Age / Sex : 22 / M

SLE (+)

Chief complaint : Lt thigh pain

What is your impression?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).

Courtesy : Jee Won Chai, SMG-SNU Boramae Medical Center

Discussion

Answer: Deep Vein Thrombosis

Findings:

• Increased T2 signal of adductor longus, brevis muscles around deep and superficial femoral veins.


• Irregular filling defects in femoral veins and external iliac vein.


• Fascial thickening and enhancements around deep and superficial femoral veins.

Differential Diagnosis: Inflammatory fasciitis, vasculitis, myositis

Discussion:

 Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by inflammation, immune complex deposition, vasculitis, and vasculopathy. Between 27% and 42% of SLE patients have aPL-ab syndrome, which presents as arterial and veno-occlusive disease, thrombocytopenia, and recurrent vascular thromboses and miscarriages

Ischemic strokes, dural venous sinus thrombosis are well known complications of SLE in CNS system. Pulmonary embolism, coronary artery disease, hepatic veno-occlusive disease and Budd-Chiari syndrome, hepatic/splenic/renal infarctions are possible complications in the thorax and abdomen. In musculoskeletal system, avascular osteonecrosis is the commonly encountered complication, but this is mostly related to the treatment with steroids.

Myalgia can occur in 50% of SLE patients, but true myositis is relatively uncommon. T2 hyper-signal intensities involving proximal muscles of bilateral extremities showing strong contrast enhancements are known MR finding, which is similar to other inflammatory myositis. Muscle atrophy, fatty changes in the muscle can be promoted by corticosteroids and mask the underlying disease process of lupus myositis.

Filling defects in external iliac vein and femoral veins are the key imaging finding to diagnose deep vein thrombosis in this patient. Muscle edema and fascial thickening/enhancements are mainly adjacent to the vessels. Clinical information of SLE can mislead us to inflammatory myositis or fasciitis, vasculitis. CT angiography revealed deep vein thrombosis and pulmonary embolism, and the patient received anticoagulation therapy.

References:

 Tasneem A.Lalani et al. Imaging Findings in Systemic Lupus Erythematosus, Radiographics2004; 24:1069–1086.

10. Barral Juez et al. Radiological manifestations of Systemic Lupus Erythematosus (SLE). EPOS, ECR 2012 / C-0939, DOI:10.1594/ecr2012/C-0939