F7f07e7dab09533bc71247a5b29a7373 2

Radial Eosinophilic Granuloma

Eosinophilic Radium Granuloma. Patient with IGA deficiency, diagnosed at two years of age through immunoglobulin measurement, carried out due to recurrent otitis. The child has difficulty in serological change.

At the age of eleven, he suffered trauma to his right hand in April 2015, being diagnosed with a fracture, which was treated with immobilization for 14 days, figures 0a and 0b,

Figura 0 a: Radiografia de abril de 2015, frente, sem alteração significativa.
Figure 0 a: Radiograph from April 2015, front, without significant changes.
Figura 0 b: Radiografia do punho direito, de abril de 2015, sem alteração.
Figure 0 b: Radiograph of the right wrist, from April 2015, unchanged.

He spent his July vacation at SnowLand, in Gramado, falling many times while skating, returning on August 2, 2015 and reporting pain in his right forearm and right foot, which was attributed to the sports activities during the vacation.

On August 6, 2015, with the persistence of symptoms, x-rays were taken of the right foot and right wrist, and it was interpreted that there was no fracture in the right foot and nothing was indicated for treatment. The forearm was immobilized for a week, due to a diagnosis of contusion. These x-rays were not recovered.

After a week, on 08/14/2015, the splint was removed and residual edema in the wrist and local pain were found. The following week, on 08/17/2015, he was evaluated by another orthopedist who repeated the x-rays and diagnosed a cyst on the radius and a small fracture above, figures 1 to 5.

Figura 1: Radiografia do antepé frente, de 17/08/2015, com lesão de rarefação óssea na falange proximal do segundo dedo do pé direito.
Figure 1: Radiograph of the front forefoot, from 08/17/2015, with bone rarefaction lesion in the proximal phalanx of the second toe of the right foot.
Figura 2: Radiografia do antepé oblíqua, de 17/08/2015, com lesão de rarefação óssea na falange proximal do segundo dedo do pé direito e descontinuidade da cortical do lado medial.
Figure 2: Oblique x-ray of the forefoot, dated 08/17/2015, with bone rarefaction lesion in the proximal phalanx of the second toe of the right foot and cortical discontinuity on the medial side.
Figura 3: Radiografia do punho, frente, de 17/08/2015, apresentando lesão de rarefação óssea na região metafisária do radio direito.
Figure 3: X-ray of the wrist, front, from 08/17/2015, showing a bone rarefaction lesion in the metaphyseal region of the right radius.
Figura 4: Radiografia do punho, oblíqua, de 17/08/2015, apresentando lesão de rarefação óssea na região metafisária do radio direito, de limites imprecisos, sem reação periosteal.
Figure 4: Oblique X-ray of the wrist, dated 08/17/2015, showing a bone rarefaction lesion in the metaphyseal region of the right radius, with imprecise limits, without periosteal reaction.
Figura 5: Laudo das radiografias do pé e punho direitos, de 17/08/2015.
Figure 5: X-ray report of the right foot and wrist, dated 08/17/2015.

He was advised to rest the joint, “without immobilization” and indicating observation and follow-up for another two to three weeks. To recover the movement, “lost with the splint”, ten physiotherapy sessions were recommended, starting immediately, between August 18th and 31st.

With the apparent reduction of pain, after 09/07/2015, he returned to sports activities at school, basketball and football, reappearing the edema of the wrist and the recurrence of pain. Basketball was stopped again.

On Sunday, 09/20/2015, after a day with lots of physical activities, walking, swimming, there was an increase in edema and pain in the right wrist. The following day, new x-rays of the wrist were taken, which identified the evolution of the injury, figures 6 and 7.

