Case Author(s): Brigid Gordon,MD and Henry Royal, MD , 10/21/96 . Rating: #D2, #Q3

Diagnosis: Sickle cell anemia with splenic infarct.

Brief history:

49 year old female with SC-sickle cell disease and acute right arm pain. Evaluate for bony abnormality including infarct.

Images:

Anterior and posterior whole-body delayed images.

View main image(bs) in a separate image viewer

View second image(bs). Lateral view of the skull.

View third image(bs). Oblique view of the chest including the right arm.

Full history/Diagnosis is available below

Diagnosis: Sickle cell anemia with splenic infarct.

Full history:

49 year old female with SC-sickle cell disease with acute onset right arm pain. Evaluate for bony abnormality including infarct.

Radiopharmaceutical:

18.9 mCi Tc-99m MDP i.v.

Findings:

No scintigraphic evidence of bony abnormality or infarct, especially in the right upper extremity. However, there is marrow expansion of the calvarium, marrow expansion in the appendicular skeleton, and mild tracer uptake in the left upper quadrant consistent with splenic infarction.

Discussion:

Distribution of an osseous imaging agent to bone depends on an intact blood supply. If the blood supply is interrupted, then uptake will be decreased or absent. In sickle cell disease, areas of bony infarcts can have a variable appearnce. Most often they are areas of decreased activity (due to vascular occlusion). During the healing phase, bony infarcts can have sites of increased uptake due to bone remodeling.

Complaints of bone and joint pain are common in patients with several types of sickle cell hemoglobinopathies. Symptomatic episodes are usually transient, occur during crisis, and resolve without producing radiologic change. The symptoms are often due to bone marrow infarction with or without secondary involvement of the bony structures. Radionuclide scintigrams are sensitive for early detection. They also aid in the evaluation of the extent of damage to the bone and marrow.

Some investigators feel that the initial evaulation of sickle cell patients presenting with bone pain should be done with bone marrow scintigraphy, as it may be more useful than bone scintigraphy for differentiating infarct from osteomyelitis in these patients.

Uptake of the bone scan agent in the spleen in sickle cell disease is quite common by the end of the first decade. Uptake takes place in areas of infarction with revascularization, but is not uniformly seen in all patients. Repetitive infarcts lead to deposition of calcium salts and iron which, in turn, cause uptake the bone agent. Uptake of these agents by the spleen in sickle cell disease correlates with the presence of functional asplenia.

Followup:

CT study of the abdomen and pelvis on a later date for adbominal pain confirmed the presence of a small, calcified spleen.

REFERENCE: Nuclear Medicine. Henkin et al., editor. Mosby, 1996.

View followup image(ct). Small, calcified spleen in the left upper quadrant.

Major teaching point(s):

Bone marrow expansion and soft tissue uptake of bone tracer.

Differential Diagnosis List

Hemeglobinopathy vs. metabolic bone disease vs. diffuse metastatic disease.

ACR Codes and Keywords:

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

Search for similar cases.

Edit this case

Add comments about this case

Read comments about this case

Return to the Teaching File home page.

Case number: bs067

Copyright by Wash U MO