case_images: PMC5748088_01
case_images: Gray scale images in transverse (a, c), longitudinal (d), and color Doppler (b) of the distal right thigh of a 51-year-old male with bilateral lower extremities pain and swelling. Images demonstrate area of heterogeneous echogenicity with internal flow in the distal right thigh. Initial interpretation was that the findings might represent muscular hematoma with possible active bleeding from overanticoagulation.
case_images: CRIRA2017-9159035.001.jpg
case_images: PMC5748088_01_CRIRA2017-9159035.001.jpg
case_images: fig1
case_images: The thigh swelling was initially evaluated with ultrasound, which was read as possibly representative of hematoma in the setting of anticoagulation (Figure 1(a)).
case_images: Lower extremity MRI for the same 51-year-old patient obtained a few days after the initial US. (a) is an axial T2 weighted fat suppressed image and (c) is a coronal T2 weighted fat suppressed image of the thighs. The images show multiple T2 hyperintense lesions. The largest lesion on the distal right thigh corresponds to the heterogeneous lesion seen on a week-earlier US. (b, d) are axial and coronal T1 fat suppressed postcontrast images, demonstrating associated enhancement of those lesions. Given the patient history of multiple myeloma, those lesions were suspected to represent extra-axial multiple myeloma, which was confirmed with surgical biopsy few days later.
case_images: CRIRA2017-9159035.002.jpg
case_images: PMC5748088_01_CRIRA2017-9159035.002.jpg
case_images: fig2
case_images: An MRI was obtained of the patient's thighs, which demonstrated extensive soft tissue enhancement bilaterally concerning for extraosseous multiple myeloma rather than hematoma (Figure 2).
case_images: PET CT of the same 51-year-old male after approximately one week from the earlier shown US. ((a) and (c)) are coronal images of the whole body (a) and thighs (c) showing multiple foci of increased FDG uptake. (b) is an axial image of the distal thighs showing multiple foci of increased FDG uptake; the largest lesion on the posterior right thigh has SUV max of 4.3. (d) is a sagittal view of the same lesion showing its craniocaudal extension. Lesions were initially presumed and later biopsy proven to represent extra-axial multiple myeloma.
case_images: CRIRA2017-9159035.003.jpg
case_images: PMC5748088_01_CRIRA2017-9159035.003.jpg
case_images: fig3
case_images: Finally, a PET/CT revealed extensive osseous lesions, pulmonary involvement with pleural effusion, and numerous intramuscular lesions (Figure 3).