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DISCUSS THE DIFFERENTIAL DIAGNOSIS AND POSSIBLE RADIOLOGICAL FINDINGS IN A 40YR OLD WOMAN WHO PRESENTS WITH ACUTE SWELLING OF THE ENTIRE LOWER LIMB
-INTRODUCTION OUTLINE -DIFFERENTIALS -CLINICO-PATHOLOGICAL FEATURES -COMPLICATIONS -IMAGING MODALITIES -MERITS & DEMERITS OF MODALITIES -RADIOLOGICAL FEATURES -INTERVENTION .
INTRODUCTION The lower limb is the region of the body that extends from the hip down to the feet.vascular lesions.and Lymphoedema. The emphasis is thus on the causes of acute swellings(swellings of rapid onset) that involve a significant aspect of the lower limb in a 40YR old FEMALE. .These causes may be from infections/inflammations.
DIFFERENTIALS 1.SOFT TISSUE INFECTIONS/INFLAMMATIONS -PYOMYOSITIS -CELLULITIS -NECROTIZING FASCITIS -DERMATOMYOSITIS -RHABDOMYOLYSIS .
VASCULAR LESION -DEEP VEIN THROMBOSIS -WET GANGRENE -ACUTE MUSCLE DENERVATION 3.LYMPHOEDEMA .2.
CLINICOPATHOLOGICAL FEATURES .
It is common in tropical countries.PYOMYOSITIS This is the inflammation of a muscle as a result of a bacterial or fungal Infection.carbuncles. .or infected sinuses that lie deep in the muscle.Staphylococcus aureus is the most Implicated cause.It may culminate to the formation of abscess.
COMPLICATIONS INCLUDE -OSTEOMYELITIS -ABSCESS -INFECTED SINUSES .
CELLULITIS It is the infection of the deep dermis of the skin commonly caused by b-hemolytic streptococci. COMPLICATIONS.LYMPHADENITIS .LYMPHANGITIS . It is most common in the lower limbs.
gm -.and commonly seen in diabetics. There is tissue necrosis and toxin production with large areas of destroyed & devitalized muscle & soft tissue.aerobic & anaerobic orgs.NECROTIZING FASCITIS Bacterial infection of the layer of fascia beneath the skin due to polymicrobial infection with a variety of gm +.alcohol/ . It occurs following minor cuts like insect bite.
-Indolent(1-21 days) before diagnosis -fever -drowsiness -diarrhoea -vomitting -crepitus(50%) -discolouration of the skin . Presentations include.The elderly are highly vulnerable.
scalp. DERMATOMYOSITIS .In the absence of this rash it is called POLYMYOSITIS. Associated with it is a bluish-red skin eruption which occurs on the face.It is an autoimmune inflammatory disorder of the Skin.and Knuckles .shoulders.subcutaneous tissues and striated mucles. The Inflammatory process is commonly non-suppurative.
bronchus.g Carcinoma of the breast.necrosis. Presentations include.stomach. -muscle weakness & aches(due to active inflammation.& Ovary. It is associated with malignancies e.It is more common in middle aged females(40- 60yrs) but a severe form is seen in children(515yrs).muscle atrophy with fatty replacement) – 1st symptom in 80% .
GI tract.Increased incidence of malignant neoplasms of the breast.ovary.Heliotrope rash(dusky eryrhema of the eyelids) with peri-orbital oedema.and kidney. Gottron sign=scaly eythematous papules at the knuckles.and upper body.prostate. lungs.major joints.-low grade fever -skin erythema. -elevated muscle enzymes -myositis specific auto-antibodies(anti-jo-1) COMPLICATIONS. .
iv heparin therapy. Causes include.trauma.viral infection.ischemia.severe exercise.toxin.autoimmune inflammation. .RHABDOMYOLYSIS It is an acute fulminant potentially fatal disease of skeletal muscle that entails destruction of muscles with loss of integrity of its cell membrane via infarction.burn.