Figura 6: 2015-09-21-Rx do punho frente.
Figure 6: 2015-09-21-Front wrist Rx.
Figura 7: 2015-09-21-Rx do punho perfil.
Figure 7: 2015-09-21-Rx of the handle profile.
With this finding, tomography, resonance, scintigraphy and laboratory tests were performed, Figures 8 to 79.
Figura 8: 2015-09-22 CT
Figure 8: 2015-09-22 CT
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Figura 61: Rm -cor fat, de 22/09/2015
Figure 61: Rm - fat color, dated 09/22/2015
Figura 62: Rm-cor t2 stir, de 22/09/2015
Figure 62: Rm-cor t2 stir, from 09/22/2015
Figura 63: Rm - cor t1 fse, de 22/09/2015
Figure 63: Rm - color t1 fse, dated 09/22/2015
Figura 64: Rm - cor t2 fat, de 22/09/2015
Figure 64: Rm - color t2 fat, dated 09/22/2015
Figura 65: Rm - cor t1, de 22/09/2015
Figure 65: Rm - color t1, dated 09/22/2015
Figura 66: Rm - cor t2 fat, de 22/09/2015
Figure 66: Rm - color t2 fat, dated 09/22/2015
Figura 67: Rm - sag t1, de 22/09/2015
Figure 67: Rm - sag t1, dated 09/22/2015
Figura 68: Rm - sag t1, de 22/09/2015
Figure 68: Rm - sag t1, dated 09/22/2015
Figura 69: Rm - ax t1, de 22/09/2015
Figure 69: Rm - ax t1, dated 09/22/2015
Figura 70: Rm - ax t1, de 22/09/2015
Figure 70: Rm - ax t1, dated 09/22/2015
Figura 71: Rm - ax t1 in-out, de 22/09/2015
Figure 71: Rm - ax t1 in-out, from 09/22/2015
Figura 72: Rm - ax t1 in-out, de 22/09/2015
Figure 72: Rm - ax t1 in-out, from 09/22/2015
Figura 73: Rm - ax t2 fat, de 22/09/2015
Figure 73: Rm - ax t2 fat, dated 09/22/2015
Figura 74: Rm - ax t2 fat, de 22/09/2015
Figure 74: Rm - ax t2 fat, dated 09/22/2015
Figura 75: Rm - ax t1 fat, de 22/09/2015
Figure 75: Rm - ax t1 fat, from 09/22/2015
Figura 76: Rm cor t1 fat,de 22/09/2015
Figure 76: Rm color t1 fat, dated 09/22/2015
Figura 77: Rm sag t1 fat, de 22/09/2015
Figure 77: Rm sag t1 fat, dated 09/22/2015
Figura 78: Exames laboratoriais 23/09/2015
Figure 78: Laboratory tests 09/23/2015
Figura 79: Exames laboratoriais 23/09/21015
Figure 79: Laboratory tests 09/23/21015
Figura 80: RX do punho frente em 29/09/2015
Figure 80: X-ray of the front wrist on 09/29/2015
Figura 81: RX do punho perfil em 29/09/2015
Figure 81: X-ray of the wrist profile on 09/29/2015
Figura 82: RX do pé frente em 29/09/2015
Figure 82: X-ray of the front foot on 09/29/2015
Figura 83: RX do pé frente em 29/09/2015
Figure 83: X-ray of the front foot on 09/29/2015
Figura 84: Cintilografia óssea de 22/09/2015, anterior.
Figure 84: Bone scintigraphy from 09/22/2015, previous.
Figura 85: Cintilografia óssea de 22/09/2015, posterior.
Figure 85: Bone scintigraphy of 09/22/2015, later.
Figura 86: Cintilografia óssea de 22/09/2015, pé direito e esquerdo, localzada.
Figure 86: Bone scintigraphy on 09/22/2015, right and left foot, located.
Figura 87: Cintilografia óssea de 22/09/2015, punhos e maos, localizada.
Figure 87: Bone scintigraphy of 09/22/2015, wrists and hands, located.
Figura 88: Cintilografia óssea de 22/09/2015, laudo.
Figure 88: Bone scintigraphy of 09/22/2015, report.
Figura 89: Exame físico em 30/09/2015
Figure 89: Physical examination on 09/30/2015
Figura 90: Exame físico em 30/09/2015
Figure 90: Physical examination on 09/30/2015

