Presentation
History of left wrist and right ankle pain which was treated conservatively.
Patient Data
There are multiple metaphyseal lucencies seen at the distal right tibia without periosteal reaction or obvious soft tissue mass.
Radiographic images obtained 2 weeks following the initial images again show multiple metaphyseal lucencies of the distal right tibia. Compared to the prior study, there appears to be increased lucency at the lateral aspect of the tibial metaphysis.
No joint effusion is seen.
There is STIR hyperintensity and T1 hypointensity located at the distal right tibial metaphysis corresponding to the lucencies seen on prior radiographs.
Whole body MRI was performed for additional areas of abnormal signal (not all sequences shown).
Corresponding to prior MRI and radiographic findings, there is increased T2 hyperintensity and T1 hypointensity in the right distal tibial metaphysis. The degree of hyperintensity is decreased compared to the prior MRI. There is an additional small focus of T2 hyperintensity of the left distal tibial metaphysis with corresponding T1 hypointensity.
Small focus of abnormal T2 hyperintensity is seen in the left medial cuneiform is likely artefactual.
Otherwise, the remaining osseous structures including the long bones and axial skeleton demonstrate normal marrow signal for patient age.
Case Discussion
This is a case of chronic recurrent multifocal osteomyelitis (also known as chronic nonbacterial osteomyelitis). On initial radiographs of the right ankle, there was increasing lucency of the distal tibial metaphysis and MRI of this region revealed STIR hyperintensity with corresponding T1 hypointensity. Whole body MRI was used which demonstrated increased T2/STIR signal and decreased T1 signal of the bilateral distal tibias. Biopsy of the right distal tibia revealed reactive bone showing reparative/remodeling changes without the presence of microorganisms.
CO-AUTHORS:
Michael Cooley, MD
Travis Bevington, MD
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