Indium-111 Leukocyte Scintigraphy - Lieberman's eRadiology ...

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
March 2005
Indium-111 Indium 111 Leukocyte Scintigraphy:
Scintigraphy
A A patient patient presentation & & discussion
Kinzya
B. Grant, BS
Drexel University College of Medicine Year IV
Advanced Clerkship in Radiology
Harvard Medical School
Gillian Lieberman, MD
1

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Overview
Patient Presentation
Background Information on Nuclear Medicine
Scintigraphy
Differential Diagnosis
Menu of Tests
Discussion of Our Patient
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61yo male
Recent history
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our patient is a…
persistent fever of unknown origin
Reason for referral
evaluation for source of infection
Type of procedure
Indium-111 Indium 111 oxine-labeled oxine labeled leukocyte scintigraphy
This study is done as outpatient procedure
3

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Let Let us us begin begin with with some some background
information.
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Nuclear Medicine Background Information
What is In-111 In 111 oxine-labeled oxine labeled leukocyte scintigraphy? scintigraphy
A diagnostic imaging test that displays radiolabeled
white blood cells in the body
What is Indium-111? Indium 111?
A group III element that decays by electron capture
emitting 2 gamma photons of 173keV and 247 keV
Physical half-life half life of 67 hrs
5

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Nuclear Medicine Background Information
What is oxine? oxine
Oxine (8-hydroxyquinolone) (8 hydroxyquinolone) is a lipid-soluble lipid soluble complex that
chelates metal ions
Leukocytes are removed from plasma for labeling
How is it taken up?
Indium-111 Indium 111 oxine complex diffuses through cell membranes
Once intracellular, the complex dissociates
Indium-111 Indium 111 binds nuclear and cytoplasmic proteins
Oxine diffuses back out of the cell
6

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Nuclear Medicine Background Information
How are Indium-111 Indium 111 oxine-labeled oxine labeled leukocytes
distributed?
After infusion, radiolabeled leukocytes are
distributed to the blood pool, lungs, liver, and spleen
Imaging is done 18-24 18 24 hrs after injection when lung
and blood pool activity are not normally seen
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Nuclear Medicine Background Information
Why do we use it?
To obtain scintigrams of specific anatomic regions
for suspected infection and/or inflammation
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
There There are are many many indications for for the the
use use of of this this radiopharmaceutical.
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Applications of 111-Indium 111 Indium Scintigraphy
Detect sites of infection/inflammation in pts with FUO
Localize unknown source of sepsis & detect additional
site(s) site(s)
on infection in pts with persistent or recurrent
fever and known infection site
Survey for site of abscess or infection in febrile post-op post op
pt without localizing signs & symptoms
Palestro
et al, Society of nuclear medicine procedure guideline for indium indium-111
111 leukocyte scintigraphy
for suspected
infection/inflammation. Version 3.0 2004
10

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
More More appropriate indications for for the the
use use of of Indium--111 Indium 111 radiolabeled
scintigraphy in in other other types types of of
patients..
patients
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Applications of 111-Indium 111 Indium Scintigraphy
Detect site(s) site(s)
and extent of IBD
Tc-99m Tc 99m labeled leukocytes may be preferable
Detect and follow up osteomyelitis when in cases of…
Joint prostheses, nonunited fractures, or sites of metallic
hardware from prior bone surgery
Detect osteomyelitis in diabetic pts when…
Degenerative or traumatic changes, neuropathic
osteoarthropathy, osteoarthropathy,
or prior osteomyelitis
Palestro
et al, Society of nuclear medicine procedure guideline for indium indium-111
111 leukocyte scintigraphy
for suspected
infection/inflammation. Version 3.0 2004
12

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
And…
And…
13

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Applications of 111-Indium 111 Indium Scintigraphy
Detect osteomyelitis in skull in post-op post op pts and
for follow up of therapy
Detect mycotic aneurysms, vascular graft
infections, and shunt infections
Palestro
et al, Society of nuclear medicine procedure guideline for indium indium-111
111 leukocyte scintigraphy
for
suspected infection/inflammation. Version 3.0 2004
14

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Additional Background information
In the case of Osteomyelitis:
Osteomyelitis
To detect abnormal bone remodeling
Three phase bone scan may be used in conjunction with
leukocyte scintigraphy
and
To assess marrow distribution at suspected
osteomyelitis sites
Tc-99m Tc 99m sulfur colloid is a useful adjunct
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Additional Background information
Other useful nuclear medicine studies
Gallium scintigraphy
Preferred in patients with neutropenia
Or nonsuppurative or lymphocyte-mediated lymphocyte mediated infections
Tc-99m Tc 99m HMPAO (exametazime
( exametazime)-labeled labeled leukocyte
scintigraphy
Frequently used option for acute infections, particularly in
pediatric patients
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Additional Background information
What type of scintigrams can we produce?
Regional
Whole-body Whole body
Planar
and/or Single Photon Emission Computed
Tomography (SPECT)
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Now Now Back Back to to Our Our Patient
Patient
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s WBC Study
Injection of autologous white blood cells labeled
with Indium-111 Indium 111
Images of whole body obtained at 24 hours
Additional SPECT images of chest
Confirm findings
19

