Indium-111 WBC scan in acute toxic centrilobular hepatic necrosis

In this case of prolonged fever and abnormal liver functions, dual tracer scintigraphy with In-111 WBCs and Tc-99m SC led to a biopsy-proven diagnosis of severe acute toxic hepatitis (hepatocellular necrosis). Correlation of the Tc-99m SC scan findings with those previously reported for "pseudotumors" of the liver is discussed. A "pseudonormal" scan pattern is described for the In-111 WBC scintigraphy. Discordance between In-111 WBC and Tc-99m SC scintigraphy in this clinical setting should raise the possibility of hepatic necrosis as a diagnostic alternative to hepatic abscess.     

Nonvisualization of the liver by indium-111 oxine labeled leukocytes in alcoholic liver disease

The liver was not visualized by In-111 WBC scan in a patient with alcoholic liver disease. The liver was visualized on repeat scan when liver function had improved.     

In-111-labeled white blood cell uptake in noninfected closed fracture in humans: prospective study

Since indium-111 white blood cell (In-111 WBC) scintigraphy is often used to evaluate for osteomyelitis in bone fractures, it is important to know if noninfected fractures have In-111 WBC uptake. Twenty-seven noninfected closed fracture sites in 19 patients were prospectively evaluated with technetium-99m methylene diphosphonate bone scintigraphy and In-111 WBC scintigraphy. In-111 WBC uptake was present in 41% of the 27 sites. In the 11 positive sites, the In-111 WBC uptake was 1+ (definite but minimal) in 55%, 2+ (moderate) in 36%, and 3+ (marked) in 9%. The visual intensity of the radioactive uptake on In-111 WBC scintigrams relative to that on bone scintigrams was less in 82%, equal in 9%, and greater in 9%. The visual size of the area of uptake on In-111 WBC scintigrams and bone scintigrams was smaller in 36%, equal in 55%, and greater in 9%. Factors that may help distinction of In-111 WBC uptake due to fracture alone from infection associated with fracture are discussed.     

The complementary role of indium-111 labeled leukocyte imaging,ultrasonography and computed tomography in the evaluation of postoperative infection or abscess

We report our experiences with the combined use of indium-111 labeled leukocyte imaging (In-III WBC scan.), computed tomography (CT) and ultrasonography (US) for evaluation of suspected postoperative infection or abscess, and discuss the complementary roles of these modalities. Postoperative abscesses or infections were diagnosed in 9 of 20 patients. All patients were correctly diagnosed by In-111 WBC imaging and 4 patients could not be diagnosed by US because of bowel gas. One false-positive CT examination and another artifact on CT images due to respiratory movements were obtained. The three modalities were found to be complementary: CT and US were efficient imaging methods for diagnosis and treatment of abscess. In-111 WBC imaging could estimate the activity of inflammation.     

Nonvisualization of sterile surgical incisions with indium-111 labeled leukocytes

The localization of In-111 labeled leukocytes (WBCs) in recent surgical incisions was studied in 18 patients. In-111 WBC images correlated well with culture results and clinical findings. No accumulation of In-111 WBCs was detected at the site of noninfected incisions in nine patients. In-111 WBCs did accumulate at incision sites in nine patients with infected surgical incisions. These results indicate that In-111 WBC study can accurately distinguish between normal healing and infection of recent surgical incisions.     

Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography

The usefulness of indium-111 white blood cell scintigraphy in the diagnosis of subacute or chronic bone infection was examined in 21 orthopedic patients. In-111 WBC imaging was compared with gallium-67 and technetium-99m methylene diphosphonate skeletal scintigraphy and bone radiography, all studies being performed within 1 week. In-111 WBC scintigraphy showed no definite advantage over Ga-67 scintigraphy in the identification of chronic bone infection. The two tests had the same sensitivity (80%) and similar specificity (In-111 WBC 75%, Ga-67 83%; difference not significant). Bone radiography had a sensitivity of 60% and a specificity of 67%. A negative Tc-99m MDP bone scintigram ruled out infection (sensitivity 100%), but because of low specificity (25%), final evaluation required performance of Ga-67 or In-111 WBC scintigraphy.     

Changes in the expression of somatostatin receptor imaging following Y-90 lanreotide therapy for carcinoid tumor: a flare response?