Wrist circumference on 10/17/2015: left= 14.0 cm; right: 16.0 cm

Figura 91: Lâmina da biópsia de congelação
Figure 91: Frozen biopsy slide
Figura 92: Relatório da biopsia de congelação
Figure 92: Frozen biopsy report
Figura 93: Laudo da anatomia patológica parafina HE.
Figure 93: HE paraffin pathological anatomy report.
Figura 94: Laudo da imunohistoquímica
Figure 94: Immunohistochemistry report
Figura 96: Lâmina b.
Figure 95: Blade a.
Figure 96: Blade b.
Figura 98: Lâmina d.
Figure 97: Blade c.
Figure 98: Blade d.
Figura 99: IH – CD1a
Figure 99: IH – CD1a
Figura 104: RX de tórax e bacia em 03/10/2015
Figure 104: Chest and pelvis X-ray on 10/03/2015
Figura 105: RX de crânio frente e perfil em 03/10/2015
Figure 105: Front and profile skull X-ray on 10/03/2015
Figura 106: RX de joelhos,tornozelos, pés e tíbia em 03/10/2015
Figure 106: X-ray of knees, ankles, feet and tibia on 10/03/2015
Figura 107: Rx de mãos e úmeros em 03/10/2015.
Figure 107: X-ray of hands and humeri on 10/03/2015.
Figura 108: RX de coluna cervical, toracica e lombar em 03/10/2015
Figure 108: X-ray of the cervical, thoracic and lumbar spine on 10/03/2015
Figura 109: Rx do antebraço, fêmur,tíbia e fíbula em 03/10/2015
Figure 109: X-ray of the forearm, femur, tibia and fibula on 10/03/2015
Figura 110: Rx do punho frente em 03/10/2015
Figure 110: Rx of the front wrist on 10/03/2015
Figura 111: Rx de punho perfil em 03/10/2015
Figure 111: Profile wrist x-ray on 10/03/2015
Figura 112: Laudo das radiografias do tórax PA e do esqueleto.
Figure 112: Report of PA chest and skeletal radiographs.
Figura 113: Pet cet em 06/10/2015
Figure 113: Pet cet on 10/06/2015
Figura 114: Pet cet em 06/10/2015
Figure 114: Pet cet on 10/06/2015
Figura 115: Pet cet em 06/10/2015
Figure 115: Pet cet on 10/06/2015
Figura 116: Pet cet em 06/10/2015
Figure 116: Pet cet on 10/06/2015
Figura 118: Pet cet em 06/10/2015
Figure 117: Pet cet on 10/06/2015
Figure 118: Pet cet on 10/06/2015
Figura 119: Pet cet em 06/10/2015
Figure 119: Pet cet on 10/06/2015
Figura 116: Pet com captação na falange proximal do segundo dedo do pé direito, SUV 2.9
Figure 116: Pet with capture in the proximal phalanx of the second toe of the right foot, SUV 2.9
Figura 117: Captação no segundo dedo do pé direito.
Figure 117: Capture in the second toe of the right foot.
Figura 118: A seta vermelha assinala a captação na falange.
Figure 118: The red arrow indicates capture in the phalanx.
Figura 119: Hipercaptação na falange, seta branca apontando a lesão na falange do pé direito.
Figure 119: Hypercapture in the phalanx, white arrow pointing to the lesion in the phalanx of the right foot.
Figura 120: Exame físico em 07/10/2015
Figure 120: Physical examination on 10/07/2015
Figura 121: Exame físico em 07/10/2015
Figure 121: Physical examination on 10/07/2015
Figura 122: Rx do punho frente em 15/10/2015
Figure 122: Rx of the front wrist on 10/15/2015
Figura 123: Rx do punho perfil em 15/10/2015
Figure 123: Rx of the wrist profile on 10/15/2015
Figura 124: Aspecto clínico em 17/10/2015.
Figure 124: Clinical appearance on 10/17/2015.
Figura 125: Aspecto clínico em 17/10/2015.
Figure 125: Clinical appearance on 10/17/2015.
Wrist circumference on 10/17/2015: left= 14.3 cm; right: 15.5 cm
Figura 126: ax-ti-fse em 16/10/2015
Figure 126: ax-ti-fse on 10/16/2015
Figura 127: ax-t1-fse 16/10/2015
Figure 127: ax-t1-fse 10/16/2015
Figura 128: ax-t1-fs em 16/10/2015
Figure 128: ax-t1-fs on 10/16/2015
Figura 129: ax-t1-fse em 16/10/2015
Figure 129: ax-t1-fse on 10/16/2015
Figura 130: ax-t1-fs em16/10/2015
Figure 130: ax-t1-fs on 10/16/2015
Figura 131: ax-t1-fsfgr em 16/10/2015
Figure 131: ax-t1-fsfgr on 10/16/2015
Figura 132: 8ax-t1-fsfgr-2
Figure 132: 8ax-t1-fsfgr-2
Figura 133: axx-t1-FSPGR em 16/10/2015
Figure 133: axx-t1-FSPGR on 10/16/2015
Figura 134: cor-t1-fs
Figure 134: cor-t1-fs
Figura 135: cor-t1-fse
Figure 135: cor-t1-fse
Figura 136: cor-t1-FSPGR
Figure 136: cor-t1-FSPGR
Figura 137: cot ti-fspgr
Figure 137: cot ti-fspgr
Figura 138: sag-t1-fsfgr
Figure 138: sag-t1-fsfgr
Figura 139: sag-ti fsfgr
Figure 139: sag-ti fsfgr
Figura 140: sag-t2-fs
Figure 140: sag-t2-fs
Figura 141: sag t2-fse
Figure 141: sag t2-fse

