Ethnic variation in certain hematological and biochemical reference intervals in a south Indian healthy adult population

BACKGROUND

We established the biochemical and hematological reference intervals among a south Indian healthy adult population attending an HIV referral centre in Chennai, southern India.

METHODS

In a cross sectional study, 213 study subjects (129 male and 84 female) were studied between March and August 2005. All of the parameters were analyzed using standard hematological and biochemical techniques.

RESULTS

Certain biochemical (viz. total bilirubin, alanine transaminase, albumin, creatinine, total protein, lipid profile, creatine phosphokinase, uric acid and lactate) and hematological (mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration and lymphocyte levels) parameters presented higher upper limits. In addition, the upper limits of white blood cell count, platelet count, hematocrit, red blood cell count and hemoglobin level were low in comparison to the currently reported ranges.

CONCLUSION

Ethnic variation in reference intervals was observed in certain biochemical and hematological analytes in a south Indian adult population.

Intraosseous myelolipoma

Two patients with lesions in the acetabulum and femur, evident on imaging, were found to have normal marrow elements without a histopathological lesion on curettage of the acetabulum and resection of the femur, respectively. Radiographs on the first patient showed a sclerotic benign appearing acetabular lesion reminiscent of a fibro-osseous lesion while MRI showed the entire lesion to contain fat. The histological features were neither of a fibro-osseous lesion nor a lipoma, but only normal to mildly hypercellular marrow elements. The second patient had a long and expansive femoral osteolytic lesion which on biopsy showed cellular marrow. A subsequent stress fracture led to resection and prosthetic replacement. Microscopic findings revealed only cellular hematopoietic marrow with mature red and white cell lines, megakaryocytes, and a few mast cells devoid of trabecular bones. The microscopic features in the first patient raised the possibility of hematopoietic hyperplasia. Neither the radiographic nor MRI features were consistent with that diagnosis. The spectrum of imaging findings and microscopic appearances in both patients best fit the diagnosis of intraosseous myelolipoma.

Extensive hematoma of the vastus intermedius showing components of subacute and chronic hemorrhage with associated myositis of the vastus intermedius and medialis

The MRI appearance of hematomas is variable and depends on the age of the hematoma. Subacute to chronic hematomas demonstrate increased signal on T1-weighted images, placing them on a short list of entities that may demonstrate this imaging characteristic, namely fatty lesions, hemangioma, hematoma and intralesional hemorrhage. Distinguishing a simple soft tissue hematoma from a hemorrhagic neoplasm is critical for proper patient management, but is often difficult. Our patient's presenting history and imaging findings were characteristic of hematoma, and our patient was managed nonoperatively, and discharged after being observed in the hospital for 48 hours. When imaging is inconclusive, or clinical history equivocal, it is important to exclude an underlying hemorrhagic soft tissue sarcoma, by follow-up to resolution.

Comparison of MR arthrography with arthroscopy of the hip for the assessment of intra-articular loose bodies

OBJECTIVE

To assess the specificity and sensitivity of MR arthrography of the hip in comparison with arthroscopy for the evaluation of intra-articular loose bodies.

DESIGN

Over a 3-year period, 81 consecutive patients underwent a total of 82 hip arthroscopies by a single orthopedic surgeon for intractable hip pain. Of the 82 arthroscopies, 70 had pre-operative MR arthrograms. Of these, 57 were available for retrospective review, after which they were compared with the operative notes of the subsequent arthroscopies.

RESULTS

Of 82 arthroscopies 16 (20%) demonstrated intra-articular loose bodies, while, in the study group, nine of 57 had loose bodies (16%). There was a total of seven discordant cases (five false negatives and two false positives). The sensitivity of MR arthrography for detection of intra-articular loose bodies was 44%, while the specificity was 96%.

CONCLUSION

While the specificity of MR arthrography for the detection of intra-articular loose bodies was high (96%), the sensitivity was not nearly as good (44%).

