Radionuclide imaging in infection and inflammation

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Presentation transcript:

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