A 53-year-old man with In-111 octreotide-positive metastatic hepatic carcinoid was referred for Y-90 lanreotide therapy. A diagnostic In-111 lanreotide scan, performed to assess suitability for therapy, showed less uptake in lesions compared with In-111 octreotide. After 3 therapy doses of Y-90 lanreotide, a repeat In-111 lanreotide scan showed intense uptake in old lesions, appearance of new lesions, and uptake in the spleen. This was associated with improvement in flushing and regression of liver size. Computed tomography scan showed stable disease. Increased expression of somatostatin receptors has been observed with In-111 octreotide but not with In-111 lanreotide. If this is a flare response, then pretreatment with "cold" lanreotide may be beneficial before Y-90 lanreotide therapy.     

Sequential technetium-99m sulfur colloid/indium-111 white blood cell imaging in macroglobulinemia of Waldenstrom

Technetium-99m sulfur colloid (SC) and indium-111 labeled leukocyte (In-111 WBC) scintigraphy was performed on a 77-year-old female patient to rule out a left periprosthetic infection. Anterior Tc-99m SC and In-111 WBC images of the pelvis and femurs revealed no abnormal deposition of radiotracer about the Austin-Moore prosthesis. Absent radiotracer uptake, however, was demonstrated within the left hemipelvis. A left iliac bone marrow aspirate and biopsy revealed a lymphoplasmacytic infiltrate consistent with Waldenstrom's macroglobulinemia.     

Importance of Tc-99m sulfur colloid liver-spleen scans performed before indium-111 labeled leukocyte imaging for localization of abdominal infection

INTRODUCTION: The localization of intraabdominal abscesses is a difficult imaging problem in nuclear medicine, especially when the location of the abscess is in the area of the liver and spleen. The need for performing Tc-99m sulfur colloid liver-spleen scans before injecting indium-111 leukocytes for improved lesion detection and characterization versus performing In-111 leukocyte scans alone has been questioned in the literature MATERIALS AND METHODS: We present 3 patients with intraabdominal abscesses in the liver-spleen area, in which liver-spleen scans were performed before In-111 leukocyte scans. The findings of all were correlated with computed tomography and interventional procedures. RESULTS: In all patients, the Tc-99m liver-spleen scan helped for accurate recognition of the location of the abscess, correlated with computed tomography findings, and were helpful for intervention and exclusion of the other sources of infection. CONCLUSION: Data from these 3 patients reinforces the need for Tc-99m sulfur colloid liver-spleen scans before performing In-111 WBC scans for better localization and interventional treatment of intraabdominal abscesses.     

Failure of indium-111 leukocyte scanning to detect nodal involvement with Mycobacterium avium-intracellulare infection in the acquired immunodeficiency syndrome

An In-111 leukocyte scan was used to evaluate fever of unknown origin in a patient with the AIDS rather than Ga-67. The scan was normal despite an impressively positive Ga-67 scan performed 48 hours later. In-111 should not be used to evaluate fever in patients with AIDS where mycrobacterium avium-intracellular infection is a diagnostic possibility.     

The 'hot halo' sign. Pyogenic pericarditis on In-111 leukocyte scintigraphy.

The authors report a patient with diffuse pyogenic pericarditis and focal myoendocarditis initially detected using In-111 WBC scintigraphy. The patient was in septic shock after hemodialysis for the treatment of chronic renal failure. This was preceded by clinical signs and symptoms of pericarditis thought to be viral in nature. Initial investigations found no septic focus, and the patient was referred for In-111 WBC scintigraphy. This revealed a striking "halo" of increased activity around the heart, strongly suggesting bacterial pericarditis. A subsequent pericardiocentesis yielded 400 ml of purulent material, confirming the diagnosis.     

Abdominal patterns of indium-111 labeled leukocyte imaging

In-111 oxine WBC abdominal scanning is now a widely accepted technique for the detection of abdominal infectious processes. High sensitivity and specificity are achieved. In-111 labeled leukocyte accumulation, however, does not always suggest the diagnosis of abscess. Higher specificity could be obtained by the knowledge of the In-111 leukocyte distribution pattern in the abdomen in other pathologic states like inflammation of abdominal wounds, stoma; surgical complication without abscess formation; inflammatory or ischemic bowel disease; or swallowing leukocytes which subsequently are visualized in the intestinal lumen. One hundred fifty-two consecutive WBC scans performed over 18 months were reviewed and classified according to their pattern of uptake: 96 cases showed no abdominal uptake, and 56 had accumulation of leukocytes in the abdomen. Twenty-eight of these patients had proven abdominal abscess, and the remaining 26 were positive due to other causes. This report briefly discusses the distribution pattern of In-111 labeled leukocytes in the latter patients and compares the results obtained using different diagnostic criteria.     

