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DEPARTMENTALSEMINAR
BY
DR.EFANGA,S.A.S
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QUESTION
DISCUSS THE DIFFERENTIALDIAGNOSIS AND POSSIBLERADIOLOGICAL FINDINGS INA 40YR OLD WOMAN WHOPRESENTS WITH ACUTE
SWELLING OF THE ENTIRELOWER LIMB
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OUTLINE-INTRODUCTION-DIFFERENTIALS
-CLINICO-PATHOLOGICAL FEATURES
-COMPLICATIONS
-IMAGING MODALITIES
-MERITS & DEMERITS OF MODALITIES-RADIOLOGICAL FEATURES
-INTERVENTION
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INTRODUCTION
The lower limb is the region of the bodythat extends from the hip down to the feet.
The emphasis is thus on the causes of
acute swellings(swellings of rapid onset) thatinvolve a significant aspect of the lower limb
in a 40YR old FEMALE.These causes may be
from infections/inflammations,vascularlesions,and Lymphoedema.
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DIFFERENTIALS
1.SOFT TISSUEINFECTIONS/INFLAMMATIONS
-PYOMYOSITIS-CELLULITIS
-NECROTIZING FASCITIS
-DERMATOMYOSITIS
-RHABDOMYOLYSIS
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2.VASCULAR LESION
-DEEP VEIN THROMBOSIS
-WET GANGRENE
-ACUTE MUSCLE DENERVA-
TION
3.LYMPHOEDEMA
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CLINICO-
PATHOLOGICAL
FEATURES
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PYOMYOSITIS
This is the inflammationof a muscle as a result of a bacterial or fungal
Infection.It may culminate to the formation of
abscess,carbuncles,or infected sinuses that lie
deep in the muscle.It is common in tropical
countries.Staphylococcus aureus is the mostImplicated cause.
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COMPLICATIONS INCLUDE
-OSTEOMYELITIS
-ABSCESS
-INFECTED SINUSES
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CELLULITIS
It is the infection of the deep dermis of the skincommonly caused by b-hemolytic streptococci.
It is most common in the lower limbs.
COMPLICATIONS- LYMPHANGITIS
- LYMPHADENITIS
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NECROTIZING FASCITIS
Bacterial infection of the layer of fascia beneaththe skin due to polymicrobial infection with a
variety of gm +,gm -,aerobic & anaerobic orgs.
There is tissue necrosis and toxin production
with large areas of destroyed & devitalized mu-
scle & soft tissue.It occurs following minor cuts like insect
bite,and commonly seen in diabetics,alcohol/
h ld l hi hl l bl
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The elderly are highly vulnerable.
Presentations include;
-Indolent(1-21 days) before diagnosis
-fever
-drowsiness
-diarrhoea-vomitting
-crepitus(50%)
-discolouration of the skin
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DERMATOMYOSITISIt is an autoimmune inflammatory disorder of the
Skin,subcutaneous tissues and striated mucles. The
Inflammatory process is commonly non-suppurative.
Associated with it is a bluish-red skin erup-tion which occurs on the face,scalp,shoulders,and
Knuckles .In the absence of this rash it is called POL-
YMYOSITIS.
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It is more common in middle aged females(40-
60yrs) but a severe form is seen in children(5-
15yrs).It is associated with malignancies e.g
Carcinoma of the breast,bronchus,stomach,&
Ovary.
Presentations include;
-muscle weakness & aches(due to active inflam-
mation,necrosis,muscle atrophy with fatty rep-
lacement)
1
st
symptom in 80%
l d f
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-low grade fever
-skin erythema,Heliotrope rash(dusky eryrhema
of the eyelids) with peri-orbital oedema.Gottron sign=scaly eythematous papules at
the knuckles,major joints,and upper body.
-elevated muscle enzymes-myositis specific auto-antibodies(anti-jo-1)
COMPLICATIONS;Increased incidence of
malignant neoplasms of the breast,prostate,
lungs,ovary,GI tract,and kidney.
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RHABDOMYOLYSISIt is an acute fulminant potentially fatal disease
of skeletal muscle that entails destruction of
muscles with loss of integrity of its cell membr-
ane via infarction.
Causes include;trauma,severe
exercise,ischemia,burn,toxin,iv heparin thera-
py,viral infection,autoimmune inflammation.
