Presentation
Hypercholesterolemia with recent history of myocardial infarction.
Patient Data
Multiple dense soft tissue swellings are seen at the base of the fifth metatarsal bone, around the tibiotalar joint, and adjacent to the first interphalangeal joint with small erosive changes. Soft thickening in the region of the Achilles tendon is also noted.
There are multiple subcutaneous soft tissue masses and fusiform areas of tendinous thickening with heterogeneous T1 and T2 weighted signal change, and mild heterogeneous enhancement. The changes are most pronounced at the distal Achilles tendon, which demonstrates a striated appearance.
Other tendinous involvements are seen in the tibialis anterior tendon (at the level of talonavicular joint), peroneus longus tendon, flexor hallucis longus (at the level of the midfoot), and proximal plantar fascia. The subcutaneous masses are noted along the outer aspect of the lateral malleolus, lateral to the fifth metatarsal base, first toe, second toe and fifth toe.
Pressure erosions of the first distal phalanx are seen. Moderate Achilles peritendinitis and mild peroneal tenosynovitis are noted.
Case Discussion
This case shows the imaging features found in subcutaneous and intratendinous xanthomas in a patient with familial hypercholesterolemia resulting in Achilles tendon xanthoma.
Xanthoma typically exhibits mildly higher signal intensity than the tendon itself, and the interposition between the normal tendon fibers causes a striated appearance 1. Xanthoma exhibits mildly high T1 and T2-weighted signal intensity 2, sometimes with erosive changes on the adjacent bones. Other systemic diseases that result in infiltration of the achilles tendon or other tendons would include amyloid arthropathy and gout disease 2.
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