Evaluation of a 3-hour indium-111 leukocyte image as a surrogate for a technetium-99m nanocolloid marrow scan in the diagnosis of orthopedic infection

OBJECTIVES: This is a retrospective study to evaluate a 3-hour In-111-labeled leukocyte image as a surrogate for a Tc-99m nanocolloid marrow scan in the investigation of suspected orthopedic infection using In-111 leukocyte scintigraphy. METHODS: Images from 51 patients who had received contemporaneous In-111-labeled leukocyte scintigraphy and Tc-99m nanocolloid marrow scintigraphy were reviewed. Initially, the 3-hour and 22-hour In-111-labeled leukocyte images were compared. Sites of abnormal uptake on the 22-hour image were correlated with the 3-hour image and were graded according to the level of concordance or discordance. One week later, the Tc-99m nanocolloid images and 22-hour In-111-labeled leukocyte images of the same patients were compared and graded for concordance or discordance. When discrepancies in grading arose between the observers, a consensus opinion was achieved after additional review of the images a week later. RESULTS: On inspection of the 22-hour In-111 leukocyte images, 93 sites of focal, potentially abnormal leukocyte accumulation were identified. When the grading system was reduced to simply "concordant" or "discordant," there was good agreement between the observers in the majority of cases, with kappa statistics 0.77 for Tc-99m nanocolloid versus 22-hour In-111-labeled leukocyte images and 0.78 for 3-hour versus 22-hour In-111-labeled leukocyte images. Using the comparison of the Tc-99m nanocolloid marrow scan and the 22-hour In-111-labeled leukocyte images to identify concordance or discordance as the "gold standard" for scintigraphic evaluation of suspected orthopedic infection, comparison of the 3-hour In-111-labeled leukocyte images with the 3-hour In-111-labeled leukocyte images gave a sensitivity of 77%, a specificity of 77%, and an accuracy of 77%. CONCLUSIONS: A 3-hour image is helpful using In-111-labeled leukocyte scintigraphy.     

In-111-labeled leukocyte scintigraphy in suspected orthopedic prosthesis infection: comparison with other imaging modalities

When infection of prosthetic orthopedic implants is suspected, optimal management requires accurate confirmation or exclusion of infection. The authors retrospectively studied 98 patients with possible infection who underwent scanning with indium-111-labeled white blood cells (WBCs) and subsequently underwent surgery within 14 days. At surgery, 50 patients had infections, as determined by means of culture or histologic results. The diagnostic accuracy of In-111 scanning was compared with that of plain radiography, arthrography, three-phase bone scanning, and various clinical and laboratory findings classically associated with infection. Positive findings on In-111 WBC scans and elevated erythrocyte sedimentation rates were found to be the most predictive variables in the diagnosis of septic prostheses (P less than or equal to .001 and P less than or equal to .002, respectively). Likelihood ratio analysis more clearly demonstrated the superiority of In-111 WBC scanning, with positive and negative scans yielding likelihood ratios of 5.0 and 0.16, respectively.     

Detection of acute osteomyelitis with indium-111 labeled white blood cells in a patient with sickle cell disease

A young patient with sickle cell disease (SCD) and multiple hospitalizations for crisis was admitted because of suspected osteomyelitis. Initial laboratory work, radiographs, and bone images were not contributory. An In-111 white blood cell (WBC) study demonstrated two areas of increased radionuclide uptake consistent with osteomyelitis. One of these had associated soft tissue infection. No other areas of active osteomyelitis were visualized, in spite of the presence of several additional infection sites. Imaging with In-111 WBC is probably not justified for routine diagnosis of acute osteomyelitis in areas free of previous disease, where conventional bone images are highly efficient. In-111 WBC imaging, however, may be helpful in detecting osteomyelitis in selected patients with SCD in whom Tc-99m bone images and radiographs are usually abnormal and difficult to interpret due to previous bone infarcts. Localization of the infection focus is very important in choosing the aspiration site for bacteriologic studies. A negative study, however, should be interpreted cautiously.     

