DEPARTMENTAL SEMINAR BY DR.EFANGA,S.A.

DISCUSS THE DIFFERENTIAL DIAGNOSIS AND POSSIBLE RADIOLOGICAL FINDINGS IN A 40YR OLD WOMAN WHO PRESENTS WITH ACUTE SWELLING OF THE ENTIRE LOWER LIMB

QUESTION

-INTRODUCTION

OUTLINE

-DIFFERENTIALS -CLINICO-PATHOLOGICAL FEATURES -COMPLICATIONS -IMAGING MODALITIES -MERITS & DEMERITS OF MODALITIES -RADIOLOGICAL FEATURES -INTERVENTION

INTRODUCTION
The lower limb is the region of the body that extends from the hip down to the feet. The emphasis is thus on the causes of acute swellings(swellings of rapid onset) that involve a significant aspect of the lower limb in a 40YR old FEMALE.These causes may be from infections/inflammations,vascular lesions,and Lymphoedema.

DIFFERENTIALS
1.SOFT TISSUE INFECTIONS/INFLAMMATIONS -PYOMYOSITIS -CELLULITIS -NECROTIZING FASCITIS -DERMATOMYOSITIS -RHABDOMYOLYSIS

2.VASCULAR LESION -DEEP VEIN THROMBOSIS -WET GANGRENE -ACUTE MUSCLE DENERVATION 3.LYMPHOEDEMA

CLINICOPATHOLOGICAL FEATURES

PYOMYOSITIS
This is the inflammation

of a muscle as a result of a bacterial or fungal Infection.It may culminate to the formation of abscess,carbuncles,or infected sinuses that lie deep in the muscle.It is common in tropical countries.Staphylococcus aureus is the most Implicated cause.

COMPLICATIONS INCLUDE -OSTEOMYELITIS -ABSCESS -INFECTED SINUSES

CELLULITIS
It is the infection of the deep dermis of the skin commonly caused by b-hemolytic streptococci. It is most common in the lower limbs. COMPLICATIONS- LYMPHANGITIS - LYMPHADENITIS

NECROTIZING FASCITIS
Bacterial infection of the layer of fascia beneath the skin due to polymicrobial infection with a variety of gm +,gm -,aerobic & anaerobic orgs. There is tissue necrosis and toxin production with large areas of destroyed & devitalized muscle & soft tissue. It occurs following minor cuts like insect bite,and commonly seen in diabetics,alcohol/

The elderly are highly vulnerable. Presentations include; -Indolent(1-21 days) before diagnosis -fever -drowsiness -diarrhoea -vomitting -crepitus(50%) -discolouration of the skin

It is an autoimmune inflammatory disorder of the Skin,subcutaneous tissues and striated mucles. The Inflammatory process is commonly non-suppurative. Associated with it is a bluish-red skin eruption which occurs on the face,scalp,shoulders,and Knuckles .In the absence of this rash it is called POLYMYOSITIS.

DERMATOMYOSITIS

It is more common in middle aged females(40-

60yrs) but a severe form is seen in children(515yrs). It is associated with malignancies e.g Carcinoma of the breast,bronchus,stomach,& Ovary. Presentations include; -muscle weakness & aches(due to active inflammation,necrosis,muscle atrophy with fatty replacement) 1st symptom in 80%

-low grade fever

-skin erythema,Heliotrope rash(dusky eryrhema of the eyelids) with peri-orbital oedema. Gottron sign=scaly eythematous papules at the knuckles,major joints,and upper body. -elevated muscle enzymes -myositis specific auto-antibodies(anti-jo-1) COMPLICATIONS;Increased incidence of malignant neoplasms of the breast,prostate, lungs,ovary,GI tract,and kidney.

RHABDOMYOLYSIS
It is an acute fulminant potentially fatal disease of skeletal muscle that entails destruction of muscles with loss of integrity of its cell membrane via infarction. Causes include;trauma,severe exercise,ischemia,burn,toxin,iv heparin therapy,viral infection,autoimmune inflammation.

