Quantitative bone gallium scintigraphy in osteomyelitis

Gallium imaging offers many practical advantages over indium-111-labeled leukocyte imaging, and calculating quantitative ratios in addition to performing the routine bone-gallium images allows accurate and easy evaluation of patients with suspected osteomyelitis. To add objectivity and improve the accuracy and confidence in diagnosis of osteomyelitis, quantitative comparison of abnormalities seen on bone scans and gallium scans was performed. One hundred and ten adult patients with 126 sites of suspected osteomyelitis were evaluated and categorized by gallium-to-bone ratios, gallium-tobackground ratios, and spatial incongruency of gallium and bone activity. Combined evaluation using these criteria gave a 70% sensitivity and 93% specificity for the diagnosis of osteomyelitis.     

Chronic recurrent multifocal osteomyelitis demonstrated by Tc-99m methylene diphosphonate bone scan

A 12-year-old Middle Eastern girl presented with abdominal pain, weight loss, and intermittent pain in both thighs. She was initially suspected of Crohn disease, but this diagnosis was excluded after extensive gastromedical evaluation. Plain x-rays of the femora were normal, whereas the initial Tc-99m methylene diphosphonate (MDP) bone scan showed several foci with increased activity in both femurs. MR scan showed excessive periostal inflammatory and mild intramedullary changes in both femurs. A percutaneous bone biopsy demonstrated changes consistent with chronic recurrent multifocal osteomyelitis (CRMO). The patient's symptoms disappeared spontaneously, but reappeared 1.5 years later, which led to a new MDP bone scan that showed normal findings.     

Cold osteomyelitis. Radionuclide bone scan findings

Absence of Tc-99m MDP accumulation in bone may be due to various causes, including infection, infarction, neoplasm, foreign bodies, or artefacts (1,2). In our patient, absence of radionuclide was noted in the proximal metaphyseal region of his left tibia, along with increased activity distally. These findings were attributed to a "cold" osteomyelitis caused by pus beneath the periosteum. Initial x-rays were interpreted as normal, while subsequent films demonstrated gross abnormalities. Few cases of cold osteomyelitis have been reported.     

The bone marrow scan in experimental osteomyelitis

Osteomyelitis causes an inflammatory reaction within the bone marrow early in its course, suggesting that bone marrow imaging with Tc-sulfurcolloid could be used for early detection of the disease. To test this hypothesis, 11 rabbits were inoculated with Staphylococcus aureus, 7 adults in the bone marrow and 4 immature rabbits in the epiphyseal plate. Six rabbits developed osteomyelitis by radiographic and pathologic criteria. Each demonstrated a marked decrease in reticuloendothelial function in the area of osteomyelitis, 4–11 days before radiographic changes were noted. The bone marrow scan was normal in septic arthritis, which was present in some animals before osteomyelitis became evident. These findings suggest that the bone marrow scan is a potentially useful study in early detection of osteomyelitis.Supported by grant UFPHF GM 10548 NIH, Bethesda, Md.     

Potential utility of bone scan in cranial bone flap osteomyelitis

Annals of Nuclear Medicine - Currently, the diagnosis of bone flap osteomyelitis (BFO) remains a challenge for medical imaging. The present study aimed to identify predictive scintigraphic patterns...     

The gallium "bone scan" in acute leukemia

A 15-year-old boy with acute leukemia had a gallium-67 scan that was virtually identical to his technetium-99m pyrophosphate bone scan, except for lack of renal visualization. The quality of the radiopharmaceutical was assured by the normal appearance of gallium scan performed in another patient on the same day and with the same radionuclide batch. This extensive osseous uptake was probably due to bone-marrow replacement by leukemia cells and is a pattern that should be recognized as indicating a diffuse marrow-infiltrating disease.     

Tumoral calcinosis associated with sarcoidosis and positive bone and gallium imaging

A 63-year-old female with biopsy proven tumoral calcinosis presented with progressive and recurrent swelling and tenderness of the right hip, thigh, elbow, and wrist. Both gallium and bone imaging demonstrated intense, congruent uptake in these areas. This is the third case of tumoral calcinosis with sarcoidosis documented in the literature. However, these are the first published bone and gallium scans in a patient with a history of sarcoidosis and tumoral calcinosis.     

Differential diagnosis of trampoline fracture from osteomyelitis by bone scan with pinhole collimator

A 2-year-old girl with recent history of trampoline fall presented to the A&E Department for complete functional impairment of the left lower extremity and fever. Blood examination revealed an inflammatory syndrome, while plain radiographs were normal. As magnetic resonance imaging was unavailable, a bone scintigraphy was performed. While standard acquisition found an intense uptake focused on the left proximal tibial metaphysis whose appearance was suggestive of acute hematogenous osteomyelitis, complementary acquisition with the pinhole collimator demonstrated that this abnormal uptake was clearly distinct from the cartilage growth plate. One month follow-up radiographs showed a fracture that confirmed the diagnosis of trampoline fracture.     

Multifocal osteomyelitis in childhood. Review by radionuclide bone scan.