Abnormal pulmonary accumulation of indium-111 chloride in pneumocystis carinii pneumonia as detected by bone marrow scintigraphy

PURPOSE: Unusual pulmonary uptake of In-111 chloride in a patient with Pneumocystis carinii pneumonia and autoimmune hepatitis is described. METHOD: In-111 chloride bone marrow scintigraphy was performed to evaluate the bone marrow activity associated with pancytopenia in a 56-year-old woman with autoimmune hepatitis. RESULTS: An In-111 chloride bone marrow scan showed increased pulmonary uptake predominantly in both upper lung fields. P. carinii pneumonia was seen to be developing as an immunocompromised complication after treatment for autoimmune hepatitis. CONCLUSION: When In-111 chloride bone marrow scintigraphy shows increased uptake in the lungs of immunocompromised patients, a combined opportunistic inflammatory disease such as P. carinii pneumonia should be considered in the diagnosis.     

Subacute splenic abscess. Appearance on indium-111 leukocyte, gallium-67, and technetium-99m sulfur colloid imaging

A case of a 23-year-old man with an encapsulated, anaerobic splenic abscess is reported. Both the In-111 leukocyte and Tc-99m sulfur colloid scans demonstrated an intrasplenic defect. The Ga-67 citrate scan revealed uptake in the rim of the abscess only where the abscess cavity was relatively photon-deficient. The combined Tc-99m sulfur colloid/In-111 leukocyte/Ga-67 scan appearance of a subacute splenic abscess has not been described previously. In cases suspected to be splenic abscesses the combined In-111 leukocyte/Tc-99m sulfur colloid imaging is the most useful.     

Skeletal photopenic lesions in In-111 WBC imaging

Four cases of skeletal photon-deficient areas in In-111 white blood cell (In-111 WBC) images are reported. These were found in patients with lymphoma, vertebral osteomyelitis, and following radiotherapy and extensive surgical procedures. We emphasize that these photopenic lesions, although uncommon, may represent tumor involvement or benign processes, including osteomyelitis. Possible mechanisms to explain this phenomenon are discussed.     

Indium-111 labeled purified granulocytes in the diagnosis of synthetic vascular graft infection

Indium-111 labeled leukocytes have been shown to be useful in the diagnosis of synthetic vascular graft infection. To minimize the potential effects of labeled red blood cells and platelets on image interpretation, the authors prepared purified autologous granulocytes (PG) from 84 ml of blood using Volex enhanced gravity sedimentation and Ficoll-Hypaque double density centrifugation. The labeling efficiency of PG with In-111 tropolone was 90 +/- 9% (mean +/- SD). Imaging was performed 18-24 hours following injection of approximately 445 microcuries of In-111 PG in 26 patients with suspected infection of vascular grafts that had been implanted 12 days to 12 years prior to the study. In ten patients with proven graft infection, seven had positive In-111 PG scans. Ten of 11 patients without infection had negative scans. In five patients with clinically equivocal findings, scan results were positive in one, negative in one, and equivocal in three. A false-positive scan occurred in a patient with an uninfected inflammatory pseudoaneurysm of an aortic graft. These results confirm an earlier report that In-111 PG imaging is a useful technique in the diagnosis of synthetic vascular graft infection.     

Postoperative bone marrow alterations: potential pitfalls in the diagnosis of osteomyelitis with In-111-labeled leukocyte scintigraphy.

Scintigraphy was used after injection of technetium-99m methylene diphosphonate (MDP) and indium-111-labeled white blood cells (WBCs) to assess for the presence of osteomyelitis in 97 patients who had undergone prior surgical procedures. Thirty-four patients with abnormal In-111-labeled WBC patterns underwent restudy with Tc-99m albumin colloid (AC). Scintigraphic findings were considered positive for osteomyelitis whenever localization of In-111-labeled WBCs exceeded Tc-99m AC activity in extent or focal intensity (discordant pattern). Ten of 12 patients with culture-proved osteomyelitis had discordant patterns; two had false-negative (concordant) patterns. The cases of 20 of 22 patients without infection who were considered to have osteomyelitis on the basis of patterns of In-111-labeled WBCs and Tc-99m MDP were reclassified correctly on the basis of concordant patterns of In-111-labeled WBCs and Tc-99m AC. Radiocolloid images improved the overall scintigraphic specificity for osteomyelitis from 59% without bone marrow imaging to 92%; sensitivity decreased from 94% to 88%.