Presentation
Atraumatic progressive swelling and pain of the distal leg and ankle, with reported history of fatigue and inability to bear weight for the past 3 weeks. Patient also endorsed increasing fatigue and intermittent fevers.
Patient Data
Multiplanar multisequence MR images demonstrate a T1 intermediate, T2/STIR hyperintense osseous lesion involving the distal tibial metaphasis with erosion through the cotex and periosteum and extension into the surrounding anteromedial soft tissues. There is associated homogeneous enhancement on post contrast images. This lesion closely abuts the physis in this skeletally immature patient.
Surrounding this lesion, there is extensive soft tissue edema. There is no subperiosteal fluid to suggest subperiosteal abscess although the adjacent periosteum is slightly elevated. The lesion is poorly marginated in the bone and there is no T1 hyperintense penumbra. To a lesser extent, there is edema and enhancement in the medial tibial epiphysis.
Given infectious symptoms, a chest radiograph was performed which revealed a consolidation of the right middle lobe concerning for pneumonia.
PA and lateral chest radiographs demonstrating consolidation of the right upper lobe.
Pathology report showing budding yeast organisms, morphologically consistent with Blastomycoses species.
Case Discussion
Fluoroscopic guided bone marrow biopsy was performed with a final pathologic diagnosis of granulomatous inflammation with suppuration and fungal elements morphologically consistent with Blastomycosis species.
This case demonstrates that an intraosseous infectious collection may develop without the presence of a T1 hyperintense rim (historically referred to as the "penumbra sign").
Patient was started on oral itraconazole and MRI head was performed to rule out CNS manifestations of disseminated Blastomycosis and ultimately negative.
Patient was discharged home with this antifungal regimen and recommended to take over-the-counter ibuprofen to help with pain associated with weight-bearing.
Unable to process the form. Check for errors and try again.