Osteochondroma with large bursa clinically mimicking malignant transformation

Osteochondroma is a common benign entity. However, symptomatic complications may arise that raise the question of malignant degeneration. Bursa formation about an osteochondroma may clinically and symptomatically mimic malignant degeneration. Magnetic resonance imaging usually permits unequivocal diagnosis distinguishing between secondary bursitis and malignant degeneration. Secondary bursitis can most often be managed conservatively. Magnetic resonance imaging also can differentiate other less common benign complications such as pseudoaneurysm formation caused by the exostosis and fracture at the base of the exostosis.

Morel-Lavallee lesion

Morel-Lavallee lesions, or closed internal degloving injuries, are most common in the subcutaneous tissues of the proximal thigh and trochanter. Bilateral lesions are rare. These post-traumatic fluid collections can be isolated or associated with concomitant pelvic fractures. Morel-Lavallee lesions may present as a pseudotumor when not recognized in the early post-traumatic period. Magnetic resonance imaging is the modality of choice in the evaluation of Morel-Lavallee lesions. The identification of a capsule on MRI can have important management implications.

A 20-year retrospective review of surgically treated liposarcoma at the Cleveland Clinic

The records of 63 patients surgically treated for liposarcoma at the Cleveland Clinic between 1975 and 1995 were examined. Both metastatic disease (Enneking stage IIl) and an abdominal location were found to be poor prognosticants for survival. Age, gender, or tumor size, setting, or grade did not have any prognostic significance. The 5-year disease-specific survival for extremity tumors was 92% (95% confidence interval [CI]; range: 84%-100%), while general 5-year survival for extremity tumors was 66% (95% Cl; range: 48%-85%).

Osteoblastomatosis of bone. A benign, multifocal osteoblastic lesion, distinct from osteoid osteoma and osteoblastoma, radiologically simulating a vascular tumor

Two adult patients are described with multifocal osteolytic lesions radiologically simulating a vascular tumor. One patient had multiple bones involved. Histologically, the individual lesions had the features of the nidus of osteoid osteoma/osteoblastoma. A review of the English language medical literature yielded only one other reported case with similar features. The process is designated as osteoblastomatosis to indicate its bone-forming character, prominent osteoblast proliferation, and multiplicity. The cases are distinguished from multifocal/multicentric osteoid osteoma and osteoblastoma, and from benign and malignant vascular tumors.

Spondyloarthropathy presenting at a young age: case report and review

The diagnosis of juvenile spondyloarthritis (JSA) is rarely entertained in young children who present with back and leg pain. We present a case of a 6-year-old male who presented with a 3-year history of severe back and leg pain and a positive Gower's sign, and was given a presumed diagnosis of muscular dystrophy. Presenting serologic evaluation included a mildly elevated sedimentation rate and C-reactive protein (CRP). Computed tomography of the pelvis demonstrated large erosions affecting both sacro-iliac joints. Despite the unusually young age of this patient, ankylosing spondylitis seemed the most plausible diagnosis. Following rheumatological evaluation and treatment for JSA, he showed significant clinical improvement. His disease, however, has not entirely remitted with signs of enthesitis at the Achilles tendon and knees. We present this case to illustrate that JSA could account for symptoms at an early age and not considering it could lead to multiple medical visits and diagnoses. To our knowledge, based on a search of the World literature, this would appear to be the youngest case of JSA reported with demonstrable severe sacroiliitis.

Decubital Ischemic Fasciitis: Clinical, Pathologic, and MRI Features of Pseudosarcoma

OBJECTIVE

The purpose of this report is to describe clinical, pathologic, and MRI findings on decubital ischemic fasciitis, which is a rare soft-tissue tumor sarcoma simulator.

CONCLUSION

Decubital ischemic fasciitis is a reactive, nonneoplastic lesion typically seen in older debilitated patients at pressure points. Because this lesion simulates soft-tissue sarcoma, both clinically and histologically, it is important to recognize the MRI features and limit misdiagnosis of sarcoma.