COMPLICATIONS -RENAL FAILURE due to myoglobinaemia -COMPARTMENT SYNDRME

DEEP VEIN THROMBOSIS

This condition is associated with venous obstruction as a result of the sluggish flow of blood plus the changes in the clotting factors in the blood that increases the tendency to thrombus formation.There is no preceeding inflammation of the venous wall.It is most common within the Deep veins of the calf (posterior surface of the lower Leg)

The causes/risk factors are as follows; -Patients on medications e.g,birth control pills, estrogen replacement therapy,tamoxifen,diabetes, -Decreased cardiac function;congestive cardiac failure,myocardial infarction -Female related;pregnancy,post partum,large fibroid, -Trauma & Surgery to the pelvis & lower limbs -prolonged immobilization

-Age>40yrs

-varicose veins -Polycythemia -Malignancy -Smoking -Patients with blood group A > blood group O Presentation include; -swelling(measurement of circumference) -warmth -Discolouration of the skin

-Deep crampy pain in the affected extremity,worse in the erect position and improves with walking. -Homans sign- Calf pain with dorsal flexion of the foot -Payr`s sisgn- Pain on compressing the sole of a foot COMPLICATIONS -PULMONARY EMBOLISM -PHLEGMASIA ALBA DOLENS(severely impaired venous drainage resulting in gangrene) -POST-PHLEBITIC SYNDROME(recanalization to a small lumen,focal wall changes) due to incompetent valves.

WET GANGRENE
This is the death and putrefactive decay of part of the body due to cessation of blood supply coexis-

ting with an infection by gas forming bacterium

e.g,clostridium perfringens.Diabetics are particularly prone to the infection.

ACUTE MUSCLE DENERVATION

The loss of nerve supply to a muscle is associated with atrophy however in most cases fatty infiltration of muscle and oedema occur causing the

Swelling of the affected limb.The cause of this

Denervation may be from stroke.

LYMPHOEDEMA
Lymphoedema is categorized as primary and second-ary.The primary type is due to Aplasia, hypoplasia or hyperplasia and is associated with syndromes like turner`s,klinefelter`s,noonan`s.It has 3 subtypes;congenital Lyphoedema,which appears shortly after birth,lyphoedema praecox,which appears at puberty,lymphoedema tarda which ussually begins after 35yrs.

Secondary lymphoedema is an acquired condition resulting from obstruction to a previously normal lymphatic channels by metastasis,parasites(FILARIAL WORMS),tuberculosis. Lymphoedema of the lower limbs that involve the foot progresses upwards,making the entire limb oedematous.

IMAGING MODALITIES
1.PLAIN RADIOGRAPHS -AP,LAT VIEWS OF THE AFFECTED LOWER LIMB,CXR 2.ULTRASOUND SCAN -B-MODE,COLOUR DOPPLER,DUPLEX DOPPLER 3.ANGIOGRAPHY 4.VENOGRAPHY 5.LYMPHOGRAPHY

6.CT SCAN + CONTRAST ENHANCEMENT 7.MRI -SE(T1 & T2 WEIGHTED) -GRADIENT RECALLED ACQUISITION IN STEADY STATE(GRASS) 8.RADIONUCLIDE IMAGING -99mTC-IN VITRO LABELLED PLATELETS -99mTC-NANOCOLLOIDS

ULTRASOUND SCAN
MERITS 1.Non invasive & convenient especially when the patient is uncomfortable 2.It is cheap and readily available 3.Non-ionizing 4.Ability to demonstrate and diferentiate soft tissues(muscles,tendons,subcutaneous layer,skin)

5.Dynamic assessment of the vascular anatomy and physiology using B-mode and Duplex doppler 6.Used for interventional procedures such as drainage and image guided biopsy. 7.Can be used for staging of soft tissue tumour

DRAW-BACKS
1.Marked operator dependence

2.Large and obese individuals coupled with intra abdominal gas may result in sub-optimal images 3Associated bony lesions can not be demonstred

PLAIN RADIOGRAPH
1.Readily available and cheap 2.Can show calcification of soft tissues,oblitera tion of fat planes(acute,active inflammation), bony metastasis,chest and skull involvement

DRAW BACK 1.Utilizes ionizing radiation( It is an issue with pregnancy) 2.Poor soft tissue contrast and spatial resolution

CT SCAN
1.Qualitative and quatitative assessment of lesions in the soft tissue of the affected limb 2.The extent of local or distant spread or involvement can assessed 3.Used in staging malignancies 4.Employs iv contrast for opacification of the blood vessels and increase lesion conspicuity 5.Helical CT to reduce motion artifacts

DRAW BACKS
1.Expensive and not widely available 2.Uses ionizing radiation(It is an issue with pregnancy) 3.Inaccurate history of allergy or multiple drug reaction when there is need for contrast.

ANGIOGRAPHY 1.Can demonstrate neo-vascularization in masses 2.Lesions in the vasculature can be determined and interventional procedures performed immediately or subsequently.

DRAW BACKS 1.Highly invasive 2.Uses ionizing radiation(except in MRA). 3.Allergy and multiple drug reactions

RADIONUCLIDE IMAGING
1.Soft tissue anomalies with propensity to develop mineralization can show ectopic activity on skeletal scintigraphy e.g,Dermatomyositis,Neoplasia,Myositis ossificans etc. 2.Helps in assessing the maturity of ectopic ossification(whether stable )prior to surgical excision.

DRAW BACKS

1.Very expensive and rarely available 2.Ionizing radiation

LYMPHOGRAPHY
-Lymphography directly studies the

lymphatic ducts and the internal architecture of the nodes. -Used for follow-up imaging of nodal diseases as the contrast persists in the nodes for up to 6-12months

DRAW BACK
-False

positive results are frequent occurrence -The procedure predisposes to oil embolism -It is very invasive -Ionizing radiation

MRI
1.Non-ionizing 2.Provides excellent soft tissue contrast and spatial resolution and has multiplanar capabilities 3.Contrast enhancement using iv contrast can help in differentiating soft tissue lesions 4.It is the best technique for follow-up

5.INTERVENTIONAL PROCEDURES Biopsies and Drainage procedures can be carried out.

DRAW BACKS
1.Very expensive and rarely available 2.Long image acquisition time 3.Claustrophobic patients 4.Patients with medical prosthesis unless it is MRI compatible 5.Obese individuals 6.Orthopneic congestive cardiac failure patients

1.PLAIN RADIOGRAPH Soft tissue swelling with the obliteration of fat plane is seen in infections and inflammation,in DVT there is also soft tissue swelling.In necrotizing fascitis gas is seen within the soft tissue swelling.

RADIOLOGICAL FEATURES

In dermatomyositis, in addition to the bilateral and symmetrical soft tissue swelling there are sheet-like calcifications along fascial and muscle planes.The differentials here include;Scleroderma,Myositis ossificans,cysticercosisi,dracunculosis,loia sis,hydatid disease,armillifer armilatus,leprosy,vascular calcifications,tendon calcifications,e.t.c.

- B-MODE US Hypoechoic/sonolucent lesion present within the muscle with or without probe tenderness is suggestive of pyomyositis,while in cellulitis the sonolucent lesion is anterior to the muscles.In DVT there might be visualization of the clot or thrombus within the vein but the incomplete luminal collapse following venous compression is an important pointer to it.Venous diameter at least twice that of the adjacent artery suggests a thrombus<10days.

ULTRASOUND

In Rhabdomyolysis there are areas of reduced echogenicity and nonhomogenous muscle texture. - COLOUR DOPPLER There is a peripheral rim pattern of blood flow seen in pyomyositis.In DVT there is reduced or absent colour signal or blood flow or a trickle of blood flow around a thrombus.

