Leukocyte ImagingLeukocyte Imaging

The Diagnostic Applications of The Diagnostic Applications of Labeled WBCs Using Labeled WBCs Using 111111In and In and 99m99mTcTc

Normal Normal 111111In WBC ScanIn WBC Scan The patient is status post left The patient is status post left

hemicolectomy with intra-hemicolectomy with intra-abdominal fluid collection. abdominal fluid collection. Evaluate for abscess. Evaluate for abscess.

FindingsFindingsWhite blood cell activity is seen White blood cell activity is seen in the spleen, liver, and axial in the spleen, liver, and axial skeleton, as expected. No areas skeleton, as expected. No areas of abnormally increased white of abnormally increased white cell activity are seen. cell activity are seen.

ConclusionsConclusionsNormal examination with no Normal examination with no evidence for abscess.evidence for abscess.

99m99mTcMDP + TcMDP + 111111IN-WBCIN-WBC

Left Above: Left Above: 99m99mTc MDP Bone Tc MDP Bone Scan indicates increased Scan indicates increased activity in the proximal tibia activity in the proximal tibia and patella. Osteomyelitis and patella. Osteomyelitis (bone infection) cannot be (bone infection) cannot be ruled out.ruled out.

Left Below: Left Below: 111111Indium-Oxine Indium-Oxine White Blood Cell Label of White Blood Cell Label of same patient reveals an area same patient reveals an area of increased activity indicating of increased activity indicating an infection in the left proximal an infection in the left proximal tibia and distal femur. tibia and distal femur.

Images courtesy of Nuclear Medicine Department, Dartmouth-Hitchcock Medical CenterImages courtesy of Nuclear Medicine Department, Dartmouth-Hitchcock Medical Center

111111Indium WBC ImagingIndium WBC ImagingWBC study shows increased WBC study shows increased WBC activity in the L femur WBC activity in the L femur at site of plate attachment. at site of plate attachment. This uptake correlates with This uptake correlates with evidence of hyperemia seen evidence of hyperemia seen on both the sulfur colloid on both the sulfur colloid study and the blood pool study and the blood pool phase of the bone scan. phase of the bone scan. These findings are strongly These findings are strongly suggestive of cellultis in the suggestive of cellultis in the soft tissues lateral to the left soft tissues lateral to the left femoral plate. No other femoral plate. No other abnormal foci of white blood abnormal foci of white blood cell accumulation are cell accumulation are identified within the chest, identified within the chest, abdomen, or pelvis. abdomen, or pelvis.

Clinical HistoryClinical History84-year-old man with left 84-year-old man with left lower extremity and hip lower extremity and hip pain. pain.

111111Indium WBC ScanIndium WBC Scan

The study demonstrates three foci of abnormal white blood cell The study demonstrates three foci of abnormal white blood cell activity. One is in the region of the heart, another in the medial activity. One is in the region of the heart, another in the medial right lower chest cavity and the third in the right upper chest right lower chest cavity and the third in the right upper chest cavity. Correlation with chest radiograph is recommended for cavity. Correlation with chest radiograph is recommended for further delineation of chest findings. Infected valve and further delineation of chest findings. Infected valve and endocarditis should be excluded. endocarditis should be excluded.

Clinical HistoryClinical HistorySevere mitral regurgitation Severe mitral regurgitation and cardiac valvular surgery. and cardiac valvular surgery.

FUO; ? abscessFUO; ? abscess. .

99m99mTc HMPAO Labeled WBCTc HMPAO Labeled WBC

Superior to In111 Leukocyte labeling, due to Superior to In111 Leukocyte labeling, due to readily available and cheaper.readily available and cheaper.

Best for osteomyeolitis in the extremitiesBest for osteomyeolitis in the extremities Higher counting statistics and can block Higher counting statistics and can block

pelvic area due to excretion thru urine.pelvic area due to excretion thru urine. Imaging time is decreased from 10 minutes Imaging time is decreased from 10 minutes

to 5 minutes.to 5 minutes. Can Imaging within hours not 24 hoursCan Imaging within hours not 24 hours SPECT Imaging can be performedSPECT Imaging can be performed

Normal Tc99m Ceretec or Normal Tc99m Ceretec or HMPAO WBCHMPAO WBC

Tc99m HMPAO WBC ScanTc99m HMPAO WBC Scan

Tc-99m-labeled WBC Scan obtained Tc-99m-labeled WBC Scan obtained one hour after injection revealed one hour after injection revealed abnormal patchy uptake throughout abnormal patchy uptake throughout the bone marrow. Normal hepatic and the bone marrow. Normal hepatic and splenic uptake. No collections of splenic uptake. No collections of tracer to suggest a focus of infection tracer to suggest a focus of infection outside the reticuloendothelial system. outside the reticuloendothelial system. Residual bowel activity in the right Residual bowel activity in the right lower quadrant of the abdomen due to lower quadrant of the abdomen due to the Tc-99m-DISIDA hepatobiliary scan the Tc-99m-DISIDA hepatobiliary scan performed 20 hours earlier was noted performed 20 hours earlier was noted prior to reinjection of the autologous prior to reinjection of the autologous labeled white cells.labeled white cells.

Tc99m Leukocyte ScanTc99m Leukocyte Scan

The image on the left shows a technetