Intern seminar Int. 郭哲佑 王富弘

Patient’s information Chart No.: 11080331 6m/o female infant G1P1, NSD, full term No gestational problem, born healthy Appropriate growth and development

Chief complaint Left lower leg swelling twice in recent two months

Present illness First episode of left lower leg swelling at about one and a half months ago, went to OPD of Chi-Mei hospital Rapid swelling followed by gradual remission in 3~4 weeks Edematous, local heat, pain No trauma, no insect-bite lesion No surgical history, no infection of other system Received NO TREATMENT

Present illness Disease free for two weeks then symptoms recur. Similar symptoms, just that less severe and less pain, and mainly in lower part of left lower leg Physical finding at admission (about 5 days after the onset) -- T/P/R: 36.3℃/148/40 -- mild swelling and local heat of left lower leg

Present illness Initial tentative diagnosis: Suspect cellulitis Suspect osteomyelitis Rule out venous thrombosis Malignant disease should be ruled out

Present illness Lab study on 8/2 WBC Band Seg Eos Baso Mono Lymph 17500/cmm - 20.2% 2.4% 0.6% 6.1% 70.7% Hb Hct Plt ESR 11.6 mg/dL 34.9% 360 K/cmm 4 CRP < 7.0 mg/dL

Present illness Plain film of lower legs

Modified tentative diagnosis Suspect osteomyelitis Malignancy could not be ruled out

Tc-99m bone Scan

MRI (FSE T1 without contrast)

MRI (FSE TI without contrast)

MRI (FSE T1 without contrast)

MRI (FSE T2 F/S without contrast)

MRI (FSE T2 F/S without contrast)

MRI (FSE T2 F/S without contrast)

MRI (FSE T1 with contrast)

MRI (FES T1 with contrast)

MRI (FES T1 with contrast)

MRI (FES T1 with contrast)

MRI (L’t FES T1 with contrast)

<磁振造影檢驗報告> 醫師: 周言穎 檢查:94/08/12 **** 9180023344 第 01次報告 -------- ------------- ------------- -------- ------------- ---------- Clinical: 5 months old baby with Lt thigh cellulitis and myositis. MRI of the Lt lower extremity from pelvis to knee without and with IV contrast was performed. The result showed: >There is signal change of the marrow cavity of the Lt tibia with periosteal reaction and enhancement of the marrow cavity and the soft tissue around the Lt tibia, compatible with osteomyelitis with periosteal reaction or cellulitis. >Irregularity of the physeal plate of the distal Lt tibia is found. IMP: >compatible with osteomyelitis of Lt tibia with periosteal reaction and suspicious reactive change or cellulitis around the Lt tibia. >Irregularity of the physeal plate of distal Lt tibia, suspected destruction by osteomyelitis, suggest follow up. 謝志強醫師-放診專 429

OP Tibial biopsy

Pathology Age: 1 Sex: F PATHOLOGICAL DIAGNOSIS: Bone, tibia, left; biopsy: compatible with chronic osteomyelitis. GROSS FINDING: The specimen consists of several bony fragments measuring 1.6 x 0.7 x 0.3 cm in aggregate. All are embedded in one cassette. MICROSCOPIC FINDING: Section shows bony trabeculae with some chronic inflammatory cell infiltration and focal fibrosis. The picture is compatible with chronic osteomyelitis.

PATHOLOGIC DIAGNOSIS Bone, tibia, left; biopsy: compatible with chronic osteomyelitis. MICROSCOPIC FINDING: After deeper section, some cellular areas composed of oval to spindle shaped cells appeared with marked crushing artifact are noted. Immunohistochemically, the cells are negative for CD99, S-100, CD1a, synaptophysin and chromogranin. However, the reality of these negative results is doubted due to severe crushing artifact of the cells. Please correlate with clinical information, and re-biopsy is recommended if tumor is highly suspected clinically.

Cultures Blood culture(-) Periostium culture(-) Bone marrow culture(-)

Treatment Treat as chronic osteomylitis Antibiotics: Oxacillin + Rocephine

8/20 WBC H 13.8 K/cmm 3.2-9.2 | RBC 4.78 M/cmm 3.73-4.93 Hb L 11.2 g/dl 11.6-14.8 | Hct L 33.7 % 33.8-43.4 MCV L 70.6 fl 82.7-95.5 | MCH L 23.4 pg 28.2-33 MCHC L 33.1 g/dl 33.2-35.2 | RDW H 15.3 % 11.6-13.6 Pl H 481 K/cmm 151-366 | Blast - % Pro - % | Myelo - % Meta - % | Band - % Seg L 16.0 % 43-64 | Eos 6.0 % 0-6 Baso 0.0 % 0-1 | Mono 6.0 % 3-9 Lymph H 72.0 % 27-47 | Aty-lym . % NRBC . % | Remarks . CRP <7.0 MG/L 0-8 |

MBD Treat as chronic osteomylitis OPD f/u

Fibrous dysplasia 20~30 yrs Diaphysis Ground-glass martix

Langerhans cell histiocytosis Rare disease 5~10 yrs Skull, ribs, pelvis, long bone, mandible, vertebrae Painful swelling of affected site Image: well-defined, lytic lesion, with or without sclerotic margin in diapysis or metaphysis Bone scan: normal ~ +

Ewing sarcoma <30 yrs M:F= 3: 2 Occurs at any portion of the bone Femur, sacrum, tibia Painful swelling Highly aggressive biologic activity Image: onion-peel appearance