Weight loss - Postgraduate Medical Journal · lumbarjunction (figure 2) shows the elliptical mass clearly. Typical changes of tuberculous infection are seen in the vertebral bodies

Massive haemobilia 373

Final diagnosis

Haemobilia due to a ruptured intrahepaticartery aneurysm.

Keywords: haemobilia, hepatic artery aneurysm

1 Bolt RJ. Diseases of the hepatic blood vessels. In: BockusHL, ed. Gastroenterology, 3rd edn, Philadelphia: Saunders,1976; pp 471-91.

2 Kadir S, Athanasoulis CA, Ring EJ, Greenfield A. Trans-catheter embolization of intrahepatic arterial aneurysms.Radiology 1980; 134: 335-9.

3 Croce MA, Fabian TC, Sapiers JP, Kudsk KA. Traumatichepatic artery pseudoaneurysm with hemobilia. Am J Surg1994; 168: 235-8.

4 Reid C, Cameron D, Simon TA, Ives J, Hall JC. Selectiveembolisation of intrahepatic aneurysms. Aust NZ J Surg,1992; 62: 582-4.

5 Baker KS, Tisnado J, Cho S-R, Beachley MC. Splanchnicartery aneurysms and pseudoaneurysms: transcatheterembolization. Radiology 1987; 163: 135-9.

Weight loss

D Scullion, A Al-Kutoubi

Department ofDiagnostic Radiology,St Mary's Hospital,London W2 1NY, UKD ScullionA Al-Kutoubi

Correspondence to Dr Al-Kutoubi

Accepted 14 August 1995

A 32-year-old Sudanese man presented with a three-month history of weight loss, night sweatsand back pain. He also noticed an enlarging subcutaneous lump in the left loin. A plain chest X-ray is shown in figure 1.

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Questions

1 What is the most likely diagnosis?2 What radiological investigations would youperform next?

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374 Scullion, Al-Kutoubi

Answers

The chest X-ray shows an increased densitybehind the left heart border consistent with aparaspinal mass. The plain film of the thoraco-lumbar junction (figure 2) shows the ellipticalmass clearly. Typical changes of tuberculousinfection are seen in the vertebral bodies andT11/12 intervertebral disc. Computed tomo-graphy (CT) is the investigation of choice to

Figure 2 Plain film ofthe thoracolumbar junc-tion showing a large para-vertebral soft tissue mass(white arrows). There issclerosis of the superiorend plate of T12 withsignificant loss of heightof the Tl 1/12 interverte- i.bral disc (black arrow)

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Figure 3 CT scan. Theparavertebral abscess isseen. The eccentric de-struction of the body ofTi 1 is apparent (arrow)

Figure 4 CT scan. Thesoft tissue settings showthe paravertebral abscessdraped anteriorly over thespinal colurmn. On the left ..!!!!!!...side it has penetrated thechest wall and involvesthe paraspinal muscles

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further delineate the extent of disease (figures 3and 4).

Spinal tuberculosis has been in existence forseveral thousand years. Its association withspinal deformity was first described by SirPercival Pott in 1779. Untreated, it may alsolead to serious neurological sequellae due tospinal cord compression. It is a commonproblem in India where it accounts for morethan 50% of all forms of osteo-articulartuberculosis. Overall, children and youngadults are affected most. It is assumed thatthe disease arises by haematogenous spreadfrom pulmonary tuberculosis, although only30% of patients will have evidence of activepulmonary disease at presentation. Althoughany bone may be affected, the spine is thecommonest site of osteo-articular tuberculosis'and is involved in approximately 50% of cases.The commonest site of spinal tuberculosis isthe lower thoracic and upper lumbar spine.Usually the disease process involves the ante-rior aspect of the vertebral body, either at theinferior or superior margin. This predilectionfor the metaphysis also occurs in the longbones. Spread to the adjacent vertebral bodyoften occurs via the intervertebral disc. Thepattern of bony abnormalities may vary be-tween caucasian and non-caucasian patients.

Caseous material may be extruded from thevertebral body and track beneath the anteriorlongitudinal ligament. The soft tissue massoften extends way beyond the area of bonyabnormality. This may cause 'scalloping' of thevertebral bodies and eventually point onto theskin surface some distance from the originalbony focus. Calcification within a paravertebralabscess is said to be pathognomonic fortuberculosis. It is important to realise that thesoft tissue component may be extensive evenwhen bony changes are subtle. CT is wellsuited to show the extent of both bony

Spinal tuberculosis

In caucasians* involvement of intervertebral disc common* predominantly lytic with little or no sclerosis* involvement of posterior arch rare

In non-caucasians* often confined to vertebral body* disc may not be involved* sclerosis common* posterior arch commonly involved

Box 1

Tuberculous spondylitis: keypoints

* the vertebral bodies are most often affected; thethoracolumbar junction is the commonest site

* bony changes may be subtle even in thepresence of extensive soft tissue involvement

* CT or MRI is ideally suited to define the extentof the disease process

Box 2

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Weight loss 375

destruction' and the paravertebral abscess, andin this respect is more sensitive than plainradiography. Aspiration of the abscess collec-tion may also be performed under CT guidanceto confirm the diagnosis, as was the case in thispatient. Magnetic resonance imaging can alsoaccurately define the extent of both bone andsoft tissue disease.The major differential diagnosis is malig-

nancy, both primary and secondary. This is notusually associated with loss of disc spaceheight, although it may rarely occur withlymphoma and myeloma. Loss of the vertebralend plates tends to occur earlier in pyogenic

osteomyelitis than in tuberculosis, but vertebralbody subluxation may be seen in both condi-tions. In Caucasian patients a marked periostealreaction favours pyogenic infection. Otherinfections that may rarely cause a similarpicture are fungi, actinomycosis, hydatid dis-ease, and histoplasmosis.

Final diagnosis

Tuberculous spondylitis with paravertebralcold abscess.

Keywords: tuberculous spondylitis

1 Chapman M, Murray RO, Stoker DJ. Tuberculosis of thebones and joints. Semin Roentgenol 1979; 14: 266-82.

2 Jain R, Sawhney S. Berry M. Computed tomography ofveterbral tuberculosis: patterns of bone destruction. ClinRadiol 1993; 47: 196-9.

3 Liu GC, Chou MS, Tsai TC, Lin SY, Shen YS. Magneticresonance evaluation of tuberculous spondylitis. Acta Radiol1993; 34: 554-8.

An unusual but important cause of sciatica

SKC Toh, S Ellis, V Bahal

Department ofVascular Surgery,East Surrey Hospital,Redhill, SurreyRHI 5RH, UKSKC TohS EllisV Bahal

Correspondence toSKC Toh, UniversitySurgical Unit, SouthamptonGeneral Hospital, TremonaRoad, SouthamptonS016 6YD, UK

Accepted 14 August 1995

An 85-year-old man presented to the rheumatologist with a three-year history of increasinglysevere lower backpain, radiating down both his legs, with reduced straight-leg raising and apositive sciatic-nerve stretch test. He had no urinary or bowel symptoms, and abdominalexamination was unremarkable. As part of his management, he had an epidural with a localanaesthetic, resulting in acute urinary retention. Rectal examination performed after catheterisa-tion revealed a 'pulsatile' prostate. Ultrasound scan (figure 1) and computed tomography (CT)(figure 2) of the pelvis were then obtained.

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Figure ...IlUlrson sca ofthplv sFigure 2 CT scan of the pelvis

Questions

1 What is the diagnosis?2 How may this condition present?3 What further investigations and management may be advised?

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