Quality of life, health status and clinical outcomes in Type 2 diabetes patients

This study examines relationships between patient reported outcomes (PROs) and clinical outcomes in Type 2 diabetes mellitus (T2DM). Patients at the outpatient clinics of a university hospital completed measures of generic health status (SF-12), diabetes-specific quality of life (Audit of Diabetes Dependent Quality of Life - ADDQoL), and depressive symptoms (Center for Epidemiologic Studies Depression - CES-D). Patient reported data were merged with a retrospective collection of clinical and utilization data, including HbA1C, from electronic medical records. A Charlson comorbidity score, diabetes complications score, BMI, and total number of ER and hospital visits were calculated. Usable response rate was 44.3% (n = 385). Patients were dichotomized into glycemic control levels based on the ADA recommended A1C level < 7.0, vs. >or= 7.0. The ADDQoL, PCS-12, and MCS-12 scores were separately examined as dependent variables using hierarchical regression models, with glycemic control as the primary explanatory variable, and controlling for demographics and clinical variables including comorbidities and complications. Glycemic control was not a significant predictor in any regression model. Obesity was a significant predictor leading to poorer PCS-12 and MCS-12 scores, while depressive symptoms significantly resulted in lower PCS-12, MCS-12 and ADDQoL scores. These and other factors related to self-management behaviors may contribute to a greater understanding of how to intervene with patients with T2DM. The use of such PROs alongside biomedical measures such as A1C is recommended.

Knee dislocation

Knee dislocations are relatively uncommon. However, due to potential neurovascular complications, it is important that the diagnosis is not missed. There are two main classification systems. The position classification system, defined by the relation of the tibia to the femur, helps identify the mechanism of injury and possible associated complications. The Schenck classification system defines the dislocation based on ligamentous and associated injuries, and thus is useful for surgical planning. It is well recognized that treatment should consist of immediate closed reduction with frequent neurovascular assessment, followed by surgical repair/reconstruction. The timing and surgical technique remain controversial.

Multicentric giant cell tumor of bone. Clinicopathologic analysis of thirty cases

BACKGROUND

Giant cell tumor of bone accounts for 4% to 5% of primary bone tumors. Approximately 1% of cases present as multiple synchronous or metachronous lesions. In this study, we describe the clinicopathologic features of thirty cases of multicentric giant cell tumor.

METHODS

Thirty patients who had two or more separate lesions that had been pathologically confirmed to be giant cell tumors were identified. Radiographs were reviewed to evaluate the characteristics and locations of the tumors. Histologic reexamination was performed to document morphologic features. Clinical information and follow-up data were obtained from the medical records.

RESULTS

The male:female ratio was 1:2, with an average age at presentation of twenty-one years. Fifty-nine percent of the patients were younger than twenty years of age. There were ninety-four tumors in the series, with an average of three (range, two to nine) per patient. Most tumors had arisen in the long bones. Six patients had synchronous ipsilateral involvement of the distal part of the femur and the proximal part of the tibia. Radiographically, the tumors in long bones manifested as expansive lytic lesions involving the metaphysis and extending into the epiphysis. A minority of the tumors were confined to the metaphysis, had features of a fibro-osseous or bone-forming lesion, or arose in skeletally immature patients. Secondary histopathologic changes including fibrohistiocytic regions, reactive bone formation, or aneurysmal bone cyst-like changes were not uncommon. Most tumors were treated with curettage (64%) or resection (22%). The recurrence rate was similar to that of solitary giant cell tumors. Metastatic disease developed in three patients, and two patients had malignant transformation.

CONCLUSIONS

Multicentric giant cell tumors occur more often in younger patients than do solitary giant cell tumors, and they frequently present as synchronous lesions around the knee. Some tumors appear as bone-forming or fibro-osseous tumors on imaging studies as a result of fibrohistiocytic regions and reactive bone formation. The risk of recurrence depends on the type of surgery that is performed.

LEVEL OF EVIDENCE

Therapeutic Level IV.

The incidence of imaging findings, and the distribution of skeletal lymphoma in a consecutive patient population seen over 5 years

OBJECTIVE

To determine the imaging incidence, distribution, and prognosis of primary and secondary osseous lymphoma from a consecutive, single-institution patient population seen over a 5-year period.

