1. Intern seminar
Int. 郭哲佑 王富弘

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

3. Chief complaint
Left lower leg swelling twice in recent two months

4. 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

5. 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

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

7. 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

8. Present illness
Plain film of
lower legs

9. Modified tentative diagnosis
Suspect osteomyelitis
Malignancy could not be ruled out

10. Tc-99m bone Scan

11. MRI (FSE T1 without contrast)

12. MRI (FSE TI without contrast)

13. MRI (FSE T1 without contrast)

14. MRI (FSE T2 F/S without contrast)

15. MRI (FSE T2 F/S without contrast)

16. MRI (FSE T2 F/S without contrast)

17. MRI (FSE T1 with contrast)

18. MRI (FES T1 with contrast)

19. MRI (FES T1 with contrast)

20. MRI (FES T1 with contrast)

21. MRI (L’t FES T1 with contrast)

24. <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

25. OP
Tibial biopsy

26. 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.

27. 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.

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

29. Treatment Treat as chronic osteomylitis
Antibiotics: Oxacillin + Rocephine

30. 8/20
WBC H 13.8 K/cmm | RBC M/cmm
Hb L 11.2 g/dl | Hct L 33.7 %
MCV L 70.6 fl | MCH L 23.4 pg
MCHC L 33.1 g/dl | RDW H 15.3 %
Pl H 481 K/cmm | Blast %
Pro % | Myelo %
Meta % | Band %
Seg L 16.0 % | Eos %
Baso % | Mono %
Lymph H 72.0 % | Aty-lym . %
NRBC % | Remarks .
CRP <7.0 MG/L |

31. MBD
Treat as chronic osteomylitis
OPD f/u

32. Fibrous dysplasia
20~30 yrs
Diaphysis
Ground-glass martix

34. 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 ~ +

35. 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