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case_images: (A) Pancreatic head collection and surrounding inflammatory changes. Portal venous contrast-enhanced CT axial image of the upper abdomen demonstrates a collection at the pancreatic head containing gas locules consistent with pancreatic duct perforation. No pancreatic necrosis. Extensive inflammatory changes in peripancreatic tissues and mesentery. Common bile duct stent in situ. (B) Pancreatitis with surrounding inflammatory changes and free fluid. Portal venous contrast-enhanced CT coronal image demonstrates inflammatory change and free fluid centred on pancreas consistent with pancreatitis. Common bile duct stent in situ.
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case_images: An initial CT scan revealed findings consistent with pancreatitis and a pancreatic head collection resulting from a perforated pancreatic duct (Figure 1A and B).
case_images: Portal vein thrombus extending into the left portal vein. Portal venous contrast-enhanced CT with maximal intensity projection (MIP) images demonstrates partially occlusive portal vein thrombus extending into left portal vein. Common bile duct and pancreatic stents are in situ.
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case_images: On a subsequent CT, further complication with the development of portal vein thrombosis was seen (Figure 2).
case_images: Ultrasound images demonstrate the appearance of subcutaneous panniculitis. (A, B) Ultrasound of the right dorsal foot demonstrates innumerable subcutaneous nodules of echogenic fat pad in keeping with panniculitis. (C) Ultrasound of the right ankle demonstrates fluid in the tendon sheaths and increased vascularity consistent with tenosynovitis of the extensor hallucis longus and digitorum longus tendons.
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case_images: Furthermore, fluid was seen associated with tendon sheaths as well as thickened synovium, this is consistent with tenosynovitis (Figure 3A-C).
case_images: Multi-sequence MRI images of the right ankle demonstrating subcutaneous panniculitis and intramedullary fat necrosis. T1 FS post-gadolinium contrast in sagittal, long and coronal (left to right). (A) T1 fat saturated and STIR images demonstrate innumerable intramedullary lesions throughout the bones of the right lower limb. They have a serpiginous border with a double rim (on STIR sequence there is a hyperintense line paralleling the inner surface of the hypointense line within the marrow). Internally the lesions demonstrate T1 hypointensity with mild heterogenous T2 hyperintensity. (B) T1 post-gadolinium contrast images demonstrate mild peripheral contrast enhancement with adjacent bone oedema.
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case_images: Increased synovial enhancement and thickening in keeping with polyarthritis (Figure 4A and B).
case_images: (A) Intramedullary fat necrosis with formation of cystic spaces in the distal femur and patella. Intramedullary lesions demonstrating T1- and T2-weighted low signal in the distal femur and patella. There is surrounding rim of enhancement. This is consistent with intramedullary fat necrosis. (B) Pathological fracture of the patella associated with intramedullary fat necrosis. Minimally displaced fracture line through the patella. There is a cystic space within the body of the patella which contains subtle calcification. (C) Intramedullary fat necrosis with cystic spaces and bone cement. Multiple lesions demonstrating low signal in T1- and T2-weighted images. There is partial collapse of the talus, which is filled with bone cement with very low signal T1 and T2 signal, this is seen with increased attenuation on radiograph.
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case_images: The diffuse intramedullary fat necrosis created cavities in the distal right femur, patella, and left ankle (Figure 5B). This resulted in a pathological fracture of the right patella (Figure 5A) as well as collapse of the left talar dome. These cystic spaces were filled with bone cement to prevent further collapse, this appears as very low signal on T1- and T2-weighted MRI images and increased density on radiographs (Figure 5C).