LEGENDS
Figure 1 Timeline of events from initiation of chemotherapy
treatment to time of publication
#1 Course 1 induction chemotherapy (MEC) with mitoxantrone
25mg/m2, etoposide 750mg/m2 and
cytarabine 2800mg/m2 administered.
#2 Course 2 induction chemotherapy (ADxE) with cytarabine
1400mg/m2, daunorubicin 180mg/m2 and
etoposide 450mg/m2 administered.
1 Day 29 marrow confirmed remission status with MRD<0.1%
2 Day 40 marrow before course 2 induction chemotherapy continued in
remission with MRD<0.1%
3 Bone marrow aspirate performed 2 weeks after completion of 1 course of
low dose bridging chemotherapy (prior to consideration of starting
consolidation chemotherapy) confirmed persistent remission status with
MRD<0.1%
4 Regular 4-weekly bone marrow aspirate confirmed remission with
MRD<0.1%
5 Regular 4-weekly bone marrow aspirate confirmed remission with
MRD<0.1%
1 MRI of right lower limb revealed bilateral shotty groin lymph nodes,
largest 1.6cm at right groin and 1cm at right popliteal fossa,
accompanied with subcutaneous edema over right upper medial and
posterior distal thigh (Fig. 1A) . Neutrophil and monocyte
counts were all along less than 1 x 109/L and
0.2x109/L respectively.
2 MRI of groins and right ankle showed abscess at right groin and
lateral aspect of right ankle with underlying osteomyelitis of calcaneus(Fig 1B) .
3 MRI of bilateral lower limbs showing interval improvement in
inflammatory changes over bilateral femur, tibia and right calcaneus
4 MRI of hips showing mild synovitis
5 MRI of right ankle showed minimal residual inflammatory changes at
right calcaneus
Bx USG-guided aspiration and biopsy were performed, which yielded
granulomas with surrounding suppurative inflammation (Fig. 1C) .
A moderate number of AFB were highlighted on aspirate sample. Neutrophil
and monocyte counts recovered.
1 PET-CT showed abscesses in right posterior thigh and popliteal fossa
(SUVmax 3.8), right calcaneal osteomyelitis
(SUVmax 9.4), as well as multiple hypermetabolic LN at
right groin (SUVmax 6.5) extending to right internal
iliac LN (Fig. 1D) .
2 PET-CT showed worsening of right calcaneal osteomyelitis with
increased bony lysis
3 PET-CT showed residual infective focus at right calcaneus with
interval reduction in metabolic activity over right groin and right
popliteal fossa.
4 PET-CT showed resolution of right groin lymphadenopathy and right
popliteal fossa subcutaneous lesion, also decreased metabolic activity
at right calcaneus.
§1 First operation on calcaneal bone excision and debridement of right
ankle
§2 Second operation involving I&D of right groin and popliteal
abscesses along with debridement of right ankle soft tissue
§3 Third operation on sequestrectomy of right calcaneus and insertion of
antibiotic-infused cement (vancomycin, amikacin and gentamycin)
§4 Fourth operation on removal of antibiotic-infused cement and bone
graft insertion
Figure 2 (A) MRI of bilateral hips and thigh showing bilateral
shotty groin LN accompanied with subcutaneous edema over right upper
medial thigh and posterior distal thigh (B) MRI of right ankle showing
T1 hypointense and T2 hyperintense signals at right talus, right distal
tibia, right third proximal metatarsal, right distal fibula, right
calcaneus and right posterior ankle. (C) Suppurative aspirate obtained
by ultrasound-guided aspiration of right groin abscess (D) PET-CT 12
days after first operation showing abscesses in right posterior thigh
and popliteal fossa (SUVmax 3.8), right calcaneal
osteomyelitis (SUVmax 9.4), as well as multiple
hypermetabolic LN at right groin (SUVmax 6.5) extending
to right internal iliac LN