1996 1997 Robert R Brown Evelyne Fliszar Ingrid

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

Evelyne Fliszar • 47 yo female, shoulder pain post fall

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

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

47 yo female, shoulder pain post fall Bone marrow edema Effusion Malalignment High grade rotator cuff tear Osseous destruction Coronal T 2 w 11/05

47 yo female, shoulder pain post fall T 2 Axial FS and post IV contrast

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

47 yo female, shoulder pain post fall Sagittal T 2 w of cervical spine, 2002

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

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

34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial and sagittal T 2 w images: edema in iliopsoas muscle

34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial T 2 w image

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.

34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial T 2 w images: muscle edema in pectineus, sartorius and quadriceps

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 T 2 w FS

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

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 • •

Ingrid Kjellin Loma Linda University Medical Center, CA

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

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

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

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

PTLD Post-Transplant Lymphoproliferative Disorder • Associated with Epstein-Barr virus infection • Heterogeneous group of diseases after solid organ transplant • WHO classification: 1. Early (reactive plasmacytic hyperplasia) 2. Polymorphic PTLD 3. Monomorphic PTLD (lymphomas)

PTLD Post-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

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

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

59 M

59 M

Discussion • 1. 2. 3. 4. 5. 6. Differential diagnosis Pyomyositis Necrotizing fasciitis Ischemia Polymyositis Scleroderma Nephrogenic systemic sclerosis

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

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 211 weeks following double-dose iv gadodiamide AJR 2007: 188, February 2007

Nephrogenic Systemic Sclerosis (Nephrogenic Fibrosing Dermopathy)

Nephrogenic Systemic Sclerosis

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

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