EURORAD ESR

Case 14925

A rare, deceptive cause of lower abdominal pain: ilio-femoral septic thrombophlebitis

Author(s)
Tonolini Massimo, MD

"Luigi Sacco" University Hospital,
Radiology Department;
Via G.B. Grassi 74
20157 Milan, Italy;
Email:mtonolini@sirm.org
 
Patient
female, 21 year(s)
 
 
  • Figure 1
    Initial contrast-enhanced multidetector CT
     

    Axial images (a...c in craniocaudal order) showed mild peritoneal cul-de-sac fluid (o); a 4-cm left subperitoneal abscess collection (arrows) surrounded by inflammatory fat stranding (+) abutting the external iliac...

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    The peripherally enhancing left subperitoneal abscess (arrows) caused mass effect on the urinary bladder, and was associated to non-opacification of ipsilateral ilio-femoral vein (arrowheads). Note peritoneal...

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    The left ilio-femoral vein (arrowhead) showed luminal non-opacification, wall enhancement and surrounding inflammatory fat stranding (+) suggesting a septic nature of the thrombosis.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    Coronal-reformatted images (d,e) confirmed peripherally enhancing left subperitoneal abscess (arrows) surrounded by fat stranding (+), exerting mass effect on hyperaemic fascia (thin arrows). Additionally, the...

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    The subperitoneal abscess (arrows), surrounded by fat stranding (+), exerted mass effect on the inflamed fascia (thin arrows. Note mass effect on bladder, ilio-femoral thrombosis (arrowhead), oedematous submucosal...

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;
     
     
  • Figure 2
    Transvaginal ultrasound
     

    Both adnexa (calipers in images a & b) showed normal size, ovoid shape, and follicular structure.

     
    Area of Interest: Genital / Reproductive system female; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    Both adnexa (calipers in images a & b) showed normal size, ovoid shape, and follicular structure.

     
    Area of Interest: Genital / Reproductive system female; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    The uterus had normal position, shape and size on this midsagittal image. The endometrium was well visible, consistent with post-ovulatory phase. Note pelvic cul-de-sac effusion (o).

     
    Area of Interest: Genital / Reproductive system female; Imaging Technique: Ultrasound; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;
     
     
  • Figure 3
    Initial unenhanced and gadolinium-enhanced MRI (48 hours after Fig.1)
     

    T1-weighted images showed minimally decreased pelvic peritoneal effusion (o), persistence of left subperitoneal mass-forming perivascular phlegmon (+) with intermediate T1 signal intensity.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    Fat-suppressed (b) and conventional (c,d) T2-weighted images showed minimally decreased pelvic peritoneal effusion (o), persistent left subperitoneal mass-forming perivascular phlegmon (+) with hyperintense signal.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    T2-weighted images (c,d) showed persistent left subperitoneal mass-forming perivascular phlegmon (+) with fluid-like abscess cavity (arrows).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    T2-weighted images (c,d) showed persistent left subperitoneal mass-forming perivascular phlegmon (+) with fluid-like abscess cavity (arrows).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    High b-value (800) diffusion-weighted acquisition showed mildly hyperintense phlegmonous inflammatory tissue (+), stronger hyperintensity of abscess cavity (arrow) with corresponding low signal on apparent diffusion...

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    High b-value (800) diffusion-weighted acquisition showed strong hyperintensity of abscess cavity (arrow) with corresponding low signal on apparent diffusion coefficient map (f), consistent with presence of pus.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    After intravenous gadolinium contrast, fat-suppressed T1-weighted images showed serpiginous enhancement of perivascular phlegmon (+).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    On post-gadolinium fat-suppressed T1-weighted images, the abscess showed central nonenhancement and strong peripheral contrast uptake. Note serpiginous enhancement of perivascular phlegmon (+).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;
     
     
  • Figure 4
    Follow-up unenhanced and gadolinium-enhanced MRI (2 weeks after Fig.2)
     

    Fat-suppressed T2- (a) and post-contrast T1-(b) weighted images showed resolution of abscess, decreased perivascular inflammatory phlegmon (+), further decrease of pelvic peritoneal effusion (o).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    Fat-suppressed T2- (a) and post-contrast T1-(b) weighted images showed resolution of abscess, decreased perivascular inflammatory phlegmon (+), further decrease of pelvic peritoneal effusion (o).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;

    Coronal T2-weighted images confirmed normal appearance of both adnexa (thick arrows).

