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INADEQUATE LABELING OF IN-111 WBC WITH INCREASED BLOOD POOL ACTIVITY
Authored By: Garima Agrawal and Keith Fischer.
Patient: 52 year old female
History: 52 year old female with right hip arthroplasty
Image Size:[small][as-submitted]

Fig. 1
Radiograph of right hip

Fig. 2
Tc-99m Sulfur colloid and In-111 WBC spot images

Fig. 3
Tc-99m Sulfur colloid and In-111 WBC spot images

Fig. 4
Image Size:[small][as-submitted]

Findings:

Radiograph of Pelvis: Progressive osteolysis surrounding the right acetabular cup

Figure 2 & Figure 3: There is greater than expected activity in the blood vessels on Indium-111 WBC spot images of the pelvis. There is lower than expected activity in the marrow on In-111 WBC images. There is decreased activity in the region of the right hip prosthesis both on Tc-99m sulfur colloid and In-111 WBC images.

Figure 4: Persistent cardiac activity at 24 hour on In-111 WBC images. The spleen appears smaller; however, as expected, there is uptake greater than liver.

DDx:

1. Excessive delay in injection of In-111 labelled WBC.

2. Platelet and red cell contamination of sample leading to labelled red blood cells and  platelets in the injectate

Diagnosis: Excessive platelet and RBC labelling with inadequate labelling of white blood cells rendering the study non-diagnostic for infection.
General Discussion:

This is a 52 year old man with a total right hip arthroplasty and an episode of sepsis. Right hip joint aspirate was yellow and turbid and had high cell counts. Dual tracer imaging with indium-111 labelled WBC's and Tc-99m sulfur colloid was performed to evauate for hip prosthesis infection. The study was non-diagnostic due to excessive labelling of RBC's and platelets resulting in excessive blood pool activity and decreased marrow activity on In-111 WBC images. The patient was offered a repeat study. The patient again presented with signs of sepsis 4 days later when he was emergently taken to the operating room for irrigation and debridement. The acetabular component was removed.

Plasma and red cell contamination impairs labeling efficiency of leukocytes. Hemolyzed blood will produce excessive blood pool activity and should be avoided.

Excessive delay in injection of labelled WBC may also result in decreased marrow uptake.

References:

European Journal of Nuclear Medicine and Molecular Imaging. Significance of diffuse cardiac activity on In-111 labeled leucocyte scans. Volume 12, Numbers 5-6, 271-273, DOI: 10.1007/BF00251985

http://md.gehealthcare.com/pifiles/Indoxy.pdf

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Additional Details:

Case Number: 352904Owner(s): Garima Agrawal and Keith FischerLast Updated: 02-07-2013
Anatomy: Skeletal System   Pathology: Infection
Modality: Conventional Radiograph, Nuc MedAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: bsnm, hip arthroplasty,infection, loosening

Case has been viewed 16 times.
Certified by Keith Fischer on 01-24-2013

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