Case Author(s): Jeff Chesnut, D.O. and Keith Fischer, M.D. , 5/22/99 . Rating: #D3, #Q4
Diagnosis: Bone marrow expansion
Brief history:
45 year old man with end stage renal disease presents with persistant fever.
Images:
Anterior and posterior images are shown.
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Lower extremity spot images are shown.
Full history/Diagnosis is available below
Diagnosis: Bone marrow expansion
Full history:
45 year old man with
end stage renal disease, has a history of failed renal transplant
and is now on hemodialysis. He presents with persistant fevers and no
definitive source of infection.
Radiopharmaceutical:
In-111 labelled leukocytes
Findings:
16 hour delayed whole-body and spot views show marked marrow expansion of the axial and
appendicular skeleton. The spleen is absent which, by history, was
surgically removed. There is subtly increased activity in the left iliac
fossa consistent with a failed renal transplant. No evidence of infectious
source was identified.
Discussion:
In-111 labelled leukocytes are bone marrow agents. In cases of increased
marrow activity, such as severe anemia, there will be increased deposition
of In-111 labelled leukocytes as well. Care must be taken, then, when
evaluating for osteomyelitis that normal bone marrow is not mistaken for
an infectious process. We regularly perform bone-marrow mapping with Tc-99m
sulfur colloid in conjunction with In-111 labelled leukocytes when evaluating
for osteomyelitis in bone, even in the distal extremities in adults. We've
found that trauma (including microtrauma from prosthetic stems) can stimulate
marrow activity. With Tc-99m sulfur colloid marrow mapping, the extremity
in question may be evaluated by changing photopeaks on the gamma camera
without moving the extremity. This gives an accurate evaluation of normal
marrow activity and can preclude unnecessary aggressive antibiotic therapy
in some cases.
Major teaching point(s):
1. In-111 labelled leukocytes are bone marrow avid.
2. Bone marrow mapping with Tc-99m sulfur colloid may be helpful in differentiating between a focus of osteomyelitis and normal bone marrow activity.
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: iw011
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