1. Case Presentation: Femur Destruction ? Malignancy ? Osteomyelitis. Pathology

2. 2 Case details:  39 Year Fijian Male  Right hip hard large swelling, difficulty in walking  Diffuse hard mass around Rt.thigh, tender,Local temp. raised, induration present.  Radiography showed destruction of upper femur.  Had a normal pelvic xray 4 months before, done for pain in Rt. Hip & thigh-interpreted as “meralgia paraesthetica” at that time.  ? Sarcoma ? Osteomyelitis.

3. 3 Investigations:  INVESTIGATIONS ON 10/06/02 :-  Hb - 10.8 gm%  TC - 8,400 /cmm  ESR- 110  Total Acid Phosphatase - 8.94 [ N 0 - 6.5 ]  Alkaline Phosphate - 210 [ N 39 - 117 ]  Sr. Albumin - 34.7 [ N 35 - 55 ]  Sr. Globulin - 51 [ N 15 - 30 ]  Bence Jones Protein - Negative  LFT’s - Within Normal Limits

4. 4 Normal X-Ray Hip - Feb. 2002 ?

5. 5 On Traction – June 2002 ?

6. 6 After Biopsy – June 2002 ?

7. 7 Femur Destruction - June 2002

8. 8 Histopathology of Tumor  Inflammatory granulation tissue  Foci of abscess

9. 9 Histopathology of Tumor  Inflammatory granulation tissue  Foci of abscess  Degenerating muscle

10. 10 Histopathology of Tumor  Inflammatory granulation tissue  Foci of abscess  Degenerating muscle

11. 11 Histopathology of Tumor  Inflammatory granulation tissue  Foci of abscess  Degenerating muscle

12. 12 Histopathology of Tumor  Focus of chronic Abscess with plenty of plasma cells.

13. 13 Histopathology of Tumor  Focus of chronic Abscess around blood vessel.

14. 14 Histopathology of Tumor  Areas of new bone formation – Callus formation.

15. 15 Histopathology of Tumor  Areas of new bone formation – Callus.

16. 16 Histopathology of Tumor  Inflammation around degenerating muscle

17. 17 Follow up X-Ray – July 2002

18. 18 SERUM ELECTROPHORESIS (at Suva Private Hospital)  TOTAL PROTEIN - 90 GM/L [65- 85]  ALBUMIN - 32 GM/L [38 -50]  alpha-1-GLOBULIN- 7 GM/L [3-7 ]  beta -1- GLOBULIN- 14 GM/L [5- 11]  BETA GLOBULIN - 8 GM/L [4- 11]  GAMMA GLOBULIN - 31 GM/L[6- 15] * Impression- Polyclonal hyper gamma globulinaemia. Pattern seen in patients with chronic inflammation [autoimmune disorders, chronic liver diseases etc.]

19. 19 Pathology Discussion:  Areas of abscess, necrosis, hemorrhage.  Large areas of granulation tissue  Areas of fibrosis, inflammation both acute and chronic  With focal abscess formation  Reactive new bone formation – Callus  Features suggest Inflammatory pathology suggestive of Osteomyelitis.  Microbiological studies, ? Fungus ? bacterial