Periphyseal edema: always pathology or sometimes physiology?
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LETTER TO THE EDITOR
Periphyseal edema: always pathology or sometimes physiology? Darshana A. Sanghvi1 Received: 8 May 2020 / Accepted: 13 May 2020 © Japan Radiological Society 2020
Dear Editor, The related syndromes of Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis (SAPHO) and Chronic Recurrent Multifocal Osteomyelitis (CRMO) are challenging diagnoses that require astute clinicoradiological correlation. Often, they are diagnoses of exclusion. In their elegant pictorial review, Himuro et al. [1] have described four adult cases of SAPHO and one pediatric case labeled as CRMO. The four adult cases from this review have polyostotic manifestations including typical sternocostoclavicular and manubriosternal involvement with palmoplantar pustulosis; the diagnosis of SAPHO is, therefore, convincing. However, the pediatric case illustrated in Fig. 7 is less classic of CRMO (the pediatric equivalent of SAPHO), as the manifestation is monostotic, without sternoclavicular involvement and with the absence of palmoplantar pustulosis. In this context, I would like to suggest an alternative diagnosis of “Focal Periphyseal Edema” or FOPE for the pediatric case. This entity was first described by Zbojniewicz et al. [2] in his landmark manuscript with the self-explanatory title “Focal Periphyseal Edema (FOPE) Zone on MRI of the Adolescent Knee: A Potentially Painful Manifestation of Physiologic Physeal Fusion?” Since then, this diagnosis has been validated by several other publications [3] with similar cases of self-limiting, benign periphyseal edema in the immature skeleton of adolescents provoked by stress of physeal closure as they approach fusion. At the initial presentation, MR images may sometimes show focal discontinuity of the growth pIate representing the first location of bone fusion of the metaphysis with the epiphysis (or apophysis). These focal, transphyseal trabeculae possibly have reduced localized pliability and respond to physiological stress in adolescents by provoking extensive, but benign periphyseal
* Darshana A. Sanghvi [email protected] 1
Department of Radiology, Kokilaben Dhirubhai Ambani Hospital, Andheri West, Mumbai 400053, India
edema [3, 4]. I would like to illustrate my alternative diagnosis with the case (Fig. 1) of an adolescent of the same age
Fig. 1 Left hip pain in a 12-year-old boy. a At presentation, coronal fat suppressed proton density MR image shows edema in the metaphysis and apophysis adjacent to the greater trochanteric physis. Focal discontinuity (arrow) in the growth plate indicates an area of localized, early bone fusion that may have provoked the periphyseal edema. b Corresponding follow up MRI at 10 months shows resolution of periphyseal edema. Left hip pain gradually resolved over 10 months with minimal supportive treatment for pain alleviation. A diagnosis of focal periphyseal edema (FOPE) was made
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with left hip pain and similar MRI findings. MRI at presentation showed periphyseal edema adjacent to the left trochanteric growth pl
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