CASE 132

By: Dr. Nizar Al-Nakshabandi MD, FRCPC

HISTORY: 35-year-old female with left shoulder pain, and high white blood cell count.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

The AP radiograph of the left shoulder [A] show subtle tiny lucencies in the epiphysis of the humeral head.

Axial T1 weighted sequence [B] demonstrates an infiltrative process in the humeral head of low signal intensity.

Axial T1 post gadolinium enhancement [C] demonstrates avid enhancement of these areas of low signal intensity seen on the axial T1-weighted images. The coronal T1 fat sat with gadolinium enhancement [D] demonstrates soft tissue enhancement beyond the confines of the bone extending into the deltoid muscle.

DIFFERENTIAL DIAGNOSIS:

·        Bone leukemia.

·        Bone lymphoma.

·        Myelofibrosis.

·        Polycythemia vera.

DIAGNOSIS:

Bone leukemia of the proximal humerus.

PEARLS AND DISCUSSION:

In bone leukemia, as other infiltrative processes of the bone, it is possible to see diffuse hypointensity of the bone structures on T1 which will enhance following gadolinium administration. Look for splenomegaly and hepatomegaly on CT or ultrasound. Also, look for lymphadenopathy.

Most patients will be asymptomatic, and incidentally detected on routine blood work up. Other findings are of hepatomegaly, splenomegaly, or hemolytic anemia.

Diagnosis in this case was made by marrow biopsy. In this case, it was obtained from the humeral head itself.

FURTHER READING:

1.      Al-Tubaikh JA. Internal Medicine, An Illustrated Radiological Guide. Springer Verlag. (2010) ISBN:3642037089.

2.      Osborn A, Blaser S, Salzman K. Encyclopedia of Diagnostic Imaging. AMIRSYS. (2008) ISBN:0721629059..

3.      Guermazi A, Abdelwahab IF. Radiological Imaging in Hematological Malignancies. Springer Verlag. (2004) ISBN:3540439994.