COMPLICATIONS -RENAL FAILURE due to myoglobinaemia -COMPARTMENT SYNDRME .
It is most common within the Deep veins of the calf (posterior surface of the lower Leg) .DEEP VEIN THROMBOSIS This condition is associated with venous obstruction as a result of the sluggish flow of blood plus the changes in the clotting factors in the blood that increases the tendency to thrombus formation.There is no preceeding inflammation of the venous wall.
large fibroid. -Trauma & Surgery to the pelvis & lower limbs -prolonged immobilization .pregnancy. -Decreased cardiac function.birth control pills.diabetes.congestive cardiac failure.g.tamoxifen.post partum.The causes/risk factors are as follows.myocardial infarction -Female related. estrogen replacement therapy. -Patients on medications e.
-Age>40yrs -varicose veins -Polycythemia -Malignancy -Smoking -Patients with blood group A > blood group O Presentation include. -swelling(measurement of circumference) -warmth -Discolouration of the skin .
Pain on compressing the sole of a foot COMPLICATIONS -PULMONARY EMBOLISM -PHLEGMASIA ALBA DOLENS(severely impaired venous drainage resulting in gangrene) -POST-PHLEBITIC SYNDROME(recanalization to a small lumen. -Homans sign.-Deep crampy pain in the affected extremity.Calf pain with dorsal flexion of the foot -Payr`s sisgn.worse in the erect position and improves with walking.focal wall changes) due to incompetent valves. .
clostridium perfringens. .WET GANGRENE This is the death and putrefactive decay of part of the body due to cessation of blood supply coexis- ting with an infection by gas forming bacterium e.g.Diabetics are particularly prone to the infection.
The cause of this Denervation may be from stroke.ACUTE MUSCLE DENERVATION The loss of nerve supply to a muscle is associated with atrophy however in most cases fatty infiltration of muscle and oedema occur causing the Swelling of the affected limb. .
The primary type is due to Aplasia. hypoplasia or hyperplasia and is associated with syndromes like turner`s.lymphoedema tarda which ussually begins after 35yrs.klinefelter`s.congenital Lyphoedema.which appears at puberty.noonan`s.lyphoedema praecox.It has 3 subtypes.which appears shortly after birth. .LYMPHOEDEMA Lymphoedema is categorized as primary and second-ary.
making the entire limb oedematous.tuberculosis. .Secondary lymphoedema is an acquired condition resulting from obstruction to a previously normal lymphatic channels by metastasis. Lymphoedema of the lower limbs that involve the foot progresses upwards.parasites(FILARIAL WORMS).
ULTRASOUND SCAN -B-MODE.PLAIN RADIOGRAPHS -AP.IMAGING MODALITIES 1.VENOGRAPHY 5.DUPLEX DOPPLER 3.LYMPHOGRAPHY .LAT VIEWS OF THE AFFECTED LOWER LIMB.CXR 2.COLOUR DOPPLER.ANGIOGRAPHY 4.
RADIONUCLIDE IMAGING -99mTC-IN VITRO LABELLED PLATELETS -99mTC-NANOCOLLOIDS .6.CT SCAN + CONTRAST ENHANCEMENT 7.MRI -SE(T1 & T2 WEIGHTED) -GRADIENT RECALLED ACQUISITION IN STEADY STATE(GRASS) 8.
ULTRASOUND SCAN MERITS 1.Non invasive & convenient especially when the patient is uncomfortable 2.subcutaneous layer.skin) .It is cheap and readily available 3.Ability to demonstrate and diferentiate soft tissues(muscles.Non-ionizing 4.tendons.
Used for interventional procedures such as drainage and image guided biopsy. 7.Dynamic assessment of the vascular anatomy and physiology using B-mode and Duplex doppler 6.5.Can be used for staging of soft tissue tumour .
