Presentation
Back pain and right lower limb pain.
Patient Data
Irregular ill-defined diffuse cortical bony erosion with periosteal reaction at bilateral iliac bone, bilateral inferior pubic rami and bilateral acetabuli. Numerous intramedullary air noted within bilateral iliac bones, notably more on the left ilium, giving rise the pumice stone sign. The intramedullary air is better appreciated in "lung window" in order to avoid considering fat locules as air pockets.
Lytic lesion at the right L4 transverse process.
Intramuscular collections/abscess noted within right gluteus medius and left iliacus muscles.
Enlarged spleen with multiple wedged shaped hypodense areas with lack of peripheral enhancement which can represent splenic infarcts.
Hepatomegaly.
Long segment of thrombosis within right external iliac vein and right common femoral vein.
A pumice stone is a type of volcanic rock that forms when lava suddenly cools during an eruption. It's porous and light and has a spongelike appearance.
Case Discussion
The pumice stone sign represents distinctive imaging appearance of emphysematous osteomyelitis on CT which represents clusters of greater than 3 distinct foci of intramedullary gas with irregularly irregular sizes ranging between 2 and 5 mm with resemblance to surface appearance of pumice stone.
This sign is highly specific for emphysematous osteomyelitis (96%). On top of the characteristic pumice stone sign, this patient also has irregular bony cortices and erosion as well as multiple sites of intramuscular abscess to support the diagnosis of disseminated infection.
This patient has underlying hematological disorder Evan syndrome and relapsed antiphospholic syndrome (APLS). Blood culture and urine culture yielded the bacteria Escherichia coli, which is commonly reported organism to cause emphysematous osteomyelitis.
Patient was treated with protracted term of intravenous and oral antibiotics.
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