Case Author(s): Hamid Latifi, M.D. and Jerold Wallis, M.D. , 5/19/95 . Rating: #D2, #Q4

Diagnosis: Sickle cell anemia

Brief history:

24-year-old man with left hip pain.

Images:

Anterior and posterior whole-body images, displayed at two different intensity settings.

View main image(bs) in a separate image viewer

View second image(iw). Another imaging study was obtained to help evaluate for infection.

View third image(bm). A final imaging study to supplement the second study. Why was it obtained?

Full history/Diagnosis is available below

Diagnosis: Sickle cell anemia

Full history:

24-year-old man with sickle cell anemia and left hip pain. Bone scintigraphy was requested to evaluate for avascular necrosis in the left hip.

A few weeks later, the patient again presented with pain at multiple sites, and an additional imaging was obtained.

Radiopharmaceutical:

Tc-99m MDP

In-111 labeled White Blood Cells

Tc-99m Sulfur Colloid

Findings:

Multiple sites of increased radiopharmaceutical uptake are noted throughout the skeleton on bone scintigraphy, most likely representing healing infarcts. There is also splenic accumulation of radiopharmaceutical, which is frequently seen in adult patients with sickle cell disease. Increased activity also is noted just superior to both orbits, probably representing bone remodeling due to marrow expansion within the sphenoid bones.

The second image set is an In-111 white blood cell study. Intense uptake is seen in the liver, with no uptake in the spleen. Activity is seen in the bone marrow, with areas of asymmetry (e.g. at the sacroiliac joints).

The third study is a Tc-99m sulfur colloid bone marrow study. It demonstrates the same sphenoid uptake as seen on bone scintigraphy, and the same sacroiliac joint pattern as seen on the In-111 white blood cell study.

Discussion:

Increased uptake in the spleen due to splenic infarction and patchy increased and decreased uptake in the bones is typical on bone scintigraphy of patients with sickle cell anemia.

On the white blood cell study, the previous splenic infarction results in the absence of uptake of labeled white blood cells in the spleen. The asymmetric uptake in the sacroiliac joints could represent infection or an asymmetric pattern of bone marrow expansion/infarction.

The bone marrow scintigraphy demonstrates an identical pattern of uptake as that seen on the white blood cell study, suggesting that no infection is present.

Followup:

At the time of the last two imaging studies the patient was having persistent fevers while on antibiotics. No bacterial infection was identified clinically, and the question of drug-induced fevers was raised.

On the basis of the negative imaging study, antibiotics were discontinued. The fevers resolved, and the patient was subsequently discharged from the hospital.

Major teaching point(s):

1) Both increased and decreased uptake may be seen on bone scintigraphy in sickle cell disease. Bone marrow expansion is common.

2) The appearance of splenic infarction varies with scintigraphic tracer, as noted above.

3) The specificity of findings on In-111 white blood cell studies may be increased by additional imaging of the bone marrow using Tc-99m sulfur colloid. Areas of discordant uptake (greater on the In-111 white blood cell study than on the Tc-99m sulfur colloid study) favor infection. Equal activity on the two studies reflects the distribution of functioning bone marrow.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Other generalized systemic disorder)

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Case number: bs023

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