technetium-tc-99m-sulfur-colloid and Osteomyelitis

A 53 year old-female patient with lupus had undergone a cephalo-medullary nailing for a femur shaft fracture 30 years ago. This was complicated by osteomyelitis, requiring multiple debridement procedures and hardware removal. Recently, she developed a painful soft tissue mass in the same region, which was ultimately diagnosed as pyomyositis. Because of chronic bone changes due to her past history, traditional imaging could not differentiate between osteomyelitis infarction and pseudotumor. A combined indium-labeled leukocyte scan with a technetium-99 sulfur colloid marrow scan ruled out osteomyelitis and guided proper treatment without osseous debridement and thus prevented unnecessary cross-contamination of the bone.

Topics: Bone Marrow; Diagnosis, Differential; Female; Femur; Humans; Indium Radioisotopes; Infarction; Leukocytes; Middle Aged; Osteomyelitis; Pyomyositis; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

Topics: Anemia, Sickle Cell; Bone and Bones; Child, Preschool; Diagnosis, Differential; Humans; Infarction; Male; Osteomyelitis; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Sulfur Colloid

In-111-white-blood-cell and Tc-99m-sulfur-colloid dual-radionuclide imaging are frequently utilized in the evaluation of patients with suspected osteomyelitis. We have developed a quantitative planar imaging method in which Tc-99m and In-111 scans are acquired simultaneously in accurate spatial registration. Long, thin tubes containing only In-111 or Tc-99m were first imaged in a list mode within a water bath inclined with respect to the water surface; from these, 12 energy spectra corresponding to different Tc/In ratios were synthesized. Triple-energy-window (TEW) parameters for scatter and radionuclide crosstalk correction, including scatter windows and weights, were optimized using 100 noise realizations of each of the spectra (1200 total). A long-bone phantom containing a simulated infection site was then imaged in water with five In/Tc ratios; 100 noise realizations of two conjugate-view images were generated from each acquisition (500 total). Two regions of interest (ROIs) were defined, and the ratio of In/Tc count ratios in these two ROIs was evaluated with and without the TEW scatter correction and geometric mean attenuation compensation. The average bias improved from 17.2% to 5.3%, with comparable precision. TEW corrections with non-optimized but practical energy windows also improved the bias to 6.4%. Compared with subjective visual assessment, quantitation of In-111/Tc-99m ratios may improve diagnostic accuracy and could eventually permit grading of osteomyelitis.

Topics: Artifacts; Bone and Bones; Bone Marrow; Energy Transfer; Extremities; Humans; Image Enhancement; Indium Radioisotopes; Leukocytes; Osteomyelitis; Phantoms, Imaging; Radionuclide Imaging; Radiopharmaceuticals; Scattering, Radiation; Signal Processing, Computer-Assisted; Subtraction Technique; Technetium Tc 99m Sulfur Colloid

Avascular osteonecrosis can be associated with septic arthritis and osteomyelitis. Combined labeled leukocyte-marrow imaging scintigraphy has demonstrated excellent accuracy for the detection of infection since both tracers accumulate in the bone marrow and only leukocytes accumulate in infection. We report an unusual total absence of 99mTc HMPAO leukocytes/9mTc-sulfur colloid tracer accumulation, not only in the femoral head but also in the acetabulum and hip in hip osteonecrosis secondary to septic arthritis and osteomyelitis.

Topics: Acetabulum; Arthritis, Infectious; Bone Marrow; Chemotaxis, Leukocyte; Female; Femur Head Necrosis; Gallium Radioisotopes; Humans; Leukocytes; Middle Aged; Osteomyelitis; Pelvic Bones; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Exametazime; Technetium Tc 99m Medronate; Technetium Tc 99m Sulfur Colloid

This study evaluated the role of combined leukocyte/marrow scintigraphy in the assessment of the neuropathic or Charcot joint.. Seventeen patients with (111)In-labeled leukocyte accumulation in 20 radiographically confirmed Charcot joints underwent 99mTc-sulfur colloid marrow scintigraphy. Studies demonstrating labeled leukocyte accumulation without corresponding activity on marrow images were classified as positive for osteomyelitis. Six of the patients also underwent three-phase bone scintigraphy. Bone scans were interpreted as positive for osteomyelitis when focal hyperperfusion, focal hyperemia and focal bony uptake on delayed images were present. Bone images were also interpreted together with labeled leukocyte images using two different criteria for a positive study. One criterion was the presence of labeled leukocyte activity in a region demonstrating abnormal activity on the bone scan, which was more intense than adjacent marrow activity or marrow activity in the corresponding region of the contralateral foot. The second criterion was either a spatially incongruent distribution of the two tracers or hyperintense activity on the leukocyte study, as compared to the bone scan.. Leukocyte/marrow studies were positive for osteomyelitis in 4 of the 20 neuropathic joints. Osteomyelitis was present in three of the four joints, whereas in the fourth, infection was confined to overlying soft tissues. None of the 16 neuropathic joints with negative leukocyte/marrow scans were infected. In one patient who underwent below-the-knee amputation, histological analysis confirmed the presence of hematopoietically active marrow corresponding to areas of congruent activity on the leukocyte and marrow images. Three-phase bone scintigraphy was positive in all six neuropathic joints studied; osteomyelitis was present in two of them. Using the first criterion, leukocyte/bone imaging was also positive in all six. Using the second criterion, leukocyte/bone imaging was positive in the two infected neuropathic joints, as well as in three uninfected ones. Leukocyte/marrow scintigraphy was positive in both infected joints and negative in the four without infection.. Labeled leukocyte accumulation in the uninfected Charcot joint does occur and is related, at least in part, to hematopoietically active marrow. Leukocyte/marrow scintigraphy is a reliable way to differentiate between marrow and infection as the cause of labeled leukocyte accumulation in the neuropathic joint and, in this series, was superior to both three-phase bone scintigraphy and combined leukocyte/bone scintigraphy.

