Case Author(s): Sarah Reimer, MD and Jerold Wallis, MD , 05/14/99 . Rating: #D3, #Q5

Diagnosis: Paget's disease

Brief history:

52-year-old man with coagulase negative Staphylococcus bacteremia.

Images:

Anterior and posterior whole body images

View main image(iw) in a separate image viewer

View second image(iw). Coronal slices from the In-111 WBC SPECT of the pelvis (orientation: right-left)

View third image(ct). Bone windows from a CT of the pelvis

Full history/Diagnosis is available below

Diagnosis: Paget's disease

Full history:

This 52-year-old man with a history of renal failure had bilateral fistulae in the forearems for hemodialysis. He developed coagulase- negative Staphylococcus bacteremia. In-WBC scintigraphy was requested to evaluate for a source of infection.

Radiopharmaceutical:

In-111 labeled autologous leukocytes i.v.

Findings:

The forearms, which are not shown, are normal in appearance. There is moderate asymmetry of activity in the sacroiliac joints, the left having relatively greater activity. Mildly increased activity is seen in the left lung, best seen on the posterior images.

Correlation was made with the patient's pelvis CT, which demonstrated findings of Paget's disease in the right iliac bone. The patient also had a chest xray (not shown), which demonstrated a moderate sized right pleural effusion. The left lung field was normal on the chest xray.

Discussion:

Since most abnormalities in nuclear medicine lead to increased activity in an image, it can be difficult to appreciate those that lead to decreased activity. This scan presents two such findings.

Indium WBC's normally distribute in the spleen more than the liver, in the lungs on the 4 hour image, and in the marrow. Other foci of accumulation are evidence of inflammation or infection. Paget's disease decreases the amount of bone marrow in the involved bone, so the abnormality is decreased WBC accumulation in the right iliac bone.

Similarly, there is apparently less activity in the right lung. Although this asymmetry could be due to slight inflammation in the left lung, followup chest radiographs failed to demonstrate any left lung abnormality. This asymmetry is most likely secondary to attenuation by the right pleural effusion (most evident on posterior images during supine imaging, due to layering of the effusion).

ACR Codes and Keywords:

References and General Discussion of Indium -111 WBC Scintigraphy (Anatomic field:Skeletal System, Category:Metabolic, endocrine, toxic)

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Case number: iw010

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