On May 30, 2016, after six months of treatment with IV Vinblastine, Mercaptopurine and Meticorten (50 mg), the patient returned for evaluation. During this period, he had an episode of pain and swelling of the wrist in January 2016, the x-rays of which are shown in figures 142 and 143. The wrist was kept immobilized and re-evaluated on 11-04-2016, figures 144 and 145.

Figura 142: Radiografia do punho frente, em 23/01/206, com fratura descolamento epifisário (Salter Harris I). Observe o desalinhamento entre a cortical metafisária, linha amarela e a epífise, linha vermelha.
Figure 142: Radiograph of the front wrist, on 01/23/206, with epiphyseal detachment fracture (Salter Harris I). Note the misalignment between the metaphyseal cortex, yellow line, and the epiphysis, red line.
Figura 143: Radiografia em perfil, salientando o desvio volar e o desnível da placa fisária.
Figure 143: Profile x-ray, highlighting the volar deviation and unevenness of the physeal plate.
Figura 144: Cicarização da lesão, permanecendo discreta deformidade, porém mantendo o alinhamento.
Figure 144: Healing of the lesion, with slight deformity remaining, but maintaining alignment.
Figura 145: Controle de 11/04/2016, com alinhamento satisfatório, não requerendo correção.
Figure 145: Control from 04/11/2016, with satisfactory alignment, not requiring correction.
Figura 146: Cintilografia de 17/-05-2016, com hipercaptação no punho e antepé direito.
Figure 146: Scintigraphy on 05/17/2016, with high uptake in the right wrist and forefoot.
Figura 147: Cintilografia de 17/-05-2016, em detalhe a hipercaptação no punho direito.
Figure 147: Scintigraphy of 17/-05-2016, in detail the hyperuptake in the right wrist.
Figura 148: Hipercaptação no antepé direito.
Figure 148: Hypercapture in the right forefoot.
Figura 149: Tomografia de 31/Maio?2016, densidade para tecido ósseo.
Figure 149: Tomography of May 31, 2016, density for bone tissue.
Figura 150: Tomografia de 31/Maio?2016, densidade para tecidos moles.
Figure 150: Tomography of May 31, 2016, density for soft tissues.
Figura 151: Tomografia de 31/Maio?2016, corte coronal.
Figure 151: Tomography of May 31, 2016, coronal section.
Figura 152: Tomografia de 31/Maio?2016, corte coronal.
Figure 152: Tomography of May 31, 2016, coronal section.
Figura 153: Reconstrução tomográfica de 31/Maio/2016, coronal.
Figure 153: Tomographic reconstruction of May 31, 2016, coronal.
Figura 154: Reconstrução tomográfica de 31/Maio/2016, sagital.
Figure 154: Tomographic reconstruction of May 31, 2016, sagittal.
Figura 155: Tomografia de 31/Maio/2016, coronal, densidade para tecidos moles.
Figure 155: Tomography of May 31, 2016, coronal, density for soft tissues.
Figura 156: Tomografia de 31/Maio/2016, sagital, densidade para tecidos moles.
