A 65-year-old female patient was admitted to our surgical department, complaining of a painful lumbar mass with high fever, which developed a few days after falling down the stairs. Physical examination revealed a temperature of 39°C and a palpable, protruding, fluctuating, and erythematous lumbar mass. Past medical history was unremarkable. Routine laboratory data on admission showed leukocytosis (WBC 41,270/μl, PMNs 87%) and anemia (Hct 29.6%, Hb 9.2 g/dl). ECG recordings and chest radiographs were normal.
Contrast-enhanced ultrasound (CEUS) revealed a hypoechoic mass of 9.8 × 8 × 11 cm with an irregular and heterogeneous structure and abundant vascularization. Having not excluded in our differential diagnosis an abscess formation, paracentesis was performed which revealed pus with abundant pyospheres and a negative culture. A wide drainage procedure was decided on, and sticky material was encountered along with extensive bleeding from the tumor site. Biopsy material was sent for pathological examination. Postoperatively, there was no clinical and biochemical improvement and our patient remained distressed, despite the use of wide spectrum intravenous antibiotics.
Abdominal CT scan was performed, and the report led to the diagnosis of a paraspinal abscess formation (fig. ). Under ultrasound guidance, percutaneous drainage was attempted unsuccessfully due to the thick consistency of the tumor content. A repeat ultrasound examination showed pronounced vascularization inside an ill-defined structure with contrast material oozing from the paracentesis site, thus a sarcoma was suspected by the radiologists.
An axial computed tomography demonstrating a right paraspinal abscess.
At that time, we obtained the biopsy results that showed malignant fibrous histiocytoma of inflammatory type. Immunohistochemistry revealed positive reactivity to CD68 and vimentin and negative reactivity to CKAE1, CKAE3, EMA, CD45, CD15, CD30, S100, HMB45, MELAN-A, actin, desmin, MVOD1, CD34, CD99, chromogranin, and synaptophysin (fig. ). Our patient was scheduled for magnetic resonance imaging, which showed a large heterogeneous space-occupying lesion with lobular peripheral architecture at the anatomical site of the right sacrospinalis muscle, with signs of malignant infiltration of the right iliac bone (fig. ).
a Phagocytic activity of neoplastic cells (H&E, × 200); b positive reactivity of malignant xanthomatous cells (CD68, × 400); c positive reactivity of malignant cells (vimentin, × 200).
Magnetic resonance imaging (sagittal and coronary views) demonstrating a large heterogeneous mass with lobular peripheral architecture at the anatomical site of the right sacrospinalis muscle, with malignant infiltration of the right iliac bone.
After an oncological consultation meeting, the tumor was considered inoperable and the patient was scheduled for neoadjuvant radiotherapy. Unfortunately, excessive bleeding occurred that required multiple transfusions. Finally, our patient died 5 months after the initial presentation of the disease.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.