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False Negative (99m)Tc-Hydroxymethane Diphosphonate Three-phase Bone Scintigraphy and (99m)Tc-besilesomab Scan in Detecting Tibia Osteomyelitis Concomitant with Necrotizing Fasciitis.

Tan TH, Lee BN - World J Nucl Med (2014)

Bottom Line: We described a case of 51-year-old female patient presented with a right calf necrotising fasciitis (NF) where osteomyelitis (OM) was suspected. (99m)Tc-hydroxymethane diphosphonate three-phase bone scintigraphy and (99m)Tc-besilosomab scan failed to demonstrate classical features of OM.As conclusions, the detection of lower limb OM by (99m)Tc-besilosomab scan is not easy when there is concurrence overlying NF.The unusual three-phase bone scan finding of pericortical accumulation of tracer as an early sign of OM is highlighted in this case.

View Article: PubMed Central - PubMed

Affiliation: Department of Nuclear Medicine, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia.

ABSTRACT
We described a case of 51-year-old female patient presented with a right calf necrotising fasciitis (NF) where osteomyelitis (OM) was suspected. (99m)Tc-hydroxymethane diphosphonate three-phase bone scintigraphy and (99m)Tc-besilosomab scan failed to demonstrate classical features of OM. The final diagnosis was only made by isolating Acinetobacter sp. in both intra-operative bone and tissue cultures from below-knee amputation. As conclusions, the detection of lower limb OM by (99m)Tc-besilosomab scan is not easy when there is concurrence overlying NF. The unusual three-phase bone scan finding of pericortical accumulation of tracer as an early sign of OM is highlighted in this case.

No MeSH data available.


Related in: MedlinePlus

Three-phase bone scan. (a) Early hyperemia is seen in the right calf. (b) Blood pool phase shows increased tracer uptake in the same area. (c and d) Delayed phase shows heterogenous pericortical accumulation of tracer in the right tibia which is more prominent anteriorly
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Figure 2: Three-phase bone scan. (a) Early hyperemia is seen in the right calf. (b) Blood pool phase shows increased tracer uptake in the same area. (c and d) Delayed phase shows heterogenous pericortical accumulation of tracer in the right tibia which is more prominent anteriorly

Mentions: This was a case of a 51-year-old newly diagnosed diabetic female patient presented with 2-week history of severe and progressive bilateral calves′ pain and ulcers. She was afebrile. Examination of right calf revealed large area of edematous and erythematous skin with multiple ulcers and blisters, whereas examination of left calf revealed a small ulcer over the mid shin with no sign of overlying cellulitis. Clinical diagnosis of right calf necrotizing fasciitis (NF) and left shin diabetic ulcer was made. Random blood glucose was 16.5 mmol/l, erythrocyte sedimentation rate was 111 mm/h and leukocyte count was 12 × 103cells/uL. No abnormality was detected by tibia-fibula X-ray. Apart of aggressive antibiotics regime, she also underwent several emergency surgical debridement. Post-operatively, her temperature remained persistently high. Wound and blood cultures were taken on several occasions but no significant pathogens were isolated. 17 days later, 99mTc-besilosomab scan was performed and showed diffuse localization of tracer overlying the skin of the right calf. No suspicious faint focal uptake was noted in the bone [Figure 1]. 99mTc-HDP three-phase bone scan was carried out a week after 99mTc-besilosomab scan. The bone scan showed increased arterial and blood pool phase over the right calf. Delayed images showed heterogeneous pericortical accumulation of tracer over the right tibia [Figure 2]. The conclusions of both studies were made as localized infection or post-surgical inflammation over the skin of the right calf with reactive changes (periosteal reaction) in the right tibia. Intravenous antibiotics were continued but her temperature remained high. At 5 days after the bone scan, patients underwent right below-knee amputation. Intra-operative findings revealed pus collection in the bone. Acinetobacter sp. was isolated in both intra-operative bone and tissue cultures.