Topics: Adult; Aged; Aged, 80 and over; Arthropathy, Neurogenic; Bone Marrow; Diagnosis, Differential; Female; Humans; Indium Radioisotopes; Joints; Leukocytes; Male; Middle Aged; Osteomyelitis; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid

We report a case of polyostotic Paget's disease of bone that caused an unusual pattern of accumulation of 111In leukocytes that mimicked, at some sites, uptake of osteomyelitis, which was suspected in this patient. Technetium-99-m sulfur colloid scan clarified the nature of 111In-leukocyte accumulation as secondary to expanded active bone marrow uptake in some pagetic bones. Additionally, a spectrum of 111In-leukocyte and 99mTc-sulfur colloid uptake was noted in the bones involved by the disease that represented uptake by pagetic foci at different pathologic phases of disease. This case suggests that Paget's disease should be considered as a diagnostic possibility for areas of 111In-leukocyte accumulation, particularly when expanded uptake is seen. When suspected, correlation with bone marrow scan and/or standard radiographs should be obtained. Recognizing that Paget's disease can not only cause absent but also expanded bone marrow (depending on the disease stage) and consequently abnormal 111In-leukocyte uptake, should help avoid interpretational confusion.

Topics: Aged; Aged, 80 and over; Bone and Bones; Bone Marrow; Diagnosis, Differential; Humans; Indium Radioisotopes; Leukocytes; Male; Osteitis Deformans; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid

Several chelates are available for leukocyte labeling. Studies indicate that cells labeled with any of the chelates have a sensitivity for infection of 90% to 95% when imaged at 24 hours postinjection. The sensitivity of 111In-labeled leukocytes at earlier imaging times is more controversial. There has been concern about the utility of labeled leukocytes in musculoskeletal infection. Recent leukocyte studies show a high sensitivity for infected prostheses, even though these infections are often walled off and do not cause systemic symptoms. However, leukocytes frequently miss osteomyelitis of the spine for reasons that are not known. Although some investigators do not recommend the use of 111In-labeled leukocytes in chronic infections, we have found a high sensitivity for infections that are 2 or more weeks old. Autopsy studies from the preantibiotic era indicate that bacterial infections with common organisms have high levels of neutrophil infiltration for months. Labeled lymphocytes from mixed-cell preparations also may play a role in detecting these inflammatory sites. Questions have been raised about the effect of antibiotic therapy on leukocyte sensitivity. Antibiotics do not appear to have a significant effect on scan sensitivity. By reducing the number of bacteria at an inflammatory site, antibiotics reduce the amount of chemotactic inhibitors. In addition, some antibiotics have been shown to directly stimulate leukocyte chemotaxis. Other factors that can theoretically reduce leukocyte function, including hemodialysis, hyperalimentation, hyperglycemia, and steroids, do not appear to reduce labeled leukocyte sensitivity for infection. The specificity of leukocyte uptake is reduced in the gastrointestinal tract and lungs. In these sites, uptake correlates with infection or the true cause of the patients' fever in only 10% to 50% of cases.

Topics: Chronic Disease; Digestive System; Humans; Indium Radioisotopes; Infections; Leukocytes; Lung; Organometallic Compounds; Osteomyelitis; Oxyquinoline; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Sulfur Colloid; Tropolone

Seventy-three patients with various underlying disorders that could potentially alter distribution of bone marrow underwent In-111 labeled autologous leukocyte and Tc-99m SC marrow imaging to exclude musculoskeletal infection. There were 22 cases of infection among the 73 patients studied. When interpreted in isolation, labeled leukocyte images were considered positive for infection when uptake of labeled cells in the region of interest exceeded uptake in the corresponding contralateral side. The sensitivity, specificity, and accuracy of the study using this criterion were 86%, 12%, and 34%, respectively. When interpreted in conjunction with sulfur colloid marrow images, studies were considered positive for infection when uptake in the region of interest on leukocyte and marrow images was spatially incongruent. The sensitivity, specificity, and accuracy of this dual tracer modality were 100%, 94%, and 96%, respectively. Three patients with infection and abnormal leukocyte/marrow images underwent repeat imaging after appropriate therapy. Images were interpreted as normal in two of them; both were infection free at subsequent surgery. Images of the third patient were interpreted as consistent with persistent infection, and operative cultures grew out Staphylococcus aureus. In summary, combined leukocyte/marrow imaging is a highly accurate method for diagnosing musculoskeletal infection and overcomes certain inherent limitations of labeled leukocyte imaging alone.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bone Marrow; Child; Child, Preschool; Female; Humans; Indium Radioisotopes; Infant; Leukocytes; Male; Middle Aged; Osteomyelitis; Radionuclide Imaging; Retrospective Studies; Technetium Tc 99m Sulfur Colloid

