case_images: PMC11349513_01
case_images: MRI imaging. The prostate lesions showed heterogeneous intensity on T2WI (A), heterogeneous hyperintensity on DWI (B), and an apparent diffusion coefficient (ADC) with hypointensity (C). A lesion with hyperintensity on T2WI around the right iliopsoas muscle (D). Bilateral iliac bone destruction on T1WI (E).
case_images: fmed-11-1430300-g001.jpg
case_images: PMC11349513_01_fmed-11-1430300-g001.jpg
case_images: fig1
case_images: Some important dates and times, as well as the magnetic resonance imaging (MRI), 2-Deoxy-2-[fluorine-18]-fluoro-D-glucose (18F-FDG), and [fluorine-18]-prostate-specific membrane antigen (18F-PSMA) of the patient, are shown in Supplementary Figure S1. The MRI showed prostate lesions with isointensity on T1-weighted imaging (T1WI), heterogeneous intensity on T2-weighted imaging (T2WI) (Figure 1A), heterogeneous hyperintensity on diffusion-weighted imaging (DWI) (Figure 1B), and an apparent diffusion coefficient (ADC) with hypointensity (Figure 1C). A lesion with hyperintensity on T2WI was observed around the right iliopsoas muscle (Figure 1D). Bilateral iliac bone destruction and multiple swollen lymph nodes adjacent to the right iliac vessels were also found (Figure 1E).
case_images: 18F-FDG and 18F-PSMA PET/CT imaging. Multiple FDG-avid lesions (A) on PET MIP images. An unevenly increased FDG uptake on the right side of the prostate, with an SUVmax of 17.6 (B). A high FDG uptake in a low-density lesion on the right iliopsoas muscle, with an SUVmax of 18.6 (C). Destruction of the left iliac bone with an increased FDG uptake (D). Multiple lymph nodes of the left neck with a high FDG uptake (E). Multiple PSMA-avid lesions (F) on PET MIP images. A slightly unevenly increased PSMA uptake in the prostate (G), the low-density lesion of the right iliopsoas muscle (H), bones (I), and lymph nodes (J).
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case_images: PMC11349513_01_fmed-11-1430300-g002.jpg
case_images: fig2
case_images: The 3-dimensional maximum intensity projection (MIP) image of the 18F-FDG PET/CT showed multiple FDG-avid lesions (Figure 2A). The prostate displayed an unevenly increased FDG uptake, especially on the right side, with an SUVmax of 17.6 (Figure 2B). A low-density lesion on the right iliopsoas muscle showed a high FDG uptake with an SUVmax of 18.6 (Figure 2C). Multiple osteolytic bone destruction was observed in the spine, bilateral ribs, bilateral iliac bones, and the right acetabulum, with an elevated FDG uptake and an SUVmax of 10.3 (Figure 2D). In the abdomen, chest, left armpit, and bilateral neck, multiple lymph nodes showed an increased FDG uptake, with an SUVmax of 18.7 (Figure 2E). The 18F-PSMA PET/CT demonstrated multiple systemic PSMA-avid lesions on the MIP image (Figure 2F). A slightly unevenly increased PSMA uptake was noted in the prostate, with an SUVmax of 3.2 (Figure 2G). In the low-density lesion of the right iliopsoas muscle, the PSMA uptake was slightly unevenly increased and SUVmax was 3.1 (Figure 2H). There was a slightly increased PSMA uptake in the bones and lymph nodes (Figures 2I,J).
case_images: Acid-fast staining of prostate biopsy. (A) Multifocal necrosis with granulomatous lesions (x40). (B) Multinucleated giant cell reaction (x100).
case_images: fmed-11-1430300-g003.jpg
case_images: PMC11349513_01_fmed-11-1430300-g003.jpg
case_images: fig3
case_images: A transperineal ultrasound-guided (TPUS) 12-core prostate biopsy revealed multifocal necrosis with granulomatous lesions (Figure 3A) and multinucleated giant cell reaction (Figure 3B).