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our patient’s whole-body whole body image
Normal liver uptake
Abnormal uptake
Normal spleen uptake
PACS, BIDMC
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sternum
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Chest frontal view
Left shoulder region
PACS, BIDMC
Normal spleen uptake
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Chest “repro” sagittal view
This image was
reformatted
from SPECT
Thoracic
vertebral
column
PACS, BIDMC
22

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s WBC Study Findings
Marked increased activity in region of L
shoulder
Smaller foci of activity
Superior aspect of sternum at R sternoclavicular
joint
Within mid thoracic vertebral column
23

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Interpretation Criteria
Normal Findings
18-24 18 24 hr: liver, liver,
spleen, spleen,
bone marrow, marrow,
minimal activity in
major blood vessels
4 hr: diffuse pulmonary activity
Abscess Detection
1/3 to ½ sites visualized by 4hr, >90% by 24 hr
Osteomyelitis
Focal accumulation > adjacent background activity
&
Corresponds to bone site of increased bone
radiopharmaceutical accumulation
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Interpretation of Patient’s study
Above findings are consistent with multiple
sources of inflammation in
L shoulder
Sternum
Thoracic spine
Review of recent plain films of L shoulder
No significant abnormality
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1.
2.
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Differential Diagnosis
Marked focus of activity within L shoulder
Infectious process: septic joint or septic bursitis
Osteomyelitis of L humerus or scapula cannot be
excluded
Additional foci of activity within the sternum
and mid thoracic spine
Multifocal infectious process: osteomyelitis or
diskitis
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Menu of tests for further imaging
Conventional Radiography
Scintigraphic Techniques
bone scan, gallium, labeled leukocytes, newer agents
Cross-Section Cross Section Imaging
US
CT
MRI
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Travels to ED
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s Course
Receives antibiotic treatment
Receives acetaminophen
Shoulder joint aspiration
Followed by Hospital Admission
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HPI
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
On Admission
2 months of fevers to 104F, weight loss, L shoulder pain
1-2 2 weeks drenching night sweats
Outpatient: + tagged WBC scan, negative TTE, ESR 130
PMH
HTN
ETOH abuse – quit 1 month ago
Hypercholesterolemia
Depression
Pancreatitis 4 yrs ago
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PE
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
On Admission
VS: 99.7 107-125 107 125 133/86 24 95%RA
+ temporal wasting
Sternal mass
No occipital, no axillary, axillary,
no auricular, no epitrochlear LAD
Shoulder erythema, erythema,
hot, indurated, indurated,
pain with active/passive
movement, decreased ROM
Lab results
ESR 130 CRP 12.56
Joint Fluid: WBC 130,500 97% PMNs
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Imaging
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
On Admission
L shoulder 3 views (AP, neutral, ax)
No fracture or osseous destructive change
Equivocal superior subluxation of humeral head within
glenoid fossa
Acromioclavicular joint space narrowed with degenerative
changes noted
Chest (PA & lat)
No interval change compared to previous exam 9 days
prior
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Axial view
of shoulder
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s CT of upper limb with
large field of view on HD #2
Humeral
head
PACS, BIDMC
small
glenohumeral
joint effusion
To assess for osteomyelitis
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CT shoulder coronal
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s CT of upper limb with
Glenoid fossa
large field of view on HD #2
Reformatted image
clavicle
acromion
Head of humerus
Note fluid density surrounding the joint
PACS, BIDMC
Can you appreciate the distended
subacromial/ subdeltoid and subscapularis
bursae?
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s CT of upper limb with
Bone windows
large field of view on HD #2
R sternal clavicular joint fragmentation
PACS, BIDMC
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s CT of upper limb with
Soft tissues
large field of view on HD #2
Small foci of calcifications
PACS, BIDMC
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Coronal STIR
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
PACS, BIDMC
on HD #2
High intensity
noted
surrounding
joint on STIR
Reason:
Soft tissue mass
versus joint fluid
collection
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
Coronal STIR PACS, BIDMC
on HD #2
Just another coronal
STIR image
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
A Coronal T2-weighted image
PACS, BIDMC
on HD #2
Notice the asymmetry of
the joints.
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Axial STIR
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
PACS, BIDMC
on HD #2
There is motion artifact.
Again, we can
appreciate the
asymmetry and the
peripheral enhancement
of the distended bursa
on the left with effusion.
39

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
Axial T2 weighted image
PACS, BIDMC
on HD #2
Another view of
high intensity
signal
surrounding the
shoulder
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
Post contrast axial T1 weighted image with
fat saturation
PACS, BIDMC
on HD #2
Final axial MRI
image depicting the
joint effusion
41

