Endgames Picture Quiz

A woman with pain and weakness in both legs

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4721 (Published 23 July 2014) Cite this as: BMJ 2014;349:g4721
  1. Shuang Wang, academic clinical fellow,
  2. Wen Wang, associate professor,
  3. Xiao-yuan Dong, associate professor,
  4. Jun Peng, professor
  1. 1Department of Haematology, Qilu Hospital, Shandong University, Jinan, 250012, China
  1. Correspondence to: J Peng junpeng88{at}sina.com.cn

A 49 year old woman was admitted with a four month history of progressive pain and weakness in both of her legs. Physical examination showed bilateral tenderness of the hips and sacroiliac joints, along with a decline in muscle strength and tension of the lower limbs. Magnetic resonance imaging was requested (fig 1). No lytic bone lesions were detected by radiography. Plasma cells made up less than 2% of nucleated cells in a bone marrow aspirate and biopsy sample, and there was no evidence of a plasma cell neoplasm. No monoclonal proteins were found on electrophoresis or immunofixation of the serum or urine. She did not have anaemia, renal insufficiency, or hypercalcaemia. Phenotyping of peripheral blood lymphocytes showed that the proportion of CD16+CD56+CD3 natural killer cells (5.34%) was low compared with the reference values in our laboratory (14.91%, standard deviation 4.87% in 68 healthy controls). No disturbance in the CD4 to CD8 ratio was noted.1

Questions

  • 1. What do the magnetic resonance images show?

  • 2. What are the differential diagnoses?

  • 3. What is the diagnosis?

  • 4. How would you manage this patient?

Answers

1. What do the magnetic resonance images show?

Short answer

Both T1 weighted and T2 weighted imaging show a mass that is slightly hypointense relative to the spinal cord. Homogeneous enhancement of the mass and a dural tail sign were also seen after intravenous injection of gadolinium-diethylenetriaminepenta-acetate (Gd-DTPA).

Long answer

Magnetic resonance imaging showed a 2.2×1.1×1.3 cm mass at the T11-T12 vertebral level, which was attached to the dura mater by a broad base; the adjacent spinal cord was deformed as a result of compression. It was slightly hypointense relative to the spinal …

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