Investig Magn Reson Imaging.  2017 Jun;21(2):97-101. 10.13104/imri.2017.21.2.97.

Rare Form of Rheumatoid Nodule around Ischial Tuberosity Mimicking Ischiogluteal Bursitis

Affiliations
  • 1Department of Radiology, Inje University Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea. jcshim96@unitel.co.kr
  • 2Department of Orthopedic Surgery, Inje University Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea.
  • 3Department of Pathology, Inje University Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea.

Abstract

We are reporting about a case of a rheumatoid nodule, beneath the ischial tuberosity, mimicking ischiogluteal bursitis. Rheumatoid nodules are frequently seen, at the subcutaneous soft tissues of repetitive mechanical irritation points, and prominent bones. There have been no reported cases of rheumatoid nodules, extending just beneath the ischial tuberosity bone. A 68-year-old woman with a seven-year history of rheumatoid arthritis, suffered for six months, from right buttock swelling and discomfort in seating. A cystic lesion postero-inferior to the ischial tuberosity, was noted in the MRI scan, which was thought to be ischiogluteal bursitis, because of its characteristic location and appearance. Histopathologic analysis and gross findings on the operation, revealed no evidence of bursitis.

Keyword

Rheumatoid nodule; Rheumatoid arthritis; MRI; Ischiogluteal bursitis

MeSH Terms

Aged
Arthritis, Rheumatoid
Bursitis*
Buttocks
Female
Humans
Magnetic Resonance Imaging
Rheumatoid Nodule*

Figure

  • Fig. 1 Cystic rheumatoid nodules in a 68-year-old woman. (a) A coronal T2-weighted image (TR/TE 5619.5/100.0) shows a lesion posteroinferior to the ischial tuberosity. The lesion is not confined only on subcutaneous layer but abutted to the bone, the ischial tuberosity. (b) An axial T1-weighted image (TR/TE 1165.2/18.0) shows a lesion (white arrow) with intermediate signal intensity located under the gluteus maximus and inferior to the ischial tuberosity. Another lesion (black arrow) is noted on the subcutaneous tissue of left buttock area. The lesion also shows intermediate signal intensity on the T1-weighted image. (c) An axial T2-weighted image (TR/TE 6426.3/100.0) shows a lesion (white arrow) with heterogeneous high signal intensity. The nodule on left buttock (black arrow) shows high signal intensity on the T2-weighted image. (d) An axial gadolinium-enhanced T1-weighted image (TR/TE 1742.3/18.0) demonstrates a lesion (white arrow) with rim-like and peripheral capsular enhancement. The gadolinium-enhanced T1-weighted image shows another lesion (black arrow) with mild peripheral capsular enhancement.

  • Fig. 2 Photograph of surgical resection specimen of a rheumatoid nodule. (a) On surgery, the surgeon approaches the lesion from the skin to the deep portion of muscle. (b) On gross finding, the inner surface of the wall of a cystic lesion shows smooth appearance and several villous projections on gross findings. No solid mass is noted.

  • Fig. 3 Photomicrograph of a histologic specimen of rheumatoid nodule. (a) Pathologic specimen (original magnification, ×40; Hematoxylin & Eosin staining) shows epithelioid granuloma with fibrinoid necrosis. Fibrinoid degeneration of collagen (black arrowheads) is surrounded by histiocytes (white star-shapes). (b) Pathologic specimen (original magnification, ×100; Hematoxylin & Eosin staining) shows a large amount of fibrinoid necrotic material surrounded by histiocytes and fibrosis in detail. Prominent number of lymphocytes and plasma cells even forming lymphoid follicles are not seen.


Reference

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