Radionuclide imaging in infection and inflammation
Inflammation A basic way in which the body reacts to infection, irritation or other injury Inflammation is now recognized as a type of nonspecific immune response
Morfology of inflammation Blood hyperperfussion Increased cappilars permeability Exudation Swelling Leukocytes migration Dysfunction of organ or tissue
Diagnosis of inflammation Physical examination Laboratory tests X-ray Ultrasound MRI
Symptoms Dolor Rubor Tumor Calor Hallmarks of inflammation were first described by Aulus (Aurelius) Cornelius Celsus, a Roman physician and medical writer, who lived from about 30 B.C. to 45 A.D.
X-ray and ultrasound Do we really need other modalities? What we see in X-ray or ultrasound? Is X-ray or ultrasound specific technique for inflammatory process?
Acute hematogenous osteomyelitis in a peadriatric patient
Hematogenous osteomyelitis in a peadriatric patient
Hematogenous osteomyelitis in a peadriatric patient
Diagnosis of inflammation Physical examination Laboratory tests X-ray Ultrasound MRI Scintigraphy
Specific radionuclide techniques In vitro labelled leukocytes In vivo labelled leukocytes Labelled poliklonal IgG Labelled antibiotics Gallium-67 scan
Non specific radiomuclide techniques Bone scintigraphy Renal static scintigraphy Salivary gland scintigraphy Brain perfussion scan
In vitro labelled leukocytes Indium-111 oxin Technetium-99m – HmPAO Labelling process outside of body Separation of leucocytes in centrifugal machine Labelling by diffusion of radioactive complex into a cell
In vitro labelling
In vitro labelling
In vivo labelled leucocytes Immunoscintigraphy Monoclonal IgG antibody Fab’ fragment labeled with Technetium-99m Injected targets NCA-90, found on the cell membrane of graunlocytes
In vivo labelling
In vivo labelling
After injection
Indications Abscess in abdomen (appendicitis) Fever of unknown origin Artery graft infections Infection ortopaedic prothesis Bowel inflamatory disease
Tc99m-HmPAO labelled leukocytes – normal abdominal scan
Appendicitis Atypical presentation of acute appendicitis in high-risk populations, such as children, make correct diagnosis difficult. Rate of complications, including death, is directly correlated with delay in diagnosis and surgery.
Appendicitis Tc99m-HmPAO labelled leukocytes scintigraphy is a rapid and very accurate method for detecting acute appendicitis in patients with acute lower abdominal pain and equivocal clinical findings.
Appendicitis
Fever of Unknown Origin (FUO) 30% of patiens with FUO have silent infection After surgery 60% Very often negative X-ray and US Tc99m-HmPAO labelled scintygraphy is method of choice
Arterial graft infections 2-6% of grafts Mortality very high 25-75% The highest sensitivity of Tc99m-HmPAO labelled leukocytes scintigraphy 100% ! Early diagnosis saves live
Bowel inflamatory diseases Crohn disease Colitis ulcerosa Non specific bowel inflamation The same efficacy that colonoscopy with mucosa biopsy Control of treatement
Crohn disease
Colitis ulcerosa
Gallium-67 citrate Labelling in vivo leucocytes Binds to transport protein laktoferrin Expensive Less specific than labelled leucocytes Also binds transferrine in tumours cells (lymphoma, HCC, leucemia)
Gallium-67 scan Spondyllitis VTh5
Pericarditis
Ga-67 - Acute pulmonary infection
Policlonal human immunoglobins IgG labelled with Tc99m Accumulation in focus of inflammation Circulating IgG`s are premeabling to intercellular space Easy to preparation and cost effective No differentiation between inflamation and infection
Policlonal IgG-Tc99m - normal
Policlonal IgG-Tc99m - normal
Policlonal IgG-Tc99m
Policlonal IgG-Tc99m
Bone scintigraphy Three-phase scintigraphy Early phase: perfussion Late phase: bone metabolism Usefull in incection and inflammation Non specific
Bone scan - normal
Bone scan - three phase
Osteomyelitis
Osteomyelitis
Otitis media complication
Septic arthritis
Rheumatoid artritis 99mTc-MDP RA 99mTc-MDP Normal
Entesopaties Achilles Tendinitis 99mTc-MDP
Seronegative arthritis
Pyelonephritis High incidence in children 1% leads to renal failure and transplantation 10% asymptomatic Renal scars
DMSA-Tc99m scan 99m Tc - DMSA
Static renal scintygraphy Gold standard in detection of inflammatory scars! Method of choice
Pyelonephritis In acute pyelonephritis DMSA scan is ALWAYS abnormal!
Inflamatory scars Sens Spec. DMSA 92.1 93.8 ECHO - 74.3 56.7 DOPPLER CT 86.8 87.5 MR 89.5
Brain vasculitis Antiphospholipide Antybody Syndrom Lupus cerebri and other colagenoses High mortality! Needs agressive treatement with cytostatics and high doses of steroids rCBF=Brain perfussion scan SPECT
Normal perfussion
Cerebral vasculitis
Cerebral vasculitis
Salivary gland function
Sjoegrens disease