PMC4677016_01
Coronal reconstruction CT in bone window at the time of admission to the outside institution shows essentially normal bone marrow other than some Schmorl's nodes. Note additional findings of splenomegaly and left basilar consolidation/atelectasis. Focus of hypoattenuation in the spleen (*) was interpreted as a focus of splenic infarction. Also note that there is no evidence of osteonecrosis in either hip.
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Initial CT of the abdomen and pelvis was obtained on the day of admission at the outside institution (Figure 1).
Axial T2 weighted images following a lumbosacral plexus protocol show right psoas fluid collections (a) and a fluid collection in the right iliopsoas muscle anterior to the sacroiliac joint (b). The smaller contralateral collection anterior to the left sacroiliac joint is not shown. Note diffuse muscle edema asymmetrically affecting the gluteal and iliacus musculature.
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Noncontrast enhanced MRI approximately 8 weeks after the initial presentation showed fluid collections anterior to the sacroiliac joints and along the right piriformis muscle, which was interpreted as concerning for abscesses by the radiologist (Figure 2).
Coronal noncontrast CT three days prior to discharge/approximately 11 weeks after initial presentation shows (a) new foci of gas (arrow) within the sacrum and iliac bones, left greater than right. Findings in keeping with the preceding iliac bone marrow biopsy showing extensive bone necrosis. (b) Spine at this point still remains normal in CT appearance.
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Three days prior to discharge (11 weeks after initial presentation), a noncontrast enhanced CT of chest, abdomen, and pelvis was obtained (Figure 3).
Lumbar spine MRI without and with contrast obtained 6 months after the initial presentation. (a) Sagittal T2 weighted and T1 weighted images without contrast and (c) sagittal postcontrast T1-weighted fat suppressed image. These images show marrow signal alteration with associated band-like areas of enhancement surrounding areas of nonenhancement with associated T1 and T2 hypointensity, consistent with diffuse osteonecrosis.
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MRI of the lumbar spine (Figure 4) was obtained to evaluate for discitis/osteomyelitis given the patient's prior history of possible abscess.
Coronal intravenous contrast enhanced CT images obtained 3 days after Figure 4. These images show (a) progression of osteonecrosis now involving the lumbar spine. (b) There is also subtle evidence of osteonecrosis of the right hip (arrow).
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Three days later, a CT scan of the abdomen and pelvis with contrast was also obtained (Figure 5).
CT lumbar spine without contrast approximately 8 months since the initial presentation shows continued progression of diffuse osteonecrosis of the visualized marrow. The bone marrow is abnormal with multiple foci of gas.
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A dedicated CT of the lumbar spine without contrast obtained approximately 8 months after the initial presentation showed further progression of the osteonecrosis (Figure 6).
Coronal T2 weighted fat suppressed image of the left shoulder obtained approximately 1 year and 9 months since the initial presentation shows image findings consistent with avascular necrosis of the left humeral head. In this image, the classic double line sign with inner T2 hyperintensity and outer T2 hypointensity for osteonecrosis is well depicted.
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Due to increasing left shoulder pain, MRI of the shoulder without contrast was obtained approximately 1 year after the initial presentation (Figure 7), which demonstrated imaging evidence of avascular necrosis.
Coronal CT with oral contrast shows progression of bilateral femoral head osteonecrosis. There is also diffuse marrow signal abnormality of the visualized pelvis and right proximal femur (arrow), also believed to be consistent with osteonecrosis by imaging.
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Approximately 14 months after the initial presentation, the patient's abdominal CT also showed further progression of osteonecrosis involving both femoral heads (Figure 8).