Marked operator dependence 2.DRAW-BACKS 1.Large and obese individuals coupled with intra abdominal gas may result in sub-optimal images 3Associated bony lesions can not be demonstred .
oblitera tion of fat planes(acute.Can show calcification of soft tissues.PLAIN RADIOGRAPH 1.active inflammation).Readily available and cheap 2.chest and skull involvement . bony metastasis.
Utilizes ionizing radiation( It is an issue with pregnancy) 2.Poor soft tissue contrast and spatial resolution .DRAW BACK 1.
The extent of local or distant spread or involvement can assessed 3.CT SCAN 1.Used in staging malignancies 4.Helical CT to reduce motion artifacts .Qualitative and quatitative assessment of lesions in the soft tissue of the affected limb 2.Employs iv contrast for opacification of the blood vessels and increase lesion conspicuity 5.
DRAW BACKS 1. .Uses ionizing radiation(It is an issue with pregnancy) 3.Inaccurate history of allergy or multiple drug reaction when there is need for contrast.Expensive and not widely available 2.
.Lesions in the vasculature can be determined and interventional procedures performed immediately or subsequently.ANGIOGRAPHY 1.Can demonstrate neo-vascularization in masses 2.
3.Highly invasive 2.DRAW BACKS 1.Uses ionizing radiation(except in MRA).Allergy and multiple drug reactions .
2.Helps in assessing the maturity of ectopic ossification(whether stable )prior to surgical excision. .RADIONUCLIDE IMAGING 1.Dermatomyositis.Soft tissue anomalies with propensity to develop mineralization can show ectopic activity on skeletal scintigraphy e.Myositis ossificans etc.Neoplasia.g.
DRAW BACKS 1.Ionizing radiation .Very expensive and rarely available 2.
-Used for follow-up imaging of nodal diseases as the contrast persists in the nodes for up to 6-12months .LYMPHOGRAPHY -Lymphography directly studies the lymphatic ducts and the internal architecture of the nodes.
DRAW BACK -False positive results are frequent occurrence -The procedure predisposes to oil embolism -It is very invasive -Ionizing radiation .
Contrast enhancement using iv contrast can help in differentiating soft tissue lesions 4.Non-ionizing 2.MRI 1.It is the best technique for follow-up .Provides excellent soft tissue contrast and spatial resolution and has multiplanar capabilities 3.
5.INTERVENTIONAL PROCEDURES Biopsies and Drainage procedures can be carried out. .
Very expensive and rarely available 2.Patients with medical prosthesis unless it is MRI compatible 5.Obese individuals 6.DRAW BACKS 1.Claustrophobic patients 4.Orthopneic congestive cardiac failure patients .Long image acquisition time 3.
RADIOLOGICAL FEATURES .1.in DVT there is also soft tissue swelling.PLAIN RADIOGRAPH Soft tissue swelling with the obliteration of fat plane is seen in infections and inflammation.In necrotizing fascitis gas is seen within the soft tissue swelling.
.cysticercosisi.The differentials here include.dracunculosis.Myositis ossificans.tendon calcifications.hydatid disease.c.vascular calcifications.Scleroderma.t.loia sis. in addition to the bilateral and symmetrical soft tissue swelling there are sheet-like calcifications along fascial and muscle planes.armillifer armilatus.leprosy.e.In dermatomyositis.
Venous diameter at least twice that of the adjacent artery suggests a thrombus<10days.In DVT there might be visualization of the clot or thrombus within the vein but the incomplete luminal collapse following venous compression is an important pointer to it..while in cellulitis the sonolucent lesion is anterior to the muscles. ULTRASOUND .B-MODE US Hypoechoic/sonolucent lesion present within the muscle with or without probe tenderness is suggestive of pyomyositis.
In Rhabdomyolysis there are areas of reduced echogenicity and nonhomogenous muscle texture. .In DVT there is reduced or absent colour signal or blood flow or a trickle of blood flow around a thrombus.COLOUR DOPPLER There is a peripheral rim pattern of blood flow seen in pyomyositis. .