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s Course
Surgical Procedures on HD #2
Arthrosopic L shoulder irrigation & debridement
and subacromial bursa irrigation & debridement
Incision & drainage of the R sternal clavicular joint
42

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s Course
Surgical Procedures on HD #5
Open irrigation & debridement of L glenohumeral
joint and subacromial bursa
Irrigation & debridement of R sternoclavicular joint
incision with VAC dressing placement
43

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s Course
Our Patient remained febrile.
Recall the positive radiolabeled white blood cell
scan in the thoracic region…
44

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of entire spine on
T2 image of spine
HD #5
Evaluation for abscess or
other evidence of infection.
Can you find the lesion?
PACS, BIDMC
Osteomyelitis
on T2 weighted
image:
Increased
signal intensity
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Osteomyelitis
on T1
weighted
image: low
medullary
signal
intensity
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
T1 pre contrast T1 post contrast
PACS, BIDMC
Gadolinium
enhancement
of T7-8 lesion
on HD #2
46

STIR
Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s MRI of
Chest/Mediastinum
Chest/ Mediastinum
PACS, BIDMC
on HD #2
Osteomyelitis of spine spreads
regionally via anastomosing venous
channels to involve at least 2 adjacent
vertebral bodies and intervening disc.
This lesion is pathognomic.
Thoracic region
abnormal signal at
T7 & T8 and in the
intervening disc
space consistent
with discitis and
osteomyelitis
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Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Summary of Hospital Course
Admitted
Joint aspiration & antibiotics
OR: irrigation & debridement by orthopedics
OR: manubrium and R 1 st rib removed, VAC device placed by thoracics
Post-op Post op compl. compl.
R pneumothorax => chest tube placement
Post-op Post op compl. compl.
Persistent R pleural effusion
Significant delirium, elective intubation
OR repeat debridement shoulder & sternum for continued fevers
Sternal debridement grew coag neg staph and group B strep
Presumed endocarditis => TEE neg
Other areas: MRA brain, brain,
LP, bronchoscopy,
bronchoscopy,
abdominal CT
MRI spine – diskitis and osteomyelitis prolonged antibiotics
Pt improving
Fever => blood, urine, urine/serum eosinophils r/o drug fever
48

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Patient Summary
61yo male with PMH of ETOH abuse,
pancreatitis, and hypercholesterolemia
presented with fevers/NS/wt loss and L shoulder
pain/sternal pain/ sternal mass
found to have
L septic shoulder
manubrium/R
manubrium/R
sternoclavicular joint osteomyelitis
T7-8 T7 8 thoracic spine diskitis/osteomyelitis
Negative blood cultures, negative TEE, negative LP,
normal MRA brain
49

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Summary of Patient Presentation
Although radiolabeled
scintigraphy
does not show bony
detail or distinguish osteomyelitis
from soft tissue
infections, nuclear medicine imaging can detect
osteomyelitis
10-14 10 14 days before changes are visible on
plain radiograph.
Our patient greatly benefited from Indium-111 Indium 111
oxine
labeled leukocyte scintigraphy
in this case
of fever of unknown origin.
50

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Our Patient’s Plan
Continue antibiotics for at least 6 weeks
&
Repeat MRI of spine in 2 months and follow up
with an appointment.
51

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
References
Palestro CJ, Brown ML, Frostrom LA, McAfee JG, Royal HD, Schauwecker DS,
Seabold JE, Signore A. Society of nuclear medicine procedure guideline for indium- indium
111 leukocyte scintigraphy for suspected infection/inflammation. Version 3.0 2004:1- 2004:1
6.
Becker W, Meller J. The role of nuclear medicine in infection and inflammation. The
Lancet 2001; 1:326-33. 1:326 33.
Turpin S, Lambert R. Imaging of musculoskeletal and spinal infections: infections:
Role of
scintigraphy in musculoskeletal and spinal infections. Radiol Clin N Amer 3:2, 2001.
Tehranzadeh J, Wong E, Wang F, Sadighpour M. Imaging of musculoskeletal and
spinal infections: Imaging of osteomyelitis in the mature skeleton. Radiol Clin N Amer
3:2, 2001.
Thrall JH, Ziessman HA. Nuclear medicine: the requisites, 2001.
Paluska SA. Osteomyelitis.
Osteomyelitis.
Clin Fam Prac 6:1, 2004.
Kjaer A, Lebech AM. Diagnostic value of (111)In-granulocyte
(111)In granulocyte scintigraphy in patients
with fever of unknown origin. J Nucl Med 2002;43(2):140-4. 2002;43(2):140 4. Abstract
52

Kinzya B. Grant, Year IV
Gillian Lieberman, MD
Acknowledgements
Maryellen Sun, MD
Nicole Nelson, MD
Jesse Wei, MD
J Anthony Parker, MD, PhD
Kevin Donohoe, Donohoe,
MD
Gerald Kolodny, MD
Gillian Lieberman, MD
Pamela Lepkowski
Larry Barbaras
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