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.