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Radiological Reasoning: Miliary Disease, Vertebral Osteomyelitis, and Soft-Tissue Abscesses

Gregory E. Wilde1, Christine Emery1 and James F. Lally1

1 Department of Radiology, Christiana Care Health System, 4755 Ogletown-Stanton Rd., Newark, DE 19718.


Figure 1
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  		Fig. 1A —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Axial CT image shows miliary pattern in both lungs, consolidation in right lower lobe with several dilated bronchi (arrow), and superior portion of patient's breast abscess (arrowheads), better visualized with soft-tissue window as shown in B.

 

Figure 2
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  		Fig. 1B —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Axial CT image shows large right breast abscess impressing on anterior chest wall (arrowheads). Second region of consolidation with bronchial dilatation (arrow) is noted in left lung.

 

Figure 3
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  		Fig. 1C —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Axial CT image shows abscess (arrowheads) within left neck causing displacement of trachea and thyroid gland anteriorly and to right. There is osseous destruction of T2 (long black arrow).

 

Figure 4
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  		Fig. 1D —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Magnified axial CT image shows osseous destruction of T8 with multiple foci of gas. There is anterior and left lateral epidural soft-tissue mass (short arrow) causing severe central canal stenosis. There is extension into paraspinal space bilaterally (arrows).

 

Figure 5
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  		Fig. 1E —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Magnified axial CT image shows large right psoas abscess (arrowheads) and destructive lesion (arrow) within right sacrum involving neural foramina on right.

 

Figure 6
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  		Fig. 2A —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Axial CT image shows large peripherally enhancing fluid collections (arrowheads) in left neck, which cause rightward displacement of larynx and hyoid bone. There is extension of fluid collection (arrow) through thyrohyoid membrane with paralaryngeal involvement.

 

Figure 7
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  		Fig. 2B —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Sagittal T2-weighted MR image of cervical spine shows large paraspinal fluid collection (arrowheads) with contiguous vertebral body involvement from C5 to T3 with relative sparing of intervertebral disks.

 

Figure 8
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  		Fig. 2C —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. Sagittal T2-weighted MR image of thoracic spine shows T7–T8 discitis and osteomyelitis with anterior epidural extension (arrow) and resultant spinal cord compression and edema (arrowhead).

 

Figure 9
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  		Fig. 2D —42-year-old African-American woman with chronic paranoid schizophrenia who presented with impressive weight loss, fever, and malaise. Patient had previously been evaluated at another hospital for multiple vertebral lesions and right breast mass that was eroding through right anterior chest wall. High-power photomicrograph of sample aspirated from patient's psoas abscess shows characteristic endospores within spherules of Coccidioides immitis. Endospores within spherules are released and can each initiate development of new spherules, resulting in exponential reproduction.

 

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