Primary Bone Lymphoma of the Tibia Mimicking Stress Injury: The Classic Imaging Paradox Between Conventional Imaging and MRI

Author(s): Kevin Pierre, Rishabh Agrawal, Kalyani N Ballur, Diego A L Garcia

Primary bone lymphoma (PBL) is an uncommon malignant neoplasm that frequently presents nonspecific symptoms and subtle findings on conventional imaging, which may delay diagnosis. A characteristic image feature of PBL is the discrepancy between minimal abnormalities on radiographs or computed tomography (CT) and extensive marrow involvement on magnetic resonance imaging (MRI).

We report the case of a 25-year-old male presenting with progressive anterior tibial pain after recreational soccer activity. Initial clinical suspicion was a tibial stress injury. Radiographs and CT demonstrated only subtle intramedullary sclerosis without cortical destruction or periosteal reaction. In contrast, MRI revealed extensive marrow infiltration involving the proximal tibial epiphysis, metaphysis, and diaphysis. Image-guided biopsy confirmed diffuse large B-cell lymphoma This case highlights the classic imaging paradox of primary bone lymphoma and emphasizes the crucial role of MRI when clinical symptoms appear disproportionate to findings on radiography or CT. Early recognition of this imaging pattern can expedite biopsy and diagnosis, preventing delays in treatment.