486 Letters to the editor / Joint Bone Spine 77 (2010) 482–491

Table 1
Blood chemical values during a 5-year follow-up.

Parameter RL 11/04 05/05 03/07 10/07 01/08 05/08 03/09 05/09 10/09

Steroid in mg 0 2.5§ 2.5§ 0 0 0 40$ 10$ 4$

AZT in mg 0 0 0 0 0 0 100 50# 0
BSR < 10/< 20 mm/ 93/115 75/104 61/92 77/101 49/80 52/77 108/128 na na
CK 172U/L 749 na 432 160 135 169 4569 62 953
Sodium 132–146mmol/L 130 na 136 132 136 143 127 136 137
␥-globulins 10–19% 29.9 na na 24.8 23.8 20.5 28.5 na 27.6
Eos 1–4% 1.4 na na 10.1 15.1 11.1 0.4 2.1 na
LYC 20–40% 16.7 na na 32.6 na na 17.0 26.7 na
HbA1c < 6% 7.2 7.2 7.8 7.9 7.7 na 8.1 8.4 na

RL: reference limits, Steroid: steroid dosage, AZT: azathioprin dosage, BSR: blood sedimentation rate, CK: creatine-kinase, Eos: eosinophils, LYC: lymphocyte count, §:
prednisolone, $: methyl-prednisolone started in 2/09 at a dosage of 80 mg, na: not available, #: AZT was discontinued after 3 months because of elevated liver function
parameters.

References

[1] Kocaaga Z, Bal S, Turan Y, et al. Camptocormia and dropped head syndrome as
a clinic picture of myotonic myopathy. Joint Bone Spine 2008;75:730–3.
[2] Leano AM, Miller K, White AC. Chronic graft-versus-host disease-related
polymyositis as a cause of respiratory failure following allogeneic bone marrow
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[3] Slobodin G, Rozenbaum M, Weller B, et al. Dropped head: an unusual presen-
tation of dermatomyositis. J Rheumatol 2005;32:1174–5.
[4] Kastrup A, Gdynia HJ, Nägele T, et al. Dropped-head syndrome due to steroid
responsive focal myositis: a case report and review of the literature. J Neurol
Sci 2008;267:162–5.
[5] Gaeta M, Mazziotti S, Toscano A, et al. Dropped-head” syndrome due to
isolated myositis of neck extensor muscles: MRI findings. Skeletal Radiol
2006;35:110–2.
[6] Bahnof R. The dropped head syndrome: rehabilitation of cervical focal myositis.
Disabil Rehabil 1999;21:563–5.
[7] Biran I, Cohen O, Diment J, et al. Focal, steroid responsive myositis causing
Fig. 1. Presented patient with dropped head syndrome due to polymyositis before dropped head syndrome. Muscle Nerve 1999;22:769–71.
(left panel) and 2 months after re-starting steroids (right panel). [8] Dalakas MC, Hohlfeld R. Polymyositis and dermatomyositis. Lancet
2003;362:971–82.
[9] Finsterer J. Dropped head syndrome in mitochondriopathy. Eur Spine J
myocardial thickening. Cerebral CT showed basal ganglia calcifi- 2004;13:652–6.
cation bilaterally, discrete diffuse atrophy, and lacunas. Cerebral [10] Rahim F, Gupta D, Bertorini TE, et al. Dropped head presentation of mitochon-
drial myopathy. J Clin Neuromuscul Dis 2003;5:108–14.
MRI revealed multiple glial spots exclusively. MRI of the cervical
spine was normal.
Josef Finsterer ∗
Since DHS was attributed to a relapse of PM, methyl-
Krankenanstalt Rudolfstiftung, Postfach 20,
prednisolone (80 mg/d) was restarted. Additionally, azathioprin
1180 Vienna, Austria
(100 mg/d) was given. Under this regimen, DHS improved by
60–70% within 2 months. Methyl-prednisolone was tapered down
Marlies Frank
to 4 mg within 8 months. Azathioprin had to be discontinued
Elisabeth Krexner
after 3 months because of hepatopathy. At the last follow-up,
First Medical Department, Krankenanstalt
8 months after re-starting steroids, his neurological condition was
Rudolfstiftung, Vienna, Austria
unchanged.
Arguments for a causative role of PM are that DHS has been ∗ Corresponding author. Tel.: +43 1 71165 92085;
previously described in PM [2], dermatomyositis [3], and as focal
fax: +43 1 4781711.
myositis of the extensor neck muscles [4,5,6,7,8], and that DHS
E-mail address: fifigs1@yahoo.de
responded well to steroids. Arguments for a mitochondrial disorder
(J. Finsterer).
(MID) are that there was basal ganglia calcification, hypoacu-
sia, diabetes, short stature, osteoporosis, recurrent hyponatremia,
10 February 2010
hyperlipidemia, myocardial thickening despite normal blood pres-
sure and short stature and hypoacusis in his mother, albinism, Available online18 May 2010
visual impairment, nystagmus and hypothyroidism in his daugh- doi:10.1016/j.jbspin.2010.02.028
ter, and that MID has been previously reported to cause DHS
[9,10]. Steroid-myopathy was excluded since DHS improved Unusual foreign body granuloma (gauzoma) found 46 years
under steroids and since DHS developed without taking steroids. after open reduction and fixation surgery for femoral shaft frac-
Chemotherapy was excluded for the long interval between ture
chemotherapy and occurrence of DHS. The most likely cause of DHS
in the presented patient is involvement of the neck extensor mus- Keywords:
Gauzoma
cles in PM, although the clinical picture additionally suggests an Foreign body granuloma
underlying MID. Soft tissue tumor
This case shows that DHS may be a feature of PM and responds
favorable to steroids.