Multifocal osteomyelitis is considered an uncommon complication of acute osteomyelitis. Over a 3-year period, 136 infants and children who had a final diagnosis of acute osteomyelitis were reviewed, and multifocal osteomyelitis was detected in 27 (19%) patients. The major age peak of acute osteomyelitis was between 6 weeks and 3 years (46%). Two age peaks were found for multifocal disease-less than 6 weeks (38%), and 9 to 12 years (44%). Three patients with multifocal disease had septicemia and photon-deficient areas on bone scans. Another adolescent group had nonspecific bone and joint pain that in some cases persisted for more than 3 months and were finally diagnosed as multifocal osteomyelitis. Organisms were isolated in 15/27 (56%). Multifocal osteomyelitis is well recognized in the neonatel age group. However, it occurs more commonly than previously described in older patients. This higher incidence can most likely be attributed to the higher use of the radionuclide bone scan early in the disease and the high sensitivity of the scan for the detection of osteomyelitis.     

Value of a 24-hour image (four-phase bone scan) in assessing osteomyelitis in patients with peripheral vascular disease

The delayed images of the four-phase 99mTc phosphonate bone scan are compared with the delayed images of the three-phase study in patients with diabetes mellitus and/or peripheral vascular disease and suspected osteomyelitis. Three-phase bone imaging includes an immediate postinjection radionuclide angiogram, a blood-pool image, and delayed static images to 7 hr. The four-phase study adds a 24-hr static image. The scan is positive for osteomyelitis if images show progressively increasing lesion to background activity ratios over time. The results of analyzing 21 three- and four-phase bone scans in 17 patients were correlated with clinical course, cultures, and/or x-rays, gallium scans, and CT scans. The accuracy of four-phase bone imaging for diagnosing osteomyelitis was 85%; for three phase, 80%. Sensitivity for four phase was 80%; specificity was 87%. Sensitivity for three phase was 100%; specificity was 73%. Since overall accuracy of the four-phase study is slightly better than three phase, in these patients with diabetes mellitus and/or peripheral vascular disease, the addition of a 24-hr image, creating a four-phase bone scan, is recommended.     

Combined bone marrow and gallium imaging. Differentiation of osteomyelitis and infarction in sickle hemoglobinopathy

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.     

Plague and the gallium scan: Case report.

Inflammation in the right axillary lymph nodes and the meninges was detected by 67Gacitrate scans in an 11-year-old boy with Yersinia pestis infection. This case provides another example of 67Ga localizing to areas of infection, indicating potential utility in future cases of bubonic plague.     

Chronic sclerosing osteomyelitis of the iliac bone. Etiological possibilities

An adolescent with chronic recurrent multifocal osteomyelitis located to both iliac bones and an adult with pustulotic arthro-osteitis, involving the left iliac bone, an invertebral space, and the sternoclavicular, first sternocostal, manubriosternal and single peripheral joints are described. Their iliac bone changes were identical, except for the occurrence of bilateral changes in the adolescent, and ankylosis of the sacroiliac joint in the adult. It is suggested that chronic recurrent multifocal osteomyelitis and pustulotic arthro-osteitis may be related diseases with age-dependent differences.     

The bone scan in inflammatory osseous disease

The 99mTc-phosphate bone scan has become a sensitive, reliable, and safe method for evaluating the patient with suspected inflammatory disease of bone. The scan may become positive as early as the first 24 hr after the symptoms and 10-14 days before roentgenographic changes occur. It can be used to differentiate successfully a variety of diseases from osteomyelitis, and in conjunction with 67Ga-citrate scan has become a mainstay in the work-up of the patient with infectious disease. Applications of the bone scan to infectious diseases in pediatric practice are especially helpful, since these diseases are common problems in this age group. Increased experience with the 99mTc-phosphate bone scan has already defined several areas of "limitations" in evaluating inflammatory disease. "Cold" defects, negative scans in early stages of osteomyelitis, and "extended uptake" may all pose problems in interpretation, but careful correlation of the bone scan results with clinical history and physical findings, blood cultures, and roentgenography will significantly reduce these problems.     

Chronic osteomyelitis with epidural abscess: CT and MR findings

A case of chronic osteomyelitis in the occipital bone associated with underlying chronic epidural abscess was diagnosed by skull radiography, CT, and MR. Skull radiography showed diffuse sclerosis of the occipital bone and dural calcifications. Computed tomography demonstrated thickened sclerotic changes of the osteomyelitic area, dural calcifications, and epidural fluid collection. The area of chronic osteomyelitis displayed, essentially, no signal intensity in the T1-weighted and T2-weighted MR images. The chronic epidural abscess had heterogeneous signal intensity on T1-weighted images and good enhancement after Gd-diethylenetriamine pentaacetic acid administration. On T2-weighted images the abscess had relatively homogeneous high signal intensity.     

The role of bone scan and radiography in the diagnostic evaluation of suspected pedal osteomyelitis

The authors reviewed the three-phase bone scans and radiographs of 24 patients with suspected pedal osteomyelitis who also had histologic confirmation of the diagnosis. Twenty patients had a pedal ulcer, cellulitis, or necrosis. Sensitivity and specificity of bone scanning were 70% and 43% respectively. Sensitivity and specificity of radiography were 70% and 50% respectively. The non-invasive diagnosis of pedal osteomyelitis remains problematic due to the poor specificity of bone scans and radiographs.