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Case Reports
. 2024 Mar 25;17(1):e9.
doi: 10.12786/bn.2024.17.e9. eCollection 2024 Mar.

Nontraumatic Myositis Ossificans After Spontaneous Subarachnoid Hemorrhage: A Case Report

Eunjin Park  1 , Junghyeon Park  2 , So-Youn Chang  1 , Youngkook Kim  1
Affiliations
Case Reports

Nontraumatic Myositis Ossificans After Spontaneous Subarachnoid Hemorrhage: A Case Report

Eunjin Park et al. Brain Neurorehabil. .

Abstract

Myositis ossificans is uncommon in patients with nontraumatic brain injuries. This report presents a challenging case in which myositis ossificans was diagnosed and treated by medical management in a patient who was unable to complain of any symptoms due to akinetic mutism that occurred after nontraumatic subarachnoid hemorrhage. The patient had intermittent high-grade fever, and laboratory tests showed elevated C-reactive protein and D-dimer levels without clinical signs of infection two months after subarachnoid hemorrhage. Lower-extremity venography using computed tomography was performed to rule out deep venous thrombosis. There was no thrombus, but right vastus medialis muscle showed inflammatory change with faint multilayered curvilinear hyperdense rims. The administration of indomethacin helped prevent abnormal bone formation. For the early detection of myositis ossificans, careful observation of clinical presentation and a high index of clinical suspicion is necessary in brain-injured patients. Further, elevated serum inflammatory markers accompanied by elevated alkaline phosphatase can be a critical clue. Early computed tomography helps identify early 'string sign' prior to characteristic ossification. Our report highlights that the myositis ossificans is remediable by early detection and appropriate nonsurgical management.

Keywords: Indomethacin; Myositis Ossificans; Subarachnoid Hemorrhage.

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Conflict of interest statement

Conflict of Interest: The authors have no potential conflicts of interest to disclose.

Figures

Fig. 1
Fig. 1. Clinical course and serial multimodal imaging findings of myositis ossificans. Four serial X-rays show soft tissue swelling and faint, apparent, and fading radiopaque lesions in the right vastus medialis muscle, respectively (black arrows). Two serial computed tomography reveals faint multilayered curvilinear hyperdense rims, suggesting the early phase of myositis ossificans, and circumferential calcification with a radiolucent center, suggesting the maturing ossification (red arrowheads). Two serial bone scintigraphy shows increased uptake in the early phase and decreased uptake after indomethacin treatment (green arrowheads).
Fig. 2
Fig. 2. As the myositis ossificans occurred two months after subarachnoid hemorrhage, the body temperature was elevated, and the CRP fluctuated following changes in body temperature. After the myositis ossificans was resolved, the body temperature and CRP were normalized.
CRP, C-reactive protein.
Fig. 3
Fig. 3. The ALP and γ-GTP were elevated simultaneously as the myositis ossificans occurred, and this trend was linked to changes in CRP level. After myositis ossificans improved, the ALP and γ-GTP were normalized.
ALP, alkaline phosphatase; γ-GTP, γ-glutamyl transferase; CRP, C-reactive protein.
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