Foreign body granuloma caused by retained surgical gauze

Conflict of interest statement
is synonymously described as gossypiboma, cottonballoma, tex-
There are no conflicts of interest tiloma or gauzoma [1,2]. Such granulomas are rarely in the soft
 Letters to the editor / Joint Bone Spine 77 (2010) 482–491 487

in the center of the mass, showing a ring-shaped appearance

Fig. 1. (a) Anteroposterior radiograph showed bony fusion with deformation after
femoral shaft fracture and a slightly osteolytic lesion (scalloping) of the left femur
(arrows). (b) A transaxial high-resolution CT following contrast administration
showed a soft tissue mass with low density in the left adductor muscle and erosive
femoral cortical bone without destructive or invasive changes. (c) A T2-weighted
transaxial MR image showed admixture of high- and low-signal mass in the left
adductor muscle. (d) A T2-weighted sagittal MR image showed a heterogeneous
and high- to low-signal intensity mass in the center of the left thigh. (e) 18 FDG-PET
showed a slightly round ring-like shaped uptake in the medial side of the left thigh.
[8].
Pathologically, there are two types of foreign body reactions.
One is an aseptic fibrinous reaction that results in adhesion and
encapsulation, with the ultimate formation of a foreign-body gran-
uloma in an otherwise asymptomatic patient. The other variety of
response is an exudative reaction leading to abscess formation or
fluid collection [6,8]. One previous report also described sarcoma-
tous changes in gauzoma after a period of retention exceeding 20
years [2].
Even in the modern era, one should be aware of retained surgi-
cal gauzes at previously operated sites that might cause tumor-like
granuloma with extensive tissue damage in the vicinity of the
retained material.
Conflict of interest statement
The authors declare no conflict of interest.
Appendix A. Supplementary material