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DEEP VEIN THROMBOSISThis condition is associated with venous obstr-
uction as a result of the sluggish flow of blood
plus the changes in the clotting factors in the
blood that increases the tendency to thrombusformation.There is no preceeding inflammation
of the venous wall.It is most common within the
Deep veins of the calf (posterior surface of the lowerLeg)
/
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The causes/risk factors are as follows;
-Patients on medications e.g,birth control pills,
estrogen replacement therapy,tamoxifen,dia-betes,
-Decreased cardiac function;congestive cardiac
failure,myocardial infarction
-Female related;pregnancy,post partum,large
fibroid,-Trauma & Surgery to the pelvis & lower limbs
-prolonged immobilization
A >40
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-Age>40yrs
-varicose veins
-Polycythemia
-Malignancy
-Smoking
-Patients with blood group A > blood group O
Presentation include;
-swelling(measurement of circumference)
-warmth
-Discolouration of the skin
i i h ff d i i
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-Deep crampy pain in the affected extremity,worse in
the erect position and improves with walking.
-Homans sign- Calf pain with dorsal flexion of the foot
-Payr`s sisgn- Pain on compressing the sole of a foot
COMPLICATIONS-PULMONARY EMBOLISM
-PHLEGMASIA ALBA DOLENS(severely impaired
venous drainage resulting in gangrene)-POST-PHLEBITIC SYNDROME(recanalization to a small
lumen,focal wall changes) due to incompetent
valves.
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WET GANGRENEThis is the death and putrefactive decay of part of
the body due to cessation of blood supply coexis-
ting with an infection by gas forming bacterium
e.g,clostridium perfringens.Diabetics are particul-
arly prone to the infection.
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ACUTE MUSCLE DENERVATION
The loss of nerve supply to a muscle is associat-
ed with atrophy however in most cases fatty infi-
ltration of muscle and oedema occur causing the
Swelling of the affected limb.The cause of this
Denervation may be from stroke.
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LYMPHOEDEMALymphoedema is categorized as primary and
second-ary.The primary type is due to Aplasia,hypoplasia or hyperplasia and is associated
with syndromes liketurner`s,klinefelter`s,noonan`s.It has 3subtypes;congenital Lyphoedema,whichappears shortly after birth,lyphoedemapraecox,which appears atpuberty,lymphoedema tarda which ussuallybegins after 35yrs.
d l h d
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Secondary lymphoedema is an
acquired condition resulting from
obstruction to a previously normallymphatic channels by
metastasis,parasites(FILARIALWORMS),tuberculosis.
Lymphoedema of the lower limbs that
involve the foot progresses
upwards,making the entire limb
oedematous.
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IMAGING MODALITIES1.PLAIN RADIOGRAPHS
-AP,LAT VIEWS OF THE AFFECTED LOWER
LIMB,CXR
2.ULTRASOUND SCAN
-B-MODE,COLOUR DOPPLER,DUPLEX DOPP-LER
3.ANGIOGRAPHY
4.VENOGRAPHY5.LYMPHOGRAPHY
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6.CT SCAN + CONTRAST ENHANCEMENT
7.MRI
-SE(T1 & T2 WEIGHTED)
-GRADIENT RECALLED ACQUISITION IN
STEADY STATE(GRASS)8.RADIONUCLIDE IMAGING
-99mTC-IN VITRO LABELLED PLATELETS
-99mTC-NANOCOLLOIDS
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ULTRASOUND SCANMERITS
1.Non invasive & convenient especially when
the patient is uncomfortable
2.It is cheap and readily available3.Non-ionizing
4.Ability to demonstrate and diferentiate soft
tissues(muscles,tendons,subcutaneous
layer,skin)
5 D i t f th l t
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5.Dynamic assessment of the vascular anatomy
and physiology using B-mode and Duplex
doppler6.Used for interventional procedures such as
drainage and image guided biopsy.
