Computed Tomography Finding of Crusty Thrombosed Arteries: An Appearance of Lower Extremity Vascular Pythiosis

Vascular pythiosis is a dreadful vascular infection that presents as a chronic leg ulcer. To distinguish this infectious disease from atherosclerotic occlusion of the lower limb, we investigated the imaging appearance and presence of thick and irregular arterial wall enhancement, named crusty thrombosed arterial sign, on computed tomography images in cases with vascular pythiosis infection of lower extremities. In this study, 13 cases of vascular pythiosis of lower extremities with available images from 2016 to 2022 were reviewed and the presence of crusty thrombosed arterial signs, segments of vascular involvement, and radiological findings of hematologic disease, including hepatosplenomegaly and bone changes were recorded. Crusty arterial sign with long segmental arterial involvement was found in all cases. All cases had hepatomegaly and abnormal spleen, either splenomegaly or splenectomy, found in 12 cases (92.3%). Six cases (46.1%) had thalassemic bone changes. We proposed the pathognomonic radiologic sign of vascular pythiosis: the crusty thrombosed arterial sign, which manifested as diffusely thick and irregular arterial wall enhancement along long arterial thrombosis without skip lesions. Other associated findings included splenomegaly, splenectomy, and thalassemic bone changes. These radiologic findings facilitated the diagnosis of vascular pythiosis, particularly in cases of atypical presentation or unreliable clinical context.