Supplementary material (Fig. S1) associated with this article can

be found, in the online version, at doi:10.1016/j.jbspin.2010.02.015.
tissues of the musculoskeletal system probably due to the lack of
space available in the regions [3,4]. References
A 66-year-old man noticed a painless soft tissue mass on
the medial side of the left thigh. The past history included [1] Chambi I, Tasker RR, Gentili F, et al. Gauze-induced granuloma (“gauzoma”): an
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open reduction and external traction for a comminuted proximal
surg 1990;72:163–70.
femoral shaft fracture at the age of 20, which were conducted [2] Sakayama K, Fujibuchi T, Sugawara Y, et al. A 40-year-old gossypiboma (foreign
at another hospital. A plain radiograph (Fig. 1a) showed a pic- body granuloma) mimicking a malignant femoral surface tumor. Skeletal Radiol
ture of “deformed union” of the proximal femoral shaft without 2005;34:221–4.
[3] Kominami M, Fujikawa A, Tamura T, et al. Retained surgical sponge in the
bony or cortical erosion or periosteal reaction. A high-resolution thigh: report of the third known case in the limb. Radiat Med 2003;21:
transaxial CT scan (Fig. 1b) showed a low-density round tumor- 220–2.
ous mass without contrast enhancement. MRIs showed the mass [4] Nakamura T, Kusuzaki K, Matsubara T, et al. Foreign-body granulomas in the
trunk and extremities may simulate malignant soft tissue tumors: report of three
was predominantly of low signal intensity on T1-weighted images cases. Acta Radiol 2008;49:80–3.
and admixture of high and low signal intensity on T2-weighted [5] Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments
images (Fig. 1c, d). 18 F-fluorodeoxyglucose (FDG)-positron emis- and sponges after surgery. N Engl J Med 2003;348:229–35.
[6] Zbar AP, Agrawal A, Saeed IT, et al. Gossypiboma revisited: a case report and
sion tomography (PET) (Fig. 1e) showed strong FDG uptake at the review of the literature. J R Coll Surg Edinb 1998;43:417–8.
periphery without FDG utilization in the middle portion of the [7] Aydogan M, Mirzanli C, Ganiyusufogle K, et al. A 13-year-old textiloma (gossyp-
mass. iboma) after discectomy for lumbar disc herniation: a case report and review of
the literature. Spine J 2007;7:618–21.
Histopathological examination of an open biopsy excluded
[8] Nakajo M, Jinnouchi S, Tateno R, et al. 18F-FDG PET/CT findings of a right sub-
hematoma, fibromatosis, schwannoma, malignant fibrous phrenic foreign-body granuloma. Ann Nucl Med 2006;20:553–6.
histiocytoma and other malignancies. Marginal excision dis- [9] Lo CP, Hsu CC, Chang TH. Gossypiboma of the leg: MR imaging characteristics. A
case report. Korean J Radiol 2003;4:191–3.
closed the lesion as necrotized granuloma around sheets of
gauze. Histopathological examination (Fig. S1; see the Sup-
plementary Material associated with this article online) Kenzo Uchida
revealed that the mass contained necrotic tissue with a Hideaki Nakajima ∗
mixture of fibrous tissue, lymphocytes, and foreign body Takafumi Yayama
giant cells clustered around barely perceptible foreign mate- Takayuki Hirai
rial. Kebing Chen
Gawande et al. [5] used multivariate analysis to determine the Alexander Rodriguez Guerrero
factors associated with a significantly increased risk of retention of Hisatoshi Baba
a foreign body during surgery. Their results showed that emergency Department of Orthopaedics and Rehabilitation
surgery, unplanned change in the operation, and body-mass index Medicine, Fukui University Faculty of Medical
were significant risk factors [5]. Sciences, Matsuoka-Shimoaizuki 23-3, Eiheiji, Fukui
Retained surgical gauzes could be suspected by ultrasonog- 910-1193, Japan
raphy in the presence of bright echogenic wavy structures in a ∗ Corresponding
cystic mass [6]. On CT scan, the typical feature is a spongiform author. Tel.: +81 776 61 8383;
pattern formed by gas bubbles or an inhomogeneous dense mass, fax: +81 776 61 8125.
low-density mass with a high-density fine capsule containing the E-mail address: nhideaki@u-fukui.ac.jp
contrast material [7,8]. In MR images, the wavy, low-signal inten- (H. Nakajima).
sity stripes seen on T2 weighted image, which represent gauze
fibers, are not apparent in other soft tissue tumors and could 10 February 2010
be characteristic of gauzoma [7,9]. 18 FDG-PET images showed Available online15 May 2010
intense FDG uptake in the hypodense rim and little FDG uptake doi:10.1016/j.jbspin.2010.02.015