1. A 35-year old female presented with cough and fever for 3 days and was suspected of having COVID-19. CT scan showed findings consistent with mild COVID-19 as well as additional findings. 2. The additional findings included paraspinal soft tissue masses with calcification in the thoracic region, decreased density of the intraventricular septum, and diffuse increased hepatic attenuation indicating iron overload. 3. The diagnosis was intrathoracic extramedullary hematopoiesis with hepatic iron overload (hemosiderosis/hemochromatosis) likely due to a chronic hemolytic anemia such as thalassemia.

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. A 35 year old female presented with cough and
fever for 3 days duration with suspicion of
COVID-19 .The patient was sent for COVID-19 CT
scan unite.

6. Finding:
1. Multiple different size patches of peripherally
located consolidation more prominent seen in
the lower lobes otherwise normal pulmonary
attenuation, no mass no consolidation…..feature
consistent with a mild form of COVID-19.

7. 2. There are paraspinal soft tissue density
mass-like lesions seen scattered along the
thoracic column .Some of those lesions
show fine calcification.

10. 3.There is a clear visualization of the
intraventricular septum indicating decrease
density of the intraventricular blood.

13. 4. Diffuse increase in hepatic attenuation
indicating iron overload.

14. On CT the normal density of the liver is between 45 and 65 HU on non-contrast
scans obtained at 120 kVp. , and usually 8-10 HU greater than the spleen.
On precontrast scans, CT density of normal splenic tissue amounts to 40
to 60 HU(in radiopaedia web site the HU range between 35-55) which is
approximately 10 HU less than liver parenchyma. Increased values are
observed in patients with thalassemia, sickle cell anemia, and
hemochromatosis.
However, changes in the density ratio most often are indicative of hepatic,
not splenic, disease.

15. In patients with hemochromatosis, the liver demonstrates
homogeneously increased density with an attenuation of greater than
72 HU . The increased attenuation highlights the lower attenuation
hepatic and portal veins on unenhanced CT.
A similar, diffuse pattern of increased attenuation can be seen in
patients treated with amiodarone and in patients with glycogen
storage disease that can be indistinguishable from iron overload with
CT.

16. PICTURE FROM THE INTERNET : UNENHANCED TRANSVERSE CT SCAN OF
NORMAL LIVER SHOWS ATTENUATION VALUE OF LIVER PARENCHYMA IS 57 HU,
SLIGHTLY HIGHER THAN THAT OF SPLEEN PARENCHYMA OF 48 HU

19. 4.Diffusely exaggerated bony trabecular
pattern more prominently seen in the spine
and sternum.

21. DIAGNOSIS
Intrathoracic extramedullary hematopoiesis
with hepatic iron overload
(hemosiderosis/hemochromatosis)

22. EMH is a physiologic response to compensate for
bone marrow dysfunction. It can occur in patients
with either neoplastic process or chronic
hemolytic anemia especially thalassemia,
hereditary spherocytosis and sickle cell anemia.

23. The pathogenesis of this outside-bone marrow
hematopoiesis is unclear. It may originate from
extension of hyperplastic marrow through the thin cortex
of ribs and vertebral bodies; the capsule of the mass is
formed by the periosteum.
Another explanation is that EMH results from
transforming of embryonal rests of osteogenic tissue into
hematopoietic one under stress conditions in order to
maintain sufficient red cell production.

24. Intrathoracic EMH is most often silent, discovered
by chance. In rare cases, it can compress
neighboring organs and leads to clinical signs
such as symptoms of spinal cord compression,
dyspnea, cough or pleuritic chest pain.

25. • Radiographic exams are useful for recognizing the diagnosis.
The chest X-ray shows smooth lobulated masses located at
the posterior mediastinum without bony erosion.
• On computed tomography scanning, intrathoracic EMH
appears as unilateral or bilateral well circumscribed,
paravertebral masses, lying between vertebra T6 and T12 and
having soft tissue density with homogeneous contrast
enhancement.
• These masses contain sometimes adipose tissue .calcification
is rare.

26. CHEST CT SCAN: A. (PRE-CONTRAST) AND B .(POST-CONTRAST)
SHOWS LOBULATED PARAVERTEBRAL MASSES WITH MILD
ENHANCEMENT, LINEAR CALCIFICATION FOCI (ARROW) AND AREAS
OF FAT ATTENUATION WITHIN (*). A SMALL PLEURAL EFFUSION (#)
CAN BE SEEN IN BOTH SIDES.

27. • Technetium 99m -labeled sulfur colloid scan is also a
noninvasive technique of detecting areas of EMH; this
radioactive agent is taken up by reticuloendothelial cells.
• The diagnosis of EMH can be established on the basis of
radiographic features especially when they occur in a patient
with a long history of anemia. Although, if the diagnosis is not
certain or if complications require surgical intervention, biopsy
is mandatory. Care should be taken because of high risk of
bleeding.

28. • Treatment of EMH remains controversial and it is generally required
only in the presence of complications such as spinal cord
compression, massive hemothorax or recurrent pleural effusion.
• Low-dose radiation, repeated blood transfusions, surgery,
corticosteroids and recently hydroxyurea therapy are the main
therapeutic tools allowing the inhibition of hematopoiesis and the
decrease of recurrence.

29. THANK YOU