1. 1996-1997 Robert R. Brown Evelyne Fliszar Ingrid Kjellin Sandy Kwak Khanh Nguyen Thomas Rand Joong-Mo Ahn,

2. Evelyne Fliszar 47 yo female, shoulder pain post fall

3. Initial radiographs 9/05

4. 47 yo female, shoulder pain post fall 6 weeks later, 11/05

5. 47 yo female, shoulder pain post fall Bone marrow edema Effusion Malalignment High grade rotator cuff tear Osseous destruction Coronal T2 w 11/05

6. T2 Axial FS and post IV contrast 47 yo female, shoulder pain post fall

7. Joint aspiration was negative for infection

8. 47 yo female, shoulder pain post fall Sagittal T2w of cervical spine, 2002

9. 47 yo female, shoulder pain post fall Final Diagnosis Neuropathic joint :

10. Evelyne Fliszar 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture.

11. Axial and sagittal T2w images: edema in iliopsoas muscle

12. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial T2w image

13. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. 8 weeks following trauma, repeat MRI because of severe weakness in quadriceps muscle.

14. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Axial T2w images: muscle edema in pectineus, sartorius and quadriceps

15. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. 8 weeks following trauma, severe weakness in quadriceps: Axial T2w FS

16. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. FINAL DIAGNOSIS Femoral nerve injury with denervation muscle edema

17. 34 yo male, hip pain following a fall down stairs. MRI done to rule out a fracture. Other causes of femoral nerve injury: Following iliopsoas hematoma Fracture of the acetabulum Surgery

18. Ingrid Kjellin Loma Linda University Medical Center, CA

20. Ingrid Kjellin 7 year-old female with a left thigh mass. History of cardiac transplantation in infancy.

23. PET 7 year-old female with a left thigh mass. History of cardiac transplantation in infancy.

24. PTLD Post-Transplant Lymphoproliferative Disorder Associated with Epstein-Barr virus infection Heterogeneous group of diseases after solid organ transplant WHO classification: 1.Early (reactive plasmacytic hyperplasia) 2.Polymorphic PTLD 3.Monomorphic PTLD (lymphomas)

25. PTLD Post-Transplant Lymphoproliferative Disorder Related to degree and duration of immunosuppression, type of organ transplanted, CMV status Fever, adenopathy Extranodal disease in >2/3 of cases (muscle involvement extremely rare) Excisional biopsy, multiple core needle biopsies, bone marrow biopsy, CT chest/abd/pelvis Rx: Reduction of immunosuppression, antiviral, anti-B-lymphocyte antibodies (rituximab), interferon, chemotherapy Reported rates of cure/survival variable because of heterogeneity of disease

26. PTLD Differential: Smooth muscle neoplasms (leiomyoma, leiomyosarcoma) increased incidence in immunocompromised

28. Ingrid Kjellin 59 year-old male with chronic renal failure, diabetes and hypertension. Recent left thigh pain and swelling. Had recent abdominal MRI/MRA

29. 59M

31. Discussion Differential diagnosis 1.Pyomyositis 2.Necrotizing fasciitis 3.Ischemia 4.Polymyositis 5.Scleroderma 6.Nephrogenic systemic sclerosis

32. Nephrogenic Systemic Sclerosis (Nephrogenic Fibrosing Dermopathy) Rare multisystemic disorder in patients with renal insufficiency first described in 1997 (200 cases reported to ICNFDR) Unknown etiology IV gadolinium may serve as a trigger in the setting of acute hepatorenal syndrome or dialysis-dependent chronic renal insufficiency Skin induration of extremities and trunk Myalgia, weakness Skin biopsy: proliferation of fibroblasts adjacent to collagen bundles and absence of inflammatory cells

33. Nephrogenic Systemic Sclerosis (Nephrogenic Fibrosing Dermopathy) Systemic fibrosis with involvement of the skeletal muscle, bone, pleura, pericardium, myocardium, kidney, testes, dura At LLUMC 12 patients 2000-2006 Skin fibrosis and joint contractures within 2- 11 weeks following double-dose iv gadodiamide AJR 2007: 188, February 2007

34. Nephrogenic Systemic Sclerosis (Nephrogenic Fibrosing Dermopathy)

35. Nephrogenic Systemic Sclerosis

36. Neprogenic Systemic Sclerosis Long term outcome: Severe inability to ambulate due to contractures and myopathy, cane required for ambulation, no disability. Skin changes persist. Plasmapheresis may have some effect. Dialysis probably of no help. FDA issued a public health advisory in June 2006 with regards to high-dose gadolinium-containing agents in patients with renal failure At LLUMC: no iv gadodiamide in acute renal failure, hepatorenal syndrome, dialysis patients or ESRD with creatinine clearance of <15 ml/min, no double/triple dose

37. Neprogenic Systemic Sclerosis Screen patients with serum creatinine and calculated creatinine clearance prior to MRI with contrast if history of kidney disease, diabetes, or >60 y.o