7.Can be used for staging of soft tissue tumour
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DRAW-BACKS1.Marked operator dependence
2.Large and obese individuals coupled with intra
abdominal gas may result in sub-optimal
images3Associated bony lesions can not be demonstr-
ed
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PLAIN RADIOGRAPH1.Readily available and cheap
2.Can show calcification of soft tissues,oblitera
tion of fat planes(acute,active inflammation),bony metastasis,chest and skull involvement
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DRAW BACK
1.Utilizes ionizing radiation( It is anissue with pregnancy)
2.Poor soft tissue contrast andspatial resolution
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CT SCAN
1.Qualitative and quatitative assessment oflesions in the soft tissue of the affected limb
2.The extent of local or distant spread or
involvement can assessed3.Used in staging malignancies
4.Employs iv contrast for opacification of the
blood vessels and increase lesion conspicuity
5.Helical CT to reduce motion artifacts
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DRAW BACKS
1.Expensive and not widely available2.Uses ionizing radiation(It is an issue
with pregnancy)3.Inaccurate history of allergy or
multiple drug reaction when there is
need for contrast.
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ANGIOGRAPHY
1.Can demonstrate neo-vascularization
in masses
2.Lesions in the vasculature can be
determined and interventional
procedures performed immediately
or subsequently.
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DRAW BACKS
1.Highly invasive
2.Uses ionizing radiation(except inMRA).
3.Allergy and multiple drug
reactions
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RADIONUCLIDE IMAGING
1.Soft tissue anomalies with propensity to
develop mineralization can show ectopic
activity on skeletal scintigraphy
e.g,Dermatomyositis,Neoplasia,Myositis
ossificans etc.
2.Helps in assessing the maturity of ectopic
ossification(whether stable )prior tosurgical excision.
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DRAW BACKS
1.Very expensive and rarelyavailable
2.Ionizing radiation
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LYMPHOGRAPHY-Lymphography directly studies the
lymphatic ducts and the internal
architecture of the nodes.
-Used for follow-up imaging of nodal
diseases as the contrast persists in
the nodes for up to 6-12months
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DRAW BACK-False positive results are
frequent occurrence
-The procedure predisposes tooil embolism
-It is very invasive
-Ionizing radiation
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MRI1.Non-ionizing
2.Provides excellent soft tissue contrast and spatial
resolution and has multiplanar capabilities
3.Contrast enhancement using iv contrast can help
in differentiating soft tissue lesions
4.It is the best technique for follow-up
5 INTERVENTIONAL
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5.INTERVENTIONAL
PROCEDURES
Biopsies and Drainage
procedures can be carriedout.
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DRAW BACKS1.Very expensive and rarely available
2.Long image acquisition time
3.Claustrophobic patients
4.Patients with medical prosthesis unless it
is MRI compatible
5.Obese individuals
6.Orthopneic congestive cardiac failure
patients
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RADIOLOGICAL FEATURES
1.PLAIN RADIOGRAPHSoft tissue swelling with the
obliteration of fat plane is seen in
infections and inflammation,in DVT
there is also soft tissue swelling.In
necrotizing fascitis gas is seen withinthe soft tissue swelling.
In dermatomyositis in addition to the
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In dermatomyositis, in addition to thebilateral and symmetrical soft tissueswelling there are sheet-like calcificationsalong fascial and muscle planes.Thedifferentials hereinclude;Scleroderma,Myositisossificans,cysticercosisi,dracunculosis,loiasis,hydatid disease,armillifer
armilatus,leprosy,vascularcalcifications,tendon calcifications,e.t.c.
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ULTRASOUND- B-MODE US
Hypoechoic/sonolucent lesion presentwithin the muscle with or without probetenderness is suggestive of pyomyositis,while
in cellulitis the sonolucent lesion is anterior tothe muscles.In DVT there might bevisualization of the clot or thrombus withinthe vein but the incomplete luminal collapse
following venous compression is an importantpointer to it.Venous diameter at least twicethat of the adjacent artery suggests a
thrombus
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In Rhabdomyolysis there are areas of
reduced echogenicity and non-
homogenous muscle texture.
- COLOUR DOPPLER
There is a peripheral rim pattern of
blood flow seen in pyomyositis.In DVT
there is reduced or absent colour signalor blood flow or a trickle of blood flow
around a thrombus.
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VENOGRAPHY
Intraluminal filling defects( tram-lineappearance) are noted.They are constant
in all the images that show the calf
veins,communicating veins,femoralveins,and iliac veins.These are the
contrast venographic findings in DVT.