False Negative (99m)Tc-Hydroxymethane Diphosphonate Three-phase Bone Scintigraphy and (99m)Tc-besilesomab Scan in Detecting Tibia Osteomyelitis Concomitant with Necrotizing Fasciitis.

Tan TH, Lee BN - World J Nucl Med (2014)

Three-phase bone scan. (a) Early hyperemia is seen in the right calf. (b) Blood pool phase shows increased tracer uptake in the same area. (c and d) Delayed phase shows heterogenous pericortical accumulation of tracer in the right tibia which is more prominent anteriorly
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4262878&req=5

Figure 2: Three-phase bone scan. (a) Early hyperemia is seen in the right calf. (b) Blood pool phase shows increased tracer uptake in the same area. (c and d) Delayed phase shows heterogenous pericortical accumulation of tracer in the right tibia which is more prominent anteriorly
Mentions: This was a case of a 51-year-old newly diagnosed diabetic female patient presented with 2-week history of severe and progressive bilateral calves′ pain and ulcers. She was afebrile. Examination of right calf revealed large area of edematous and erythematous skin with multiple ulcers and blisters, whereas examination of left calf revealed a small ulcer over the mid shin with no sign of overlying cellulitis. Clinical diagnosis of right calf necrotizing fasciitis (NF) and left shin diabetic ulcer was made. Random blood glucose was 16.5 mmol/l, erythrocyte sedimentation rate was 111 mm/h and leukocyte count was 12 × 103cells/uL. No abnormality was detected by tibia-fibula X-ray. Apart of aggressive antibiotics regime, she also underwent several emergency surgical debridement. Post-operatively, her temperature remained persistently high. Wound and blood cultures were taken on several occasions but no significant pathogens were isolated. 17 days later, 99mTc-besilosomab scan was performed and showed diffuse localization of tracer overlying the skin of the right calf. No suspicious faint focal uptake was noted in the bone [Figure 1]. 99mTc-HDP three-phase bone scan was carried out a week after 99mTc-besilosomab scan. The bone scan showed increased arterial and blood pool phase over the right calf. Delayed images showed heterogeneous pericortical accumulation of tracer over the right tibia [Figure 2]. The conclusions of both studies were made as localized infection or post-surgical inflammation over the skin of the right calf with reactive changes (periosteal reaction) in the right tibia. Intravenous antibiotics were continued but her temperature remained high. At 5 days after the bone scan, patients underwent right below-knee amputation. Intra-operative findings revealed pus collection in the bone. Acinetobacter sp. was isolated in both intra-operative bone and tissue cultures.

Bottom Line: We described a case of 51-year-old female patient presented with a right calf necrotising fasciitis (NF) where osteomyelitis (OM) was suspected. (99m)Tc-hydroxymethane diphosphonate three-phase bone scintigraphy and (99m)Tc-besilosomab scan failed to demonstrate classical features of OM.As conclusions, the detection of lower limb OM by (99m)Tc-besilosomab scan is not easy when there is concurrence overlying NF.The unusual three-phase bone scan finding of pericortical accumulation of tracer as an early sign of OM is highlighted in this case.

View Article: PubMed Central - PubMed

Affiliation: Department of Nuclear Medicine, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia.

ABSTRACT
We described a case of 51-year-old female patient presented with a right calf necrotising fasciitis (NF) where osteomyelitis (OM) was suspected. (99m)Tc-hydroxymethane diphosphonate three-phase bone scintigraphy and (99m)Tc-besilosomab scan failed to demonstrate classical features of OM. The final diagnosis was only made by isolating Acinetobacter sp. in both intra-operative bone and tissue cultures from below-knee amputation. As conclusions, the detection of lower limb OM by (99m)Tc-besilosomab scan is not easy when there is concurrence overlying NF. The unusual three-phase bone scan finding of pericortical accumulation of tracer as an early sign of OM is highlighted in this case.

No MeSH data available.


Related in: MedlinePlus