PMC1131917_01
Plain radiographs of the right elbow. A. AP view, demonstrating no changes. B. Lateral view demonstrating a joint effusion (arrowed).
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F1
Initial investigation with plain XR of the right elbow joint revealed a joint effusion (Figure 1).
Ultrasound examination of the right elbow. This confirms the presence of a hypoechoic joint effusion (arrowed).
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Ultrasound examination of the elbow showed a large joint effusion (Figure 2).
Limited bone scan using Tc99m. This demonstrates diffusely increased radioactive tracer uptake by the right elbow, particularly at the lateral epicondyle (dashed arrow) and the proximal ulna, as well as by the distal left radius (solid arrow).
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Scintigraphic imaging with Tc99m three phase bone scanning demonstrated increased blood pool activity, and diffusely increased osteoblastic activity, involving the right elbow joint, particularly the distal humerus and ulna, as well as the distal left radius (Figure 3).
Multiplanar CT of the right elbow joint. A. Axial view showing a complex joint effusion (arrowed) and soft tissue swelling adjacent to the elbow. B. Axial slice through the proximal forearm, demonstrating the joint effusion surrounding the radial head (solid arrow) and increased soft tissue density involving the medullary shaft of the ulna (dashed arrow). C. Sagittal bone targeted reconstruction, showing subtle cortical erosions (arrowed) of the proximal ulna. D. Sagittal soft tissue reconstruction, demonstrating increased soft tissue density (arrowed) of the medullary shaft of the proximal ulna.
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F4
Further, there was increased attenuation within the proximal medullary shaft of the ulna, and diffuse soft tissue thickening around the proximal ulna and radial head, with an associated joint effusion (Figure 4).
Functional metabolic imaging, using Thallium 201 chloride. A. Early planar images of the right elbow, showing intense radioactive tracer accumulation in the lateral humeral epicondyle and the proximal ulna. B. Delayed images at 4 hours, showing retention of tracer.
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Thallium 201 chloride revealed intense early uptake in the right lateral epicondyle of the humerus and proximal ulna (Figure 5A). The delayed 4 hour images demonstrated tracer retention (Figure 5B). The delayed whole body views showed further abnormal thallium retention involving the mediastinum, para-aortic regions of the abdomen, the left inguinal region and the distal left radius (Figure 6).
Functional metabolic imaging, using Thallium 201 chloride. Delayed whole body images, demonstrating abnormal tracer retention involving the mediastinum. (solid arrow), para-aortic region and left inguinal area (dashed arrow).
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The delayed 4 hour images demonstrated tracer retention (Figure 5B). The delayed whole body views showed further abnormal thallium retention involving the mediastinum, para-aortic regions of the abdomen, the left inguinal region and the distal left radius (Figure 6).
Multiplanar MR imaging of the right elbow. A. T1 weighted axial image at the level of the elbow joint, demonstrating a complex effusion (arrow), particularly adjacent to the proximal ulna. B. Contrast enhanced axial image showing enhancement around the joint (arrow). C. T2 weighted axial image again showing extensive joint effusion D. Coronal contrast enhanced image showing the complex effusion and abnormal signal intensity in the medullary canal of the proximal ulna (arrow).
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These changes suggested either a neoplasm or possibly infection (Figure 7).
CT guided core biopsy of the elbow. A. Tissue adjacent to proximal ulna, at the level of the elbow joint, was obtained under CT guidance. B. Histological examination, after haematoxylin and eosin staining, demonstrated non-specific chronic inflammation and numerous polymorphonuclear cells.
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F8
Biopsy of the right elbow joint demonstrated chronic synovial inflammation and numerous polymorphonuclear cells in the synovial fluid, but no malignant cells (Figure 8).
Multiplanar chest CT. This demonstrates mediastinal lymphadenopathy and subtle pulmonary involvement. A. Contrast enhanced axial slice, showing enlarged lymph nodes (arrowed) in the para-aortic window. B. Axial slice showing subcarinal lymphadenopathy (arrowed). C. Coronal slice, showing small nodules in the left upper lobe (arrowed).
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The lymphadenopathy was characterised by peripheral enhancement with prominent central areas of low attenuation (Figures 9 and 10).
Multiplanar abdominal and pelvic CT, demonstrating extensive lymphadenopathy. A. Large low attenuation portal lymph node (solid arrow) showing peripheral enhancement, and associated para-aortic nodes (dashed arrows). B. Extensive heterogenous attenuation side wall pelvic adenopathy. C. Coronal image, demonstrating extensive low attenuation para-aortic and pelvic lymphadenopathy (arrowed)
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The lymphadenopathy was characterised by peripheral enhancement with prominent central areas of low attenuation (Figures 9 and 10).
CT guided biopsy of the para-aortic lymph nodes. A. 14 gauge core needle biopsy. B. The core of tissue obtained. C. Histological examination after haematoxylin and eosin staining, demonstrating classic caseating granulomata of tuberculous infection (arrowed).
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Subsequent CT guided biopsy of the retroperitoneal lymphoid tissue revealed necrotising granulomatous lymphadenitis indicative of Mycobacterium tuberculosis infection (Figure 11).