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.


Anterior and posterior images are shown.

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View second image(iw). 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.


In-111 labelled leukocytes


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.


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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