DESIGN AND PATIENTS

Of 1098 newly diagnosed consecutively seen patients with lymphoma between 1996 and 2000, 975 comprised the study group. From the electronic medical records and imaging studies, age, gender, date of diagnosis of lymphoma, bone involvement, location in bone, multifocality in bone, histopathologic type of the lesion and patient survival were recorded. Primary lymphoma of bone was defined as osseous disease with or without regional node involvement and no evidence of systemic disease for 6 months. Secondary osseous lymphoma was considered present when osseous lymphoma was associated with systemic disease or the appearance of systemic disease within 6 months of osseous disease.

RESULTS

Ninety-eight patients had osseous lymphoma (10%, 95% confidence interval [CI] 8.2, 11.9). Ages ranged from 9 to 92 years (mean 54) and gender 6:4 (M:F). Ten patients (1%) had primary lymphoma of bone. Eighty-eight patients (9%) had secondary lymphoma of bone. The vertebral column was the favored site for secondary osseous lymphoma. At 5 years, there were no deaths in the primary osseous lymphoma group and a 51% mortality rate in the secondary osseous lymphoma group.

CONCLUSIONS

Primary lymphoma of bone remains a rare primary malignancy, favors the appendicular skeleton, and has a significantly better 5-year prognosis than secondary lymphoma of bone.

Acute calcific retropharyngeal tendinitis

Knowledge of the characteristic clinical spectrum and imaging features of this disorder are crucial for a correct diagnosis of this uncommon cause of odynophagia and dysphagia.

Advances in musculoskeletal tumor imaging

In the last 2 decades, there has been a dramatic change in the clinical approach to the tumors of the musculoskeletal system. The role of medical imaging in diagnosis, staging,and eventual follow-up of patients who have musculoskeletal neoplasia has expanded. This article presents an overview of the role of imaging, recent advances in technology,and state-of-the-art techniques for evaluating musculoskeletal neoplasms. Conventional imaging modalities, ultrasound, CT, MRI, positron emission tomography, and image-guided interventions are discussed.

Isolated teres minor atrophy: manifestation of quadrilateral space syndrome or traction injury to the axillary nerve?

This article prospectively determines through magnetic resonance imaging (MRI) the incidence of isolated teres minor atrophy and its gender and age distribution, and documents associated findings related to the rotator cuff, labroligamentous complex, and quadrilateral space. Two hundred seventeen consecutive shoulder MRI examinations performed over a 3-month period were prospectively reviewed and evaluated for isolated teres minor atrophy. Twelve (5.5%) patients had non-compressive isolated teres minor atrophy. Ninety-two percent (n=11) of these patients had rotator cuff or labroligamentous complex tears. No patients had an associated mass within the quadrilateral space. The average patient age was 60 years and 11 of the 12 patients were male. Isolated teres minor atrophy on MRI is most commonly seen in older patients who do not fit the expected clinical presentation of quadrilateral space syndrome. The anatomical relationship of the teres minor nerve to the joint capsule and the frequency of associated shoulder injuries in these patients raises the possibility of an association between humeral decentering and teres minor atrophy. Quadrilateral space syndrome would appear to be a very rare cause of isolated teres minor atrophy.

Calcific tendonitis of the fibular collateral ligament

This article describes calcific tendonitis within the fibular collateral ligament, presumably from hydroxyapatite deposition, a rare cause of acute, severe lateral knee pain. Imaging findings confirmed calcifications in an intact but thickened fibular collateral ligament with adjacent soft-tissue reaction, consistent with calcific tendonitis. Magnetic resonance imaging can appear aggressive, and therefore the findings often can be mistaken for other knee abnormalities; specifically, the presentation following a twisting injury that requires avulsion fracture or ligamentous injury be excluded. Confirmation of crystal deposition with thin-section CT is helpful when suspected on MRI because it is unequivocal in depicting calcifications and bony detail.