Figure 156: Tomography of May 31, 2016, sagittal, density for soft tissues.
Figura 157: Tomografia de 31/Maio/2016, sagital, densidade para tecido ósseo.
Figure 157: Tomography of May 31, 2016, sagittal, density for bone tissue.
Figura 158: Tomografia de 31/Maio/2016, sagital, densidade para tecido ósseo.
Figure 158: Tomography of May 31, 2016, sagittal, density for bone tissue.
On the same date, 05/23/2016, he underwent an MRI exam, shown in figures 159 to 172.
Figura 159: Rm axial T1
Figure 159: T1 axial Rm
Figura 160: Rm axial T1
Figure 160: T1 axial Rm
Figura 161: Rm axial T1 Fat Sat.
Figure 161: Axial Rm T1 Fat Sat.
Figura 162: Rm axial T1, Fat Sat.
Figure 162: T1 axial Rm, Fat Sat.
Figura 163: Rm axial T2
Figure 163: T2 axial Rm
Figura 164: Rm axial T2
Figure 164: T2 axial Rm
Figura 165: Rm coronal T1
Figure 165: Coronal MRI T1
Figura 166: Rm coronal T1, Fat Sat
Figure 166: Coronal MRI T1
Figura 167: Rm coronal T1, Fat Sat
Figure 167: Coronal Rm T1, Fat Sat
Figura 168: Rm coronal T1, Fat Sat.
Figure 168: Coronal Rm T1, Fat Sat.
Figura 169: Rm coronal T2
Figure 169: Coronal MRI T2
Figura 170: Rm coronal T2.
Figure 170: Coronal T2 MRI.
Figura 171: Rm sagital T2.
Figure 171: T2 sagittal MRI.
Figura 172: Rm sagital T2.
Figura 172: Rm sagital T2.
Figura 173: Rm sagital T1, pós Gad..
Figure 173: T1 sagittal MRI, post Gad..
Figura 174: Rm sagital T1, pó Gad..
Figure 174: T1 sagittal MRI, Gad powder.
The patient came for our reevaluation, after six months of chemotherapy, with IV Vinblastine, Mercaptopurine and Meticorten (50 mg). The clinical aspect can be seen in figures 175 and 176.
Figura 175: Aspecto clínico em 30/05/2016, extensão dos dedos e pronação do punho, discreto alargamento do lado direito.
Figure 175: Clinical appearance on 05/30/2016, finger extension and wrist pronation, slight enlargement on the right side.
Figura 176: Aspecto clínico em 30/05/2016, flexão dos dedos, discreta deformidade angular, com desvio volar à direita.
Figure 176: Clinical appearance on 05/30/2016, flexion of the fingers, slight angular deformity, with volar deviation to the right.
Due to persistent changes in images and clinical signs of recurrent episodes of pain and swelling in the wrist, we advised people to stay away from sports, avoid movements that lead to wrist sprains, and suspend analgesic medication for a period of approximately two months. After this period of observation, perform imaging tests for analysis and definition of management. Return/inform the office beforehand if you present unfavorable clinical symptoms, or return early for our reevaluation.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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