.femoral veins.VENOGRAPHY Intraluminal filling defects( tram-line appearance) are noted.They are constant in all the images that show the calf veins.These are the contrast venographic findings in DVT.communicating veins.and iliac veins.
LYMPHOGRAPHY There is obliteration of lymphatic channels due to intraluminal coagulum gel deposition/reactive inflammation Filling defects may also be present .
heterogenous attenuation of the enlarged soft tissues with fluid collection(exudate. .Rim enhancement following iv contrast administration is typical.CT SCAN In infections. gas may be seen along thickened fascial planes with deep fluid collections. or hemorrhage).In Necrotizing fascitis.
Infections and inflammations invariably show high signal intensity on T2WI and low/intermediate intensity on T1WI.Peripheral enhancement with Gadollinium occurs. MRI SCAN .Fascial thickening(NECROTIZING FASCITIS) is best demonstrated using this modality.
99m-Technetium labelled nanocolloid show lymphatic uptake and trapping RADIONUCLIDE IMAGING .It is usefull for demonstrating thrombus in DVT using 99mTechnitium labelled platelets.
INTERVENTIONAL PROCEDURES 1.vasodilators in gangrene.e.ANGIOGRAPHY -Therapeutic embolization of malignancies -Vascular access allows the introduction of drugs directly to the site of the pathology.g. .cytotoxic drugs in malignancy.Fibrinolytic drugs in DVT.
2.Some of the angiographic interventional procedures involve this modality.ULTRASOUND SCAN -Ultrasound guided drainage in the case of pyomyositis and also biopsy can be done.CT SCAN CT guided biopsy . 3.-Percutaneous transluminal angioplasty can be used to treat gangrene -vena caval filters can be introduced.
4.MRI SCAN -Biopsy -Guidance of open surgery .
Multiple abscess following pyomyositis.Hy perintense on T2WI and rim enhancement on contrast administration .
Pyomyositis Soft tissue swelling hyperintens en on T2WI .
AND FASCITIS ON T2WI .CELLULIT IS.PYOMYOSIT IS.
CT SCAN A CENTRAL LOW ATTENUAT ING COLLECTI ON WITH ILL DEFINED RIM ENHANCE MENT .
NECROTIZING FASCITIS/GAS GRANGRENE Swelling of the left thigh with gas present .
NECROTIZING FASCITIS/GAS GANGRENE .
Fascial thickening on T1WI & T2WI .
NECROTIZING FASCITIS/GAS GANGRENE(CT SCAN) .
NEROTIZIN G FASCITIS/G AS GANGRENE Gas present in soft tissue swelling
PYOMYOSITIS Transverse ultrasound with doppler showing marked vascularity surrounding an anechoic collection in the thigh(abscess)
CELLULITIS Hypoechoic strands surroundin g hyperechoi c fat
DERMATO MYOSITIS Swelling and sheetlike calcificatio n .
PICTURE OF THE SKIN LESION AND PLAIN RADIOGRA PH OF THE SAME MAN .
INDICATING INTRALUMINAL THROMBUS.THE VEIN DOES NOT COMPRESS WITH TRANSDUCER PRESSURE.ENLARGEMENT OF THE CFV WITH INTRALUMINAL THROMBUS. B.TRANSVERSE POWER DOPPLER IMAGE WITH TRANSDUCER COMPRESSION APPLIED SHOWS FLOW IN THE FEMORAL ARTERY(A) AND NO FLOW IN THE FEMORAL VEIN(V.DEEP VENOUS THROMBOSIS A.ARROW). .
DVT Venography which shows filling defects and irregularitie s in the femoral vein .
Increased signal intensity in the edematous left leg of a patient with lymphoede ma .
Post inflammatory lymphedema of both limbs .
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