VENOGRAPHY
Intraluminal filling defects( tram-line appearance) are noted.They are constant in all the images that show the calf veins,communicating veins,femoral veins,and iliac veins.These are the contrast venographic findings in DVT.

LYMPHOGRAPHY There is obliteration of lymphatic channels due to intraluminal coagulum gel deposition/reactive inflammation Filling defects may also be present

CT SCAN
In infections,heterogenous attenuation of the enlarged soft tissues with fluid collection(exudate, or hemorrhage).Rim enhancement following iv contrast administration is typical.In Necrotizing fascitis, gas may be seen along thickened fascial planes with deep fluid collections.

Infections and inflammations invariably show high signal intensity on T2WI and low/intermediate intensity on T1WI.Fascial thickening(NECROTIZING FASCITIS) is best demonstrated using this modality.Peripheral enhancement with Gadollinium occurs.

MRI SCAN

It is usefull for demonstrating thrombus in DVT using 99mTechnitium labelled platelets. 99m-Technetium labelled nanocolloid show lymphatic uptake and trapping

RADIONUCLIDE IMAGING

INTERVENTIONAL PROCEDURES
1.ANGIOGRAPHY -Therapeutic embolization of malignancies

-Vascular access allows the introduction of drugs directly to the site of the pathology,e.g,Fibrinolytic drugs in DVT,cytotoxic drugs in malignancy,vasodilators in gangrene.

-Percutaneous transluminal angioplasty can be used to treat gangrene -vena caval filters can be introduced. 2.ULTRASOUND SCAN -Ultrasound guided drainage in the case of pyomyositis and also biopsy can be done.Some of the angiographic interventional procedures involve this modality. 3.CT SCAN CT guided biopsy

4.MRI SCAN -Biopsy -Guidance of open surgery

Multiple abscess following pyomyositis.Hy perintense on T2WI and rim enhancement on contrast administration

Pyomyositis Soft tissue swelling hyperintens en on T2WI

PYOMYOSIT IS,CELLULIT IS,AND FASCITIS ON T2WI

CT SCAN A CENTRAL LOW ATTENUAT ING COLLECTI ON WITH ILL DEFINED RIM ENHANCE MENT

NECROTIZING FASCITIS/GAS GRANGRENE Swelling of the left thigh with gas present

NECROTIZING FASCITIS/GAS GANGRENE

Fascial thickening on T1WI & T2WI

NECROTIZING FASCITIS/GAS GANGRENE(CT SCAN)

NEROTIZIN G FASCITIS/G AS GANGRENE Gas present in soft tissue swelling

PYOMYOSITIS Transverse ultrasound with doppler showing marked vascularity surrounding an anechoic collection in the thigh(abscess)

CELLULITIS Hypoechoic strands surroundin g hyperechoi c fat

DERMATO MYOSITIS Swelling and sheetlike calcificatio n

PICTURE OF THE SKIN LESION AND PLAIN RADIOGRA PH OF THE SAME MAN

DERMATOMYOSITIS

DVT

DEEP VENOUS THROMBOSIS

A.TRANSVERSE POWER DOPPLER IMAGE WITH TRANSDUCER COMPRESSION APPLIED SHOWS FLOW IN THE FEMORAL ARTERY(A) AND NO FLOW IN THE FEMORAL VEIN(V,ARROW).THE VEIN DOES NOT COMPRESS WITH TRANSDUCER PRESSURE,INDICATING INTRALUMINAL THROMBUS.

B.ENLARGEMENT OF THE CFV WITH INTRALUMINAL THROMBUS.

DVT Venography which shows filling defects and irregularitie s in the femoral vein

LYMPHOEDEMA

Increased signal intensity in the edematous left leg of a patient with lymphoede ma

Post inflammatory lymphedema of both limbs

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