Case Report:
The authors report a case of a 73-year-old, Caucasian male with
background history of type 2 diabetes and arterial hypertension
diagnosed with prostatic adenocarcinoma in December 2018. Radical
prostatectomy was performed, and the patient was started on hormone
therapy with cyproterone and adjuvant radiotherapy (March 2019). He had
1 month history of night sweats and headache and 1 week history of
moderate, non-irradiating pain in the anterior thighs and low-grade
fever. At examination, the patient was pale, sweaty and had a grade 2/5
panfocal heart murmur. Laboratory tests revealed normocytic normochromic
anemia, erythrocyte sedimentation rate (ESR), transaminases, C-reactive
protein (CRP) and procalcitonin. Cultures were drowned and empirical
antibiotics were started. The head CT-scan and lumbar CT-scan were
unremarkable. Blood cultures and serologic tests for atypical agents
were negative. A transthoracic echocardiogram was performed and showed
no valvular vegetations. A thoracic-abdominal-pelvic CT-scan was
performed and showed only moderate hepatomegaly. After ten days of
empirical antibiotic with doxyciclin and gentamicin, the patient
maintained low grade fever and pain in the anterior thighs with
worsening of anemia, SR and transaminases. The CRP and procalcitonin
remained unchanged and the multidisciplinary team decided to suspend
local radiotherapy.
A bone scintigram was performed and suggested the hypothesis of aseptic
femoral head necrosis that was excluded with hip MRI. With development
of mandibular claudication during the hospital stay, a doppler
ultrasound of the temporal arteries was performed and revealed
periluminal hypoechogenic halo reflecting arterial wall edema more
pronounced in the left temporal artery (Figure 1).
The patient was started on 1mg/Kg of prednisolone with clinical
improvement at the first 48 hours and resolution of laboratory
abnormalities. It was not possible to perform the temporal artery biopsy
until the 10th day of therapy and it showed only slight lymphocytic
infiltration.
Local radiotherapy was restarted and the patient was discharged home.
Three months later the patient re-started bilateral hip pain and a
lumbosacral spine MRI was performed and revealed new osteoblastic
lesions in S1, S2 and S3 compatible with bone metastasis.