     
    Area of Interest: Veins / Vena cava; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Embolism / Thrombosis;
     
     
Axial images (a...c in craniocaudal order) showed mild peritoneal cul-de-sac fluid (o); a 4-cm left subperitoneal abscess collection (arrows) surrounded by inflammatory fat stranding (+) abutting the external iliac vessels. Note bladder displacement.
 
The peripherally enhancing left subperitoneal abscess (arrows) caused mass effect on the urinary bladder, and was associated to non-opacification of ipsilateral ilio-femoral vein (arrowheads). Note peritoneal cul-de-sac fluid (o).
 
The left ilio-femoral vein (arrowhead) showed luminal non-opacification, wall enhancement and surrounding inflammatory fat stranding (+) suggesting a septic nature of the thrombosis.
 
Coronal-reformatted images (d,e) confirmed peripherally enhancing left subperitoneal abscess (arrows) surrounded by fat stranding (+), exerting mass effect on hyperaemic fascia (thin arrows). Additionally, the contracted sigmoid colon (thick arrows) showed oedematous submucosal thickening.
 
The subperitoneal abscess (arrows), surrounded by fat stranding (+), exerted mass effect on the inflamed fascia (thin arrows. Note mass effect on bladder, ilio-femoral thrombosis (arrowhead), oedematous submucosal thickening of sigmoid colon (thick arrows).
 
Both adnexa (calipers in images a & b) showed normal size, ovoid shape, and follicular structure.
 
Both adnexa (calipers in images a & b) showed normal size, ovoid shape, and follicular structure.
 
The uterus had normal position, shape and size on this midsagittal image. The endometrium was well visible, consistent with post-ovulatory phase. Note pelvic cul-de-sac effusion (o).
 
T1-weighted images showed minimally decreased pelvic peritoneal effusion (o), persistence of left subperitoneal mass-forming perivascular phlegmon (+) with intermediate T1 signal intensity.
 
Fat-suppressed (b) and conventional (c,d) T2-weighted images showed minimally decreased pelvic peritoneal effusion (o), persistent left subperitoneal mass-forming perivascular phlegmon (+) with hyperintense signal.
 
T2-weighted images (c,d) showed persistent left subperitoneal mass-forming perivascular phlegmon (+) with fluid-like abscess cavity (arrows).
 
T2-weighted images (c,d) showed persistent left subperitoneal mass-forming perivascular phlegmon (+) with fluid-like abscess cavity (arrows).
 
High b-value (800) diffusion-weighted acquisition showed mildly hyperintense phlegmonous inflammatory tissue (+), stronger hyperintensity of abscess cavity (arrow) with corresponding low signal on apparent diffusion coefficient map (f).
 
High b-value (800) diffusion-weighted acquisition showed strong hyperintensity of abscess cavity (arrow) with corresponding low signal on apparent diffusion coefficient map (f), consistent with presence of pus.
 
After intravenous gadolinium contrast, fat-suppressed T1-weighted images showed serpiginous enhancement of perivascular phlegmon (+).
 
On post-gadolinium fat-suppressed T1-weighted images, the abscess showed central nonenhancement and strong peripheral contrast uptake. Note serpiginous enhancement of perivascular phlegmon (+).
 
Fat-suppressed T2- (a) and post-contrast T1-(b) weighted images showed resolution of abscess, decreased perivascular inflammatory phlegmon (+), further decrease of pelvic peritoneal effusion (o).
 
Fat-suppressed T2- (a) and post-contrast T1-(b) weighted images showed resolution of abscess, decreased perivascular inflammatory phlegmon (+), further decrease of pelvic peritoneal effusion (o).
 
Coronal T2-weighted images confirmed normal appearance of both adnexa (thick arrows).
 
 
 
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