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Pediatric Radiology

, Volume 40, Issue 9, pp 1566–1568 | Cite as

Detection of multifocal osteonecrosis in an adolescent with dermatomyositis using whole-body MRI

  • Tania C. M. CastroEmail author
  • Henrique Lederman
  • Maria Teresa A. Terreri
  • Sue C. Kaste
  • Maria Odete E. Hilario
Case Report

Abstract

Osteonecrosis is a well-recognized complication of corticosteroid use resulting in significant morbidity, often requiring surgical intervention. Whole-body MRI is a promising method that allows imaging of the whole patient in a reasonable time without the use of ionizing radiation. This technique has the potential for evaluating nonmalignant multifocal skeletal disease like osteonecrosis. This case highlights the value of whole-body MR in an adolescent with dermatomyositis who developed multifocal osteonecrosis.

Keywords

Osteonecrosis Dermatomyositis Whole-body MRI Adolescent 

Introduction

Osteonecrosis is a debilitating disease affecting patients with autoimmune diseases and corticosteroid use. Severe pain, loss of joint mobility and eventual collapse of the articular surface may necessitate joint replacement [1, 2]. An early diagnosis of osteonecrosis is of great importance for optimal therapeutic management. MRI has reached a high diagnostic level in delineating bone marrow diseases like osteonecrosis [2]. Whole-body MRI can provide excellent image quality, is easy to use and is fast enough for broad clinical use [3]. It can demonstrate extension of osteonecrosis or identify sites that are not visible by joint-specific MRI. This case shows the value of whole-body MRI with reduced imaging time in detecting osteonecrosis sites without compromising image quality.

Case report

A 13-year-old girl was diagnosed with dermatomyositis. She was treated with oral glucocorticoids (GC), methylprednisolone pulse therapy, chloroquine, methotrexate and azathioprine.

Three years after starting GC therapy, she presented with pain in her right hip and claudication. One year later she complained of pain in both knees. Joint-specific MR (hips, knees and ankles) was obtained on a 1.5-T unit (Intera Achieva, Philips, Best, Netherlands). For the hips, we used coronal T1-W and T2-W images with fat suppression, and sagittal T1-W sequences. For knees and ankles, coronal T1-W and T2-W images with fat suppression were used. Joint-specific MRI revealed osteonecrosis involving the right proximal femoral epiphysis, right distal femoral epiphysis, metaphysis and diaphysis, right proximal tibial diaphysis, right distal tibial diaphysis, left distal femoral epiphysis, metaphysis and diaphysis and left proximal tibial diaphysis (Figs. 1 and 2). Whole-body STIR (short tau inversion recovery) was performed to identify other possible osteonecrosis sites and to compare its performance against joint-specific MRI in assessing osteonecrosis lesions. We found no osteonecrosis lesions in humeral heads, a site that is usually involved, but the whole body STIR was able to detect all osteonecrosis sites seen in joint-specific MRI and measure the extension of osteonecrosis in diaphyses of long bones that were missed by joint-specific MRI (Figs. 3 and 4).
Fig. 1

Right hip 3 years post glucocorticoid therapy. a Coronal T1-W image shows a lesion of osteonecrosis. b Coronal T2-W fat-suppressed image shows a lesion of osteonecrosis and epiphyseal deformities

Fig. 2

Coronal T2-W fat-suppressed image of the right knee shows lesions of osteonecrosis

Fig. 3

Whole-body STIR image shows the same osteonecrosis lesions seen on joint-specific MRI and its extension (arrows). There are no osteonecrosis lesions in shoulders

Fig. 4

Whole-body STIR image shows osteonecrosis lesion in right hip (arrow)

Discussion

Whole-body MRI is a fast and accurate modality for detection and monitoring of disease throughout the entire body [3]. The technique has its greatest impact in the evaluation of children with suspected bone marrow or skeletal involvement [3, 4, 5]. Emerging potential applications include the evaluation for osteonecrosis, chronic multifocal recurrent osteomyelitis, myopathies and vascular malformations [5]. Whole-body STIR permits evaluation of the entire skeleton with a single examination within 10–15 min and without the use of ionizing radiation [6, 7]. The joint-specific MR takes 15–20 min to assess a single joint (hips or knees or ankles).

This study demonstrated that osteonecrosis lesions are highly correlated between joint-specific and whole-body MRI. This technique is very useful in determining the extent of necrotic lesions but further studies need to address its use as a screening tool in high-risk patients. Health-care providers need to be aware that osteonecrosis can develop as a complication in DM patients and that whole-body MRI is effective in the evaluation of patients with suspected bone marrow involvement such as osteonecrosis.

References

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Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Tania C. M. Castro
    • 1
    Email author
  • Henrique Lederman
    • 2
  • Maria Teresa A. Terreri
    • 1
  • Sue C. Kaste
    • 3
  • Maria Odete E. Hilario
    • 1
  1. 1.Department of Pediatrics, Division of Allergy, Clinical Immunology and RheumatologyFederal University of São PauloSão PauloBrazil
  2. 2.Image Diagnosis DepartmentFederal University of São PauloSão PauloBrazil
  3. 3.Department of Radiological Sciences, Division of Diagnostic ImagingSt. Jude Children’s Research HospitalMemphisUSA

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