A total of 20 patients with posttraumatic osteomyelitis were investigated with 99mTc- and 111In-labeled leukocytes. Their elevated accumulation in inflammatory zones were detected on scintigrams of 12 patients. Osteomyelitis in 11 of them was confirmed on the basis of routine clinico-laboratory investigations. This method is a highly specific test in the diagnosis of posttraumatic osteomyelitis and in the assessment of the efficacy of its therapy.

Topics: Adult; Aged; Female; Humans; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Organometallic Compounds; Osteomyelitis; Oxyquinoline; Radionuclide Imaging; Technetium Tc 99m Sulfur Colloid; Time Factors

The uptake of white blood cells (WBC) into normal bone marrow may lead to difficulty in detecting bone infection. Twenty-one patients in whom the WBC scan was equivocal or positive underwent a technetium 99m colloid scan to show the distribution of bone marrow. Six patients had a positive WBC scan, and in five of them a discordant colloid scan confirmed infection. However, in one the colloid scan was concordant, indicating that the WBC activity was not due to infection but the result of normal bone marrow uptake. Fifteen patients had an equivocal WBC scan. In 14, infection was excluded by a concordant scan, and 1 patient with a discordant scan was lost to follow-up. We conclude that the combination of a WBC scan and a colloid scan is an effective method to distinguish infection from normal bone marrow activity and, in particular, reduces the number of incorrect diagnoses of infection.

Topics: Bone Marrow; Female; Hip Prosthesis; Humans; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Organotechnetium Compounds; Osteomyelitis; Oximes; Radionuclide Imaging; Technetium Tc 99m Exametazime; Technetium Tc 99m Sulfur Colloid

The clinical records and scintigrams of patients with sickle hemoglobinopathy who underwent combined Tc-99m bone marrow imaging and Ga-67 imaging to differentiate osteomyelitis from bony infarction were reviewed. Of 18 paired examinations in 15 patients, osteomyelitis was diagnosed correctly in six cases; in all six, gallium uptake at the symptomatic site was incongruently increased relative to the bone marrow activity. Of the 12 episodes of infarction, 11 showed congruent activity on both Tc-99m and Ga-67 images. The remaining study was interpreted incorrectly as osteomyelitis due to incongruent Tc-99m and Ga-67 uptake. The use of sequential Tc-99m bone marrow and Ga-67 imaging is an effective means of distinguishing osteomyelitis from bony infarction in patients with sickle hemoglobinopathy.

Topics: Adolescent; Adult; Anemia, Sickle Cell; Bone and Bones; Bone Marrow; Child; Child, Preschool; Diagnosis, Differential; Gallium Radioisotopes; Humans; Infant; Infarction; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Aggregated Albumin; Technetium Tc 99m Sulfur Colloid

Bone scans or bone marrow scans or both were obtained during 42 episodes of bone pain in 40 children with sickle cell disease, and the usefulness of these procedures was compared. On the basis of the subsequent clinical course, a diagnosis of bone infarction was made in 34 episodes, and osteomyelitis in eight. Among 22 patients with bone infarction, uptake on bone scan was increased in 14, decreased in three, and normal in five. Seven of eight patients with osteomyelitis had increased uptake on bone scan; one had normal uptake. In contrast, marrow scan uptake was markedly decreased in 15 of 16 patients with bone infarction, and was normal in five of five patients with osteomyelitis. Thus, decreased uptake on bone marrow scan in a patient with sickle cell disease and bone pain almost invariably indicates infarction, whereas normal uptake strongly suggests the diagnosis of osteomyelitis. We found marrow scans more useful than bone scans for this differential diagnosis.

Topics: Adolescent; Anemia, Sickle Cell; Bone and Bones; Bone Marrow; Child; Child, Preschool; Diagnosis, Differential; Female; Humans; Infant; Infarction; Male; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Medronate; Technetium Tc 99m Sulfur Colloid

Thirty-two patients with fractures of the limbs were studied 15-30 min following 99mtechnetium sulphur colloid injection. In 17 of the 19 patients where osteomyelitis was superimposed on the various fractures, significant uptake of sulphur colloid was noted at the fracture sites. The sensitivity for the test was 89.5%. In 12 of the 13 cases where osteomyelitis was absent, the sulphur colloid scan was negative giving a specificity of 92.3%. Hence a technetium sulphur colloid scan has shown to be a successful method for detecting osteomyelitis complicating a limb fracture.

Topics: Adult; Fractures, Bone; Humans; Leg Injuries; Male; Osteomyelitis; Radionuclide Imaging; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid

Topics: Adult; Humans; Lymphoscintigraphy; Middle Aged; Osteomyelitis; Sulfur; Technetium; Technetium Tc 99m Sulfur Colloid; Tibia