Land Mine Radiology 2LT Justin P. Dodge and James Smirniotopoulos, MD Uniformed Services University of the Health Sciences

1
Case of the Day Monday Musculoskeletal

• Smith SE1, Davis KW2
• University of Maryland School of Medicine,
  Baltimore, MD
• University of Wisconsin, Madison, Wisconsin

History 42 year old male with bilateral hip pain
and history of renal transplants.
Figure 1(a,b) AP and Frogleg Hip Radiographs
Figure 2 Pelvic Hip MRI (a) Cor T1 (b) Cor IR
(c) Cor T1 FS post Gadolinium
Findings Bilateral hip radiographs demonstrate
large smooth well defined subchondral lucencies
on both sides of the joint, with the acetabular
lesions more elongated. There is mild medial
widening of the hip joints. Lesions are low/iso
signal intensity on T1, intermediate/high
intensity on IR and demonstrate diffuse moderate
enhancement post gadolinium on MRI imaging. The
right femoral neck lesion becomes more visible
post gadolinium. Vascular calcification is in
keeping with history of long term renal failure.
Diagnosis Amyloid Arthropathy of the Hips
Secondary to Long Term Hemodialysis.
Discussion The form of amyloid unique to renal
dialysis patients is B2 microglobulin, a low
molecular weight protein that does not filter
well through dialysis membranes therefore
accumulating in tissues and joints of patients
who present with symptoms after at least 5 years
of dialysis therapy. Deposition of amyloid about
major joints with subchondral bone cyst formation
is a common presentation, with amyloid
accumulating beneath the articular cartilage
which eventually leads to an erosive arthropathy.
This most commonly occurs in the shoulder and the
femoral heads. If the deposits become very large
and pain is increased, curettage and bone
grafting can be performed to avoid impending
fractures.
Figure 3. Axial T1 image demonstrates
intraarticular extension of the nodular amyloid
deposits.
References 1. Otake S, Tsuruta Y, Yamana D,
Mizutani H, Ohba S. Amyloid arthropathy of the
hip joint MR demonstration of presumed amyloid
lesions in 152 patients with long term
hemodialysis. Eur Radiol 19988(8)1352-6. 2.
Comesana L, DelCastillo M, Martin R, Rodrigues E,
Guerra JL, Soler R. Musculoskeletal amyloid
disease MRI features. Ann Radiol
199538(3)150-2. 3. Kaplan PA, Dussault RG,
Buchanan PK, Berardo PV. Gizienski TA, Short JG.
Amyloid Arthropathy. AJR 1996 Jul
167(1)254,257-8.