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LYMPHOGRAPHY
There is obliteration of lymphaticchannels due to intraluminal
coagulum gel deposition/reactiveinflammation
Filling defects may also be present
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CT SCAN
In infections,heterogenousattenuation of the enlarged soft
tissues with fluid collection(exudate,
or hemorrhage).Rim enhancement
following iv contrast administration is
typical.In Necrotizing fascitis, gas may
be seen along thickened fascial
planes with deep fluid collections.
MRI SCAN
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MRI SCANInfections and inflammations
invariably show high signal intensity
on T2WI and low/intermediate
intensity on T1WI.Fascialthickening(NECROTIZING FASCITIS) is
best demonstrated using thismodality.Peripheral enhancement
with Gadollinium occurs.
RADIONUCLIDE
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RADIONUCLIDE
IMAGINGIt is usefull for demonstratingthrombus in DVT using 99m-
Technitium labelled platelets.
99m-Technetium labelled
nanocolloid show lymphatic
uptake and trapping
INTERVENTIONAL
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INTERVENTIONAL
PROCEDURES1.ANGIOGRAPHY
-Therapeutic embolization of malignancies
-Vascular access allows the introduction of
drugs directly to the site of the
pathology,e.g,Fibrinolytic drugs inDVT,cytotoxic drugs in malignancy,vasodilators
in gangrene.
-Percutaneous transluminal angioplasty can be
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Percutaneous transluminal angioplasty can be
used to treat gangrene
-vena caval filters can be introduced.2.ULTRASOUND SCAN
-Ultrasound guided drainage in the case of
pyomyositis and also biopsy can bedone.Some of the angiographic interventional
procedures involve this modality.
3.CT SCAN
CT guided biopsy
4 MRI SCAN
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4.MRI SCAN
-Biopsy
-Guidance of open surgery
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Multiple
abscessfollowing
pyomyositis.Hy
perintense onT2WI and rim
enhancement
on contrast
administration
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Pyomyositis
Soft tissue
swellinghyperintens
en on T2WI
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PYOMYOSIT
IS,CELLULIT
IS,ANDFASCITIS
ON T2WI
CT SCAN A
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CT SCAN A
CENTRAL
LOWATTENUAT
ING
COLLECTION WITH
ILL
DEFINEDRIM
ENHANCE
MENT
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NECROTIZINGFASCITIS/GAS
GRANGRENE
Swelling ofthe left thigh
with gas
present
NECROTIZING FASCITIS/GAS
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NECROTIZING FASCITIS/GAS
GANGRENE
Fascial thickening on T1WI & T2WI
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Fascial thickening on T1WI & T2WI
NECROTIZING FASCITIS/GAS
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NECROTIZING FASCITIS/GAS
GANGRENE(CT SCAN)
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NEROTIZIN
GFASCITIS/G
AS
GANGRENEGas present
in soft
tissueswelling
T
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Transverse
ultrasound
with dopplershowing
marked
vascularitysurrounding
an anechoic
collection inthe
thigh(abscess)
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CELLULITISHypoechoic
strands
surrounding
hyperechoi
c fat
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DERMATO
MYOSITIS
Swellingand sheet-
like
calcification
PICTURE
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PICTURE
OF THE
SKIN
LESION
ANDPLAIN
RADIOGRA
PH OF THESAME
MAN
DERMATOMYOSITIS
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DERMATOMYOSITIS
DVT
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DVT
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DEEP VENOUS THROMBOSIS
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A.TRANSVERSE POWER DOPPLER IMAGE WITH
TRANSDUCER COMPRESSION APPLIED SHOWS
FLOW IN THE FEMORAL ARTERY(A) AND NO FLOW
IN THE FEMORAL VEIN(V,ARROW).THE VEIN DOES
NOT COMPRESS WITH TRANSDUCER
PRESSURE,INDICATING INTRALUMINAL THROMBUS.
B.ENLARGEMENT OF THE CFV WITH
INTRALUMINAL THROMBUS.
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DVT
Venographywhich
shows fillingdefects and
irregularitie
s in thefemoral vein
LYMPHOEDEMA
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LYMPHOEDEMA
Increased
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signal
intensity inthe
edematousleft leg of a
patient
withlymphoede
ma
Post inflammatory lymphedema of
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Post inflammatory lymphedema of
both limbs
THANK
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THANK
YOU