Rheum Mimics: Bone Lesions & Neoplasms 1.5% Flashcards
A 10-year-old otherwise healthy male presents with severe leg pain at night that responds well to ibuprofen but not acetaminophen. XR and MRI results shown (Image from Petty 8th ed, ch. 47).
What is the diagnosis? What is the treatment? What is the prognosis?
Osteoid osteoma
XR reveals lytic lesion with surrounding sclerosis. MRI highlighting extensive bone and soft tissue reaction.
Treatment: CT-guided radiofrequency ablation or resection or long-term NSAIDs
Resolves spontaneously over years
A 15-year-old male presents with worsening, severe nighttime leg pain that responds to ibuprofen but not acetaminophen. CBC with diff and other labs normal. XR reveals a 25 mm lytic lesion with surrounding sclerosis of the femoral medullary bone.
What is the diagnosis?
Osteoblastoma
Histologically similar to osteoid osteoma but larger with a predilection for medullary bone, in older children.
A 16 year-old boy has painful swelling of his distal joints and soft tissues. The pain is all the time and wakes him up from sleep. Recently he has noticed that his fingers have changed their shape. He has had recent weight loss and night sweats. His x-ray is shown. Which of the following is his most likely underlying diagnosis?
Osteogenic sarcoma can metastasize to lungs and cause hypertrophic osteoarthropathy. Patient will have symmetric severe pain in distal extremities. Resection of pleural/lung lesion may result in dramatic resolution of symptoms.
Radiographs showing sclerotic lesion involving dia-metaphyseal region of the tibia with a wide zone of transition, osteoid matrix, periosteal elevation (Codman,s Triangle) and characteristic “ Sunburst “ type of periosteal reaction.
What disease should you think of if the Xray had these findings:
transverse lucent or opaque metaphyseal bands (Trummerfeld zones) with periosteal reaction and soft tissue swelling or edema.
metaphyseal beaking (pelkan spurs),
cortical thinning (pencil thin cortex),
epiphyseal ring with increased opacity (Wimberger sign)
periosteal elevation caused by subperiosteal hemorrhage
Scury (vitamin C deficiency)
The diagnosis of scurvy is made with low vitamin C levels (< 0.2 mg/dL [11 µmol/L]).
Vitamin C is responsible for collagen synthesis, and its deficiency results in a variety of manifestations. Skin findings include the presence of petechiae, bruising, or ecchymosis. Bleeding from gums may also be seen. Corkscrew appearance of hair follicles may be noted (Figure 2). Scurvy can mimic rheumatologic conditions because it may cause musculoskeletal pain leading to pseudoparalysis or refusal to ambulate. This pain can be caused by hemorrhage into the muscles or periosteum. Other systemic symptoms include malaise, fatigue, arthralgias, neuropathy, and impaired vasomotor response.
Radiographs of involved bones may show transverse lucent or opaque metaphyseal bands (Trummerfeld zones) with periosteal reaction and soft tissue swelling or edema. Other radiologic findings include metaphyseal beaking (pelkan spurs), cortical thinning (pencil thin cortex), epiphyseal ring with increased opacity (Wimberger sign), and periosteal elevation caused by subperiosteal hemorrhage
from PREP April 2019
What disease should you think of if
radiographs show wide and frayed epiphyses and rachitic metaphysis?
Rickets
Rickets is most commonly caused by a nutritional deficiency of vitamin D. However, other rarer causes include inadequate absorption of vitamin D, vitamin D–resistant and –dependant forms, and hypophosphatasia (low alkaline phosphatase level). Nutritional deficiency commonly presents with joint pain and bony tenderness.
A patient has irritability, alopecia, hyperostosis on imaging, and abnormal epiphyseal growth with periosteal new bone formation.
What are you worried about?
Hypervitaminosis A caused by excessive intake of vitamin A
Hypervitaminosis A is caused by excessive intake of vitamin A and can present with irritability, alopecia, hyperostosis on imaging, or abnormal epiphyseal growth with periosteal new bone formation.
