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Case

Case. M/23 C.C. : 1 st MTP joint pain (1YA). 20070210 Foot AP/ sesamoid. 20061202 Outside CT (Rt. Foot). Radiologic findings-CT. Expansile osteolytic mass at medial sesamoid of hallux - with suspicious fracture lines -> DDx) 1. chondroblastoma or GCT 2. ABC

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Case

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  1. Case • M/23 • C.C. : 1st MTP joint pain (1YA)

  2. 20070210 Foot AP/ sesamoid

  3. 20061202 Outside CT (Rt. Foot)

  4. Radiologic findings-CT • Expansile osteolytic mass at medial sesamoid of hallux - with suspicious fracture lines -> DDx) 1. chondroblastoma or GCT 2. ABC 3. intraosseous gout • Rec) Rt foot MRI using microcoil

  5. T1 sagittal T1 coronal T1 sagittal (FS/Gd+) 20070220 Foot MRI (Rt.)_Contrast

  6. T1 axial T2 axial T1 axial (FS/Gd+) 20070220 Foot MRI (Rt.)_Contrast

  7. Radiologic findings-MRI • Expansile mass involving medial sesamoid of hallux - peripheral irregular thick enhancement and central nonenhancing cystic or necrotic area - with its associated synovial enhancement of lst MTP joint - with bony erosion at lst metatarsal neck c reactive bone marrow edema • vascular structures anterior to the mass • closely abutting flexor hallucis tendon ->DDx) 1. intraosseous gout,most likely 2. tbc 3. tumorous condition such as giant cell tumor or chondroblastoma

  8. Hospital course • Op: Excision of Sesamoid, Rt.(2007-02-26) • Pathologic diagnosis • Soft tissue, right foot, excision • 1. Numerous rhomboid crystals showing birefringence • 2. Some foci of calcium deposit • 3. Chronic granulomatous inflammation            with 1) multinucleated giant cells                  2) central hyaline degeneration consistent with calcium pyrophosphate dihydrate deposition disease 

  9. Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease • Etiology • Idiopathic: most common • Increased with age (7% of population near age 70 and 30-60% by the age 80) • Hereditary: autosomal dominant condition • Maybe associated with ANK(chromosome 5p15) • Secondary: 5-10% of patients have metabolic disease. • Hyperparathyroidism, Hemochromatosis, Hypophosphatasia… • Clinical patterns • Asymptomatic chondrocalcinosis • CPPD crystal arthropathy • Pseudogout (18%), pseudo-osteoarthritis with/without synovitis (40%/18%), pseudorheumatoid arthritis (8%) • Common location: Knee, wrist, MCP joint Seminars in musculoskeletal radiology 2003;07:175-186

  10. Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease • Diagnositic imagings • Conventional radiography • Calcification within or around joints • Chondrocalcinosis • Synovial and capsular calcifications • Other soft tissue calcification • Findings of pyrophosphate arthropathy • Bilateral, symmetrical involvement of affected articulations • Cartilage loss, subchondral plate sclerosis, subchondral cyst formation • Subchondral collpase, fragmentation, intra-articular loose body • MRI • Less dense calcium deposition->GRE sequence is more sensitive than conventional radiography. Seminars in musculoskeletal radiology 2003;07:175-186

  11. Seminars in musculoskeletal radiology 2003;07:175-186

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