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Presented by Edward McCarthy, M.D. and prepared by Greg Seidel, M.D.
Case 1: A 14 year old boy had pain in his forearm for two weeks.
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Question 1 of 1
1. Question
Week 113: Case 1
A 14 year old boy had pain in his forearm for two weeks. A radiograph showed a poorly defined radiolytic lesion in the mid shaft of the radius with a periosteal reaction./images/Lyn’s/nov4-mc-1.a.jpg
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/images/Lyn’s/nov4-mc-1.e.jpgCorrect
Answer: Osteomyelitis
Histology: The histologic features show a heterogeneous mixture of inflammatory cells. These include neutrophils, histocytes, lymphocytes and plasma cells. In addition, there is some marrow fibrosis.
Discussion: This inflammatory tissue, in the present radiographic setting, is consistent with acute osteomyelitis. The absolute diagnosis of osteomyelitis, however, rests on positive wound and intraoperative cultures.
Although the lesion is radiographically consistent with the Ewing’s sarcoma, the histologic pattern of inflammatory tissue rules this diagnosis out. Complicating this difficult differential diagnostic problem of Ewing’s tumor vs osteomyelitis is the fact that many patients with Ewing’s sarcoma present with an elevated white count, a high fever, and an elevated sed rate. This makes the clinical and radiographic presentation of Ewing’s tumor and acute osteomyelitis identical. The differential diagnosis rests on a biopsy.
Although eosinophilic granuloma presents with a heterogeneous mixture of inflammatory cells, the histocytes in eosinophilic granuloma are positive with S-100 protein and CD 1A. Because of similarities of radiographs and H & E patterns, these immunohistochemical stains should be performed in all cases of presumed osteomyelitis in order to rule out Langerhans’ cell histiocytosis.
Incorrect
Answer: Osteomyelitis
Histology: The histologic features show a heterogeneous mixture of inflammatory cells. These include neutrophils, histocytes, lymphocytes and plasma cells. In addition, there is some marrow fibrosis.
Discussion: This inflammatory tissue, in the present radiographic setting, is consistent with acute osteomyelitis. The absolute diagnosis of osteomyelitis, however, rests on positive wound and intraoperative cultures.
Although the lesion is radiographically consistent with the Ewing’s sarcoma, the histologic pattern of inflammatory tissue rules this diagnosis out. Complicating this difficult differential diagnostic problem of Ewing’s tumor vs osteomyelitis is the fact that many patients with Ewing’s sarcoma present with an elevated white count, a high fever, and an elevated sed rate. This makes the clinical and radiographic presentation of Ewing’s tumor and acute osteomyelitis identical. The differential diagnosis rests on a biopsy.
Although eosinophilic granuloma presents with a heterogeneous mixture of inflammatory cells, the histocytes in eosinophilic granuloma are positive with S-100 protein and CD 1A. Because of similarities of radiographs and H & E patterns, these immunohistochemical stains should be performed in all cases of presumed osteomyelitis in order to rule out Langerhans’ cell histiocytosis.
