Findings of cesium chloride therapy by CT

Posted By christen chaconas
Findings of cesium chloride therapy by CT

Case Presentation & Clinical History: Patient DP is a 65-year-old Caucasian male with metastatic castration-resistant prostate cancer involving multiple bones. He began androgen deprivation therapy in September 2016 and underwent a routine contrasted Chest CT in December 2016. There was no notable change on this exam from the prior exam. In January of 2017, he began self-administration of an oral solution of cesium chloride (CsCl), at the described dose of 3grams per day. He returned for routine follow-up imaging approximately 2 months after initiating the CsCl therapy. Images from the non-contrasted CT of the chest are attached (Figures 1 and 2). There was marked increase in density of the muscles throughout the chest and abdomen, including muscular layers of the small bowel and esophagus. The most striking feature of this non-contrasted exam was the hyperdensity of the myocardium, approaching 90 Hounsfield units (HU) (Figures 1B and 2B), while only 50 HU on previous non-contrasted exam (Figure 1A, and 2A). Additionally, there was increased density of the liver, spleen, pancreas and spinal cord (Figure 2B). The initial differential diagnosis included iron vs other heavy metal deposition in the body. Because the patient had recently started taking CsCl, the physicians investigated the relationship between CsCl and the striking radiographic findings. Mr. DP’s blood cesium level was found to be markedly elevated, exceeding the maximum measurable level of 5000 mcg/L (upper limit of normal ≤ 3 mcg/L). Since both primary and secondary hemochromatosis can have similar, albeit less striking imaging feature, iron studies were also performed, and found to be normal (Figure 3). Genotyping of the HFE gene for mutations at codons 282, 63, and 65 was also performed. No C282Y or H63D mutations were identified. The patient was heterozygous for the S65C mutation. He reported muscle cramps diffusely, but did not endorse angina, syncope or any other signs of arrhythmia. At the recommendation of his treatment team, Mr. DP discontinued CsCl use, but no additional conventional therapy was initiated. Follow-up labs and non-contrasted CT scan of the chest abdomen and pelvis were obtained 3 months after stopping CsCl. The reported cramping had resolved. Repeat CT scans at that time showed that the muscle hyperdensity had normalized (Figures 1C and 2C and Figure 3). Nearly one year after stopping CsCl the blood cesium level remained markedly elevated, at 2100 mcg/L, though lower than the initial concentration (Table 1). At this point, we have established that CT imaging findings of CsCl therapy exist and can yield striking and unique findings on CT. Radiologists should be aware of these unique CsCl-related findings as the radiologist could be the first to discover a patient’s use of this alternative therapy. Additionally, awareness of this entity may help avoid the pitfall of misdiagnosing other entities which share similar CT findings. With the limited

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