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Age / Sex : 32 / M
Age / Sex : 32 / Male
Chief complaint : Multiple
nodules
1) What is your impression?
Two weeks later, you can see the final diagnosis with a brief discussion of
this case.
* Send Application Answers to In Sook Lee, MD (lis@pusan.ac.kr)
Courtesy : In Sook Lee, Pusan National University Hospital
Diagnosis: Multiple tendon xanthomata
Discussion
Findings:
Figure 1. Ankle
and knee radiographs show soft tissue masses at calcaneal
insertion sites of both Achilles tendons and anterior portion of right tibial
tuberosity.
Figure 2. Axial
MR images of ankle show nodular masses at the insertion sites of the Achilles
and peroneus tendons. The masses have heterogeneously intermediate-to-low
signal intensities with speckled appearance on both T1- and T2WIs. They demonstrate
diffuse heterogeneous enhancement.
Figure 3. Another
mass that has similar signal and enhancement pattern is located at the
subcutaneous fat layer anterior to right tibial tuberosity.
Diagnosis:
Multiple tendon xanthomata
Differential diagnosis : Multiple gouty tophi, tendinitis
Discussion:
Tendon
xanthomata are associated with disorders of lipid metabolism such as familial
hypercholesterolemia. Their produces nodular
masses in the tendons of the hand, the patellar tendon, the Achilles tendon,
the plantar aponeurosis, the peroneal tendon, and around the elbow and lower
tibia.
MRI and US
are useful adjuncts to diagnosis, along with conventional radiographs.
Axial-view MR images characteristically show heterogeneous signal, speckled or
reticulated pattern within the diffusely enlarged tendon in all image
sequences(T1, T2, proton density weighted). The heterogeneity of signal
decreases in sagittal images, in which the tendons look more nodular and
enlarged than speckled. On ultrasonography, the xanthomas appear as diffuse or
focal hypoechoic lesions with lack of characteristic fibrillar architecture of
normal tendons.
Surgery is
required only in cases of mechanical obstruction of the joints resulting in
disability or pain.
References:
1. Sudhir
K., Kappor MS, Himanshu Kataria MS. Multiple nodular outgrowth in the hands and
feet of a 60-year-old man. Clin Orthop Relat Res 2010: 468: 637-642
2. S.Otake,
N.Imagumbai, A.Tajima, S.Ohba. Unusual high signal intensity on MR images in a
patient with multiple tendinous xanthomas. Eur. Radiol. 1997: 7: 1025-1027
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