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 hyperperfussionIncreased cappilars permeabilityExudationSwellingLeukocytes migrationDysfunction of organ or tissue

Diagnosis of inflammation

Physical examinationLaboratory testsX-rayUltrasoundMRI

Symptoms

DolorRuborTumorCalor

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 osteomyelitisin a peadriatric patient

Hematogenous osteomyelitisin a peadriatric patient

Diagnosis of inflammation

Physical examinationLaboratory testsX-rayUltrasoundMRI

Scintigraphy

Specific radionuclide techniques

In vitro labelled leukocytesIn vivo labelled leukocytesLabelled poliklonal IgGLabelled antibioticsGallium-67 scan

Non specific radiomuclide techniques

Bone scintigraphyRenal static scintigraphySalivary gland scintigraphyBrain perfussion scan

In vitro labelled leukocytes

Indium-111 oxinTechnetium-99m – HmPAOLabelling process outside of bodySeparation of leucocytes in centrifugal machineLabelling by diffusion of radioactive complex into a cell

In vitro labelling

In vitro labelling

In vivo labelled leucocytes

ImmunoscintigraphyMonoclonal IgG antibody Fab’ fragment labeled with Technetium-99mInjected 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 originArtery graft infectionsInfection ortopaedic prothesisBowel inflamatory disease

Tc99m-HmPAO labelled leukocytes – normal abdominal scan

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

Appendicitis

Fever of Unknown Origin (FUO)

30% of patiens with FUO have silent infectionAfter surgery 60%Very often negative X-ray and USTc99m-HmPAO labelled scintygraphy is method of choice

Arterial graft infections

2-6% of graftsMortality very high 25-75%The highest sensitivity of Tc99m-HmPAO labelled leukocytes scintigraphy100% !Early diagnosis saves live

Bowel inflamatory diseases

Crohn diseaseColitis ulcerosaNon specific bowel inflamationThe same efficacy that colonoscopy with mucosa biopsyControl of treatement

Crohn disease

Colitis ulcerosa

Gallium-67 citrate

Labelling in vivo leucocytesBinds to transport protein laktoferrinExpensiveLess specific than labelled leucocytesAlso 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 inflammationCirculating IgG`s are premeabling to intercellular spaceEasy to preparation and cost effectiveNo differentiation between inflamation and infection

Policlonal IgG-Tc99m - normal

Policlonal IgG-Tc99m - normal

Policlonal IgG-Tc99m

Policlonal IgG-Tc99m

Bone scintigraphy

Three-phase scintigraphyEarly phase: perfussionLate phase: bone metabolismUsefull in incection and inflammationNon 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 children1% leads to renal failure and transplantation10% asymptomaticRenal 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 56.7DOPPLER

CT 86.8 87.5

MR 89.5 87.5

Brain vasculitis

Antiphospholipide Antybody SyndromLupus cerebri and other colagenosesHigh mortality!Needs agressive treatement with cytostatics and high doses of steroidsrCBF=Brain perfussion scanSPECT

Normal perfussion

Cerebral vasculitis

Cerebral vasculitis

Salivary gland function

Sjoegrens disease