1996-1997

1. 1996-1997 • Robert R. Brown • Evelyne Fliszar • Ingrid Kjellin • Sandy Kwak • Khanh Nguyen • Thomas Rand • Joong-Mo Ahn,

2. Evelyne Fliszar • 47 yo female, shoulder pain post fall

3. 47 yo female, shoulder pain post fall Initial radiographs 9/05

4. 47 yo female, shoulder pain post fall 6 weeks later, 11/05

5. 47 yo female, shoulder pain post fall Bone marrow edema Effusion Malalignment High grade rotator cuff tear Osseous destruction Coronal T2 w 11/05

6. 47 yo female, shoulder pain post fall T2 Axial FS and post IV contrast

7. 47 yo female, shoulder pain post fall • Joint aspiration was negative for infection

8. 47 yo female, shoulder pain post fall Sagittal T2w of cervical spine, 2002

9. 47 yo female, shoulder pain post fall • Final Diagnosis • Neuropathic joint :

10. Evelyne Fliszar • 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture.

11. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial and sagittal T2w images: edema in iliopsoas muscle

12. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial T2w image

13. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. • 8 weeks following trauma, repeat MRI because of severe weakness in quadriceps muscle.

14. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial T2w images: muscle edema in pectineus, sartorius and quadriceps

15. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. 8 weeks following trauma, severe weakness in quadriceps: Axial T2w FS

16. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. • FINAL DIAGNOSIS • Femoral nerve injury with denervation muscle edema

17. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. • Other causes of femoral nerve injury: • Following iliopsoas hematoma • Fracture of the acetabulum • Surgery

18. Ingrid Kjellin Loma Linda University Medical Center, CA

20. Ingrid Kjellin • 7 year-old female with a left thigh mass. History of cardiac transplantation in infancy.

21. 7 year-old female with a left thigh mass. History of cardiac transplantation in infancy.

22. 7 year-old female with a left thigh mass. History of cardiac transplantation in infancy.

23. 7 year-old female with a left thigh mass. History of cardiac transplantation in infancy. PET

24. PTLDPost-Transplant Lymphoproliferative Disorder • Associated with Epstein-Barr virus infection • Heterogeneous group of diseases after solid organ transplant • WHO classification: • Early (reactive plasmacytic hyperplasia) • Polymorphic PTLD • Monomorphic PTLD (lymphomas)

25. PTLDPost-Transplant Lymphoproliferative Disorder • Related to degree and duration of immunosuppression, type of organ transplanted, CMV status • Fever, adenopathy • Extranodal disease in >2/3 of cases (muscle involvement extremely rare) • Excisional biopsy, multiple core needle biopsies, bone marrow biopsy, CT chest/abd/pelvis • Rx: Reduction of immunosuppression, antiviral, anti-B-lymphocyte antibodies (rituximab), interferon, chemotherapy • Reported rates of cure/survival variable because of heterogeneity of disease

26. PTLD • Differential: Smooth muscle neoplasms (leiomyoma, leiomyosarcoma) increased incidence in immunocompromised

28. Ingrid Kjellin • 59 year-old male with chronic renal failure, diabetes and hypertension. Recent left thigh pain and swelling. Had recent abdominal MRI/MRA

29. 59M

30. 59M

31. Discussion • Differential diagnosis • Pyomyositis • Necrotizing fasciitis • Ischemia • Polymyositis • Scleroderma • Nephrogenic systemic sclerosis

32. Nephrogenic Systemic Sclerosis(Nephrogenic Fibrosing Dermopathy) • Rare multisystemic disorder in patients with renal insufficiency first described in 1997 (200 cases reported to ICNFDR) • Unknown etiology • IV gadolinium may serve as a trigger in the setting of acute hepatorenal syndrome or dialysis-dependent chronic renal insufficiency • Skin induration of extremities and trunk • Myalgia, weakness • Skin biopsy: proliferation of fibroblasts adjacent to collagen bundles and absence of inflammatory cells

33. Nephrogenic Systemic Sclerosis(Nephrogenic Fibrosing Dermopathy) • Systemic fibrosis with involvement of the skeletal muscle, bone, pleura, pericardium, myocardium, kidney, testes, dura • At LLUMC 12 patients 2000-2006 • Skin fibrosis and joint contractures within 2-11 weeks following double-dose iv gadodiamide AJR 2007: 188, February 2007

34. Nephrogenic Systemic Sclerosis(Nephrogenic Fibrosing Dermopathy)

35. Nephrogenic Systemic Sclerosis

36. Neprogenic Systemic Sclerosis • Long term outcome: Severe inability to ambulate due to contractures and myopathy, cane required for ambulation, no disability. Skin changes persist. • Plasmapheresis may have some effect. Dialysis probably of no help. • FDA issued a public health advisory in June 2006 with regards to high-dose gadolinium-containing agents in patients with renal failure • At LLUMC: no iv gadodiamide in acute renal failure, hepatorenal syndrome, dialysis patients or ESRD with creatinine clearance of <15 ml/min, no double/triple dose

37. Neprogenic Systemic Sclerosis • Screen patients with serum creatinine and calculated creatinine clearance prior to MRI with contrast if history of kidney disease, diabetes, or >60 y.o