History of multiple sacral decubitus ulcers with green discharge, lower extremity paralysis, bedbound. Osteomyelitis? There are multiple soft tissue defects posteriorly. A large gas-filled defect to the left of midline extends to the ischial tuberosity with enhancement of the adjacent soft tissues indicating inflammation. There is abnormal signal intensity and enhancement of the ischial tuberosity indicating osteomyelitis. Nonenhancing tissue also extends from the skin surface of the upper medial right thigh posteriorly to the right ischium, with enhancement of the adjacent soft tissues indicating inflammation. There is focal signal abnormality and enhancement of the adjacent ischial tuberosity that is suggestive of focal osteomyelitis. Nonenhancing tissue is also noted extending from the greater trochanters bilaterally to the posterior skin surface with enhancement of the adjacent soft tissues indicating inflammation. Although there is perhaps minimal enhancement of the underlying marrow of the greater trochanters, the fatty marrow signal intensity on the unenhanced on T1-weighted images is relatively preserved, arguing against osteomyelitis. Evaluation of the lower lumbar spine and sacrum is limited by metallic susceptibility artifact related to orthopedic hardware. There is ulceration of the soft tissues posterior to the sacrum and coccyx. Abnormal signal intensity and enhancement of the underlying in the lower sacral segments and coccyx is suspicious for osteomyelitis as well.There is a peculiar signal intensity pattern of the bone marrow of the pelvis and proximal femora. On the STIR sequences, the signal intensity of the majority of the left innominate bone and sacrum suppresses, as would be expected with fatty marrow. The right innominate bone however is of relatively increased signal intensity on the STIR sequence and shows heterogeneous signal intensity on the T1-weighted sequences. The process involving the right innominate bone is presumably the same process causing the mottled appearance of the right innominate bone and proximal femur on a prior CT scan; of note, I see no increased enhancement of the right innominate bone, nor was there FDG avidity of the bone on the prior PET scan. This could reflect treated tumor or perhaps osteonecrosis. A 3 cm focus of abnormal signal intensity in the intertrochanteric region of the left femur corresponds to a lesion on CT with a sclerotic rim, also perhaps representing treated tumor or osteonecrosis. This likewise did not show uptake on the recent PET scan.A small amount of fluid is noted within both hip joints but I see no large joint effusion. There is generalized increased signal intensity of the musculature on the fat-suppressed T2-weighted images which may reflect edema, but I see no frank enhancement of the musculature (other than that adjacent to the aforementioned ulcers) to confirm inflammation. There is also edema of the subcutaneous tissues. I see no drainable fluid collection. There appears to be relative loss of subcutaneous fat involving the upper right thigh compared to the upper left thigh. There is a Foley catheter in the bladder.
1. Extensive decubitus ulceration with tracks leading to both ischia and both greater trochanters. There are findings of osteomyelitis of the ischia, particularly on the left. Preservation of fatty marrow within the greater trochanters on the T1-weighted images argues against osteomyelitis of the proximal femora. Abnormal signal intensity and enhancement of the lower sacral segments and coccyx is also suspicious for osteomyelitis. The diagnosis of osteomyelitis was relayed to the clinical service prior to dictation.2. Peculiar bone marrow signal intensity pattern as described above may reflect treated tumor or perhaps osteonecrosis.3. Other findings as described above.