported. Fibroma of tendon sheath is a rare benign tumour, more frequent in males, composed of fibroblasts embedded in a dense, fibrous stroma. The tumour was fully characterized by Chung and Enzinger [1] who presented a series of 138 cases. Fibromas of tendon sheath are usually well circumscribed masses, small and lobulated, firm or hard, attached to tendon and/or tendon sheath. Typically the fibroblasts are spindleshaped and the fibrous stroma is markedly collagenized. The pathognomic microscopic feature of this tumour is the presence of numerous thin-walled vascular channels that range from dilated spaces to slitlike structures. Occasionally fibroma of tendon sheath may resemble, focally, fibrous histiocytoma or nodular fascitis and exhibits the same multilobular pattern and attachment to tendon sheath as a giant cell tumour of the tendon sheath. It differs microscopically because of haphazardly arranged fibroblasts embedded within a dense collagen matrix. Unlike the rounded cells of giant cell tumour of Correspondence to: Dr Michele Bertolotto, Via Zara 21/7-16145, Genova, Italy.
tendon sheath, the cells of fibroma of the tendon sheath are predominantly spindle-shaped and there are no associated xanthoma cells or siderophages which are typical findings in giant cell tumour of the tendon sheath. In the reported case, a fibroma of tendon sheath was detected in the distal forearm in a patient who underwent sonography for suspected carpal tunnel syndrome. To our knowledge, the radiologic appearance o f this unusual tumour has not previously been reported.
CASE REPORT An 80-year-old, left-handed man presented with pain, numbness and paraesthesia o f the fingers of the left hand in the distribution of the median nerve. The wrist and the distal forearm were stiff and swollen but no distinct masses were appreciable at clinical examination. Tinel's sign and Phalen's test were positive; the sensory latency suggested a distal entrapment of the median nerve (3.8 ms left median nerve, 3.2 ms right median nerve palmar surface conduction velocity with antidromic technique). Although these findings are non-specific, sonographic examination of the wrist was performed for suspected carpal tunnel syndrome. No pathologic findings were detected in the carpal tunnel. A solid, hypoechoic, flattened mass about 30ram x 5 mm in size was identified in distal forearm (Fig. 1). The tumour was in the region of the distal radius and ulna superficial to the pronator quadratus muscle. The median nerve and the flexor tendons were displaced in a radial and superficial direction. No direct involvement of the median nerve by the tumour was appreciable. Further imaging examinations were per© 1996 The Royal College of Radiologists, Clinical Radiology, 51, 370 372.
Case Report: Brucella Osteomyelitis of the Pubic Bone C. H O F F M A N , R. M A R A N * a n d S. T. Z W A S t
Departments of Diagnostic Imaging, *Internal Medicine B, tNuclear Medicine, The Chaim Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel
W e present a p a t i e n t with osteomyelitis o f the p u b i c b o n e caused b y Brucella Melitensis. The p a t i e n t presented with lower a b d o m i n a l p a i n a n d difficulty in walking. P l a i n X - R a y s o f the pelvis a n d a C T scan d e m o n s t r a t e d a lytic lesion s u r r o u n d e d by a n ill defined sclerotic area in the p u b i c b o n e s a d j a c e n t to the symphysis, m o r e pron o u n c e d o n the right side. 99mTc a n d Ga-67 scans showed increased u p t a k e in this area, consistent with a n i n f l a m m a t o r y process. This l o c a t i o n for Brucella osteomyelitis has not, to o u r knowledge, been previously described. Brucella has become a rare disease in most developed countries. I n Israel between 150-250 cases are still diagnosed every year (181 in 1991, 137 in 1992) [1]. Osteoarticular complications of Brucellosis occur in 10% to 20% of cases with spine most often involved. A m u c h higher incidence was reported in a large study, in which 169 (37.4%) out of a total of 452 patients with Brucellosis suffered from arthritis or spondylitis [2]. W e report here a case of Brucellosis osteomyelitis of the pubic bone. This location has to the best of our knowledge n o t previously been reported.
Discussion Osteoarticular c o m p l i c a t i o n s of Brucellosis seem to affect p r e d o m i n a n t l y weight-bearing joints, such as the hip a n d knee j o i n t s [3]. The spine m a y also become involved [4]. The symphysis pubis has n o t previously been m e n t i o n e d as a site of Brucellosis osteomyelitis. All the imaging studies performed showed the characteristic appearance of a non-aggressive infectious process with the b o n e scans being more sensitive, while the C T showed the extent of the lesion in more detail. I n the initial scout film the lesion was clearly visible in the right pubic bone, while C T scans performed 6 m o n t h s later showed lytic a n d sclerotic lesions in the left pubic b o n e as well. This is further evidence of osteomyelitis which has involved the articulation a n d the contralateral pubic joint. D i a g n o s i s i n this p a t i e n t was d e l a y e d for m o r e t h a n 6 m o n t h s , u n t i l the r a d i o n u c l i d e scans were o b t a i n e d , a l t h o u g h she h a d b e e n a d m i t t e d twice with a b d o m i n a l p a i n a n d i n t e r m i t t e n t fever. B l o o d c u l t u r e s h a d b e e n n e g a t i v e i n this period. T h e lesion w h i c h was clearly
CASE R E P O R T A 52-year-old woman was admitted to the hospital with prolonged fever, pain in the lower abdomen and in the right hip joint. Marked limitation in movement of both lower extremities and difficulty in walking were also present• On three earlier admissions for abdominal pain during the previous year, the only positive finding was E. eoliin the urine, and the patient was treated for urinary tract infection. A plain abdominal film taken on one of these admissions showed normal distribution of gas. On examination the patient had fever 38°C and a tender lower abdomen. An X-Ray of the right hip joint was normal, but a small lyric lesion surrounded by an ill defined sclerotic area was seen in the right pubic bone, adjacent to the symphysis pubis (Fig. 1). Review of the earlier abdominal film showed the lesion with less sclerosis around it (Fig. 2). The lesion was compatible with a chronic, non-aggressive infectious process. In addition there was increased sclerosis of the vertebrae on either side of the L4/L5 intervertebral space, with • narrowing of this space (]Fig. 3). A radionuclide scan with 9 9 m Tc showed initially increased uptake in the pubic region, more prominent on the right, as well as in the lumbar spine, while a Ga-67 scan showed increased uptake in the pubic area only, consistent with active inflammation (Figs 4 & 5). The lumbar spine lesions were interpreted as compatible with chronic degenerative changes. Blood cultures proved positive for BrucellaMelitensisand serological examination revealed an IgM titre of 1 : 1280. A CT scan of the pubis showed lytic and sclerotic areas in both pubic bones, but mainly on the right side with destruction of the cortex (Fig. 6). The patient was treated with I.V. gentamicin for 3 weeks and doxycyclinefor 6 weeks. Recovery was rapid with a gradual return of lower limb function. A repeat Ga scan 6 months later was negative. On enquiry the source of the infection proved to be goat cheese from the southern part of the country. Correspondence to: Dr C. Hoffman, Department of Diagnostic Imaging, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel. © 1996The RoyalCollegeof Radiologists.
Fig. 1 - X-ray of the right hip joint shows that the joint is normal but a small lytic lesion surrounded by an ill defined sclerotic area is present in the right pubic bone adjacent to the symphysis.
CASE REPORTS
369
Fig. 4 - 24 h 99mTC bone scan. Anterior and posterior views demonstrate markedly increased tracer uptake in the pubic region bilaterally, more extensive on the right side consistent with a pubic lesion. In addition increased uptake is shown in the 5th lumbar vertebra.
Fig. 2 - Detail of a plain abdominal film taken 6 months previously, shows essentially the same lesion with less sclerosis.
visible on the plain film of the abdomen taken 6 months prior to the present admission had not been appreciated at that time. In 38 patients with Brucellosis seen at our hospital, the time between onset of symptoms and diagnosis ranged between 1 to 12 weeks [5]. The radiographic appearance of lytic and sclerotic lesions in the pubic bones can occur in patients with osteitis pubis, in men after surgery of the bladder and prostate and in women following pelvic operations or delivery [6]. This 52year-old female patient had not undergone pelvic surgery. It
Fig. 5 - 48 h gallium scan anterior pelvic view shows increased gallium accumulation in the pubic region only, compatible with an active pubic inflammatory process and probably degenerative bone changes in Ls.
Fig. 3 Lateral film of the lower lumbar spine shows narrowing o f the joint space anterior osteophytes and sclerosis of the adjoining margins of L 4 and Ls. © 1996 The Royal College of Radiologists, Clinical Radiology, 51, 368 370.
Fig. 6 CT of the symphysis pubis area shows partial destruction of hoth pubic bones near the midline, more pronounced on the right.
370
CLINICAL RADIOLOGY
may also rarely be seen in athletes due to an avulsive injury of one of the muscles attached to the pubic bones [7]. Regarding Brucellosis infection involving bones and joints, partial or complete obliteration of the joint space in sacroileitis and destruction of the medial end of the clavicle in sternoclavicular arthritis have been reported [2]. In our patient, a lytic lesion surrounded by an illdefined area of sclerosis and localized destruction of the cortex adjacent to the symphysis pubis were demonstrated. The joint space itself was not affected and the soft tissues were normal. This relatively indolent process is consistent with other reports mentioning that Brucellosis infection usually does not cause joint destruction [3]. Plain X-rays, CT scans and radiosotope studies all contributed to the diagnosis of osteomyelitis with the CT scan giving a more detailed demonstration of the lesion. Although Brucellosis is not a c o m m o n disease nowadays it should be included in the differential diagnosis of patients with fever and arthralgia, and it may present
as low grade osteomyelitis seen in flat bones such as in the pelvis.
REFERENCES
1 State of Israel Ministry of Health. Monthly Epidemiological Bulletin 1992;27:1-3. 2 Mousa ARM, Muhtaseb SA, Ahnudallal DS et al. Osteoarticular complications of Brucellosis: A study of 169 cases. Review of Infectious Diseases 1987;9:531-543. 3 A1-Eissa YA, Kambal AM, Alrabeeah A A et al. Osteoarticular Brucellosis in children. Annals of the Rheumatic Diseases 1990;49:896 900. 4 Samra Y, Shaked Y, Hertz M e t al. Brucellosis: difficulties in diagnosis and a report of 38 cases. Injection 1983;11:310-312. 5 Samra Y, Hertz M, Shaked Y e t al. Brucellosis of the spine. Journal of Bone and Joint Surgery 1982;64:429-431. 6 Resnick D, Niwayama G. Diagnosis of bone and joint disorders. Philadelphia: WB Saunders, 1981:1875 1879. 7 Schneider L, Kaye JJ, Gelman B. Adductor avulsive injuries near the symphysis pubis. Radiology 1976;120:567 569.
Clinical Radiology (1996) 51, 370-372
Case Report: Fibroma of Tendon Sheath in the Distal Forearm With Associated Median Nerve Neuropathy: US, CT and MR Appearances M: B E R T O L O T T O , I. R O S E N B E R G * , R. C. PARODI~, R. P E R R O N E , S. G E N T I L E S, G. A. R O L L A N D I * and S. S U C C I t
Servizio di Ecografia, *Servizio di Tomografia Computerizzata, tServizio di Risonanza Magnetica, Istituto di Radiologia and ~.Clinica Neurochirurgica, Universith di Genova, Genova, Italy A fibroma of tendon sheath has been identified in the distal forearm in a patient presenting with pain and sensory impairment in the distribution of the median nerve. The sonographic CT and M R appearances are reported. Fibroma of tendon sheath is a rare benign tumour, more frequent in males, composed of fibroblasts embedded in a dense, fibrous stroma. The tumour was fully characterized by Chung and Enzinger [1] who presented a series of 138 cases. Fibromas of tendon sheath are usually well circumscribed masses, small and lobulated, firm or hard, attached to tendon and/or tendon sheath. Typically the fibroblasts are spindleshaped and the fibrous stroma is markedly collagenized. The pathognomic microscopic feature of this tumour is the presence of numerous thin-walled vascular channels that range from dilated spaces to slitlike structures. Occasionally fibroma of tendon sheath may resemble, focally, fibrous histiocytoma or nodular fascitis and exhibits the same multilobular pattern and attachment to tendon sheath as a giant cell tumour of the tendon sheath. It differs microscopically because of haphazardly arranged fibroblasts embedded within a dense collagen matrix. Unlike the rounded cells of giant cell tumour of Correspondence to: Dr Michele Bertolotto, Via Zara 21/7-16145, Genova, Italy.
tendon sheath, the cells of fibroma of the tendon sheath are predominantly spindle-shaped and there are no associated xanthoma cells or siderophages which are typical findings in giant cell tumour of the tendon sheath. In the reported case, a fibroma of tendon sheath was detected in the distal forearm in a patient who underwent sonography for suspected carpal tunnel syndrome. To our knowledge, the radiologic appearance o f this unusual tumour has not previously been reported.
CASE REPORT An 80-year-old, left-handed man presented with pain, numbness and paraesthesia o f the fingers of the left hand in the distribution of the median nerve. The wrist and the distal forearm were stiff and swollen but no distinct masses were appreciable at clinical examination. Tinel's sign and Phalen's test were positive; the sensory latency suggested a distal entrapment of the median nerve (3.8 ms left median nerve, 3.2 ms right median nerve palmar surface conduction velocity with antidromic technique). Although these findings are non-specific, sonographic examination of the wrist was performed for suspected carpal tunnel syndrome. No pathologic findings were detected in the carpal tunnel. A solid, hypoechoic, flattened mass about 30ram x 5 mm in size was identified in distal forearm (Fig. 1). The tumour was in the region of the distal radius and ulna superficial to the pronator quadratus muscle. The median nerve and the flexor tendons were displaced in a radial and superficial direction. No direct involvement of the median nerve by the tumour was appreciable. Further imaging examinations were per© 1996 The Royal College of Radiologists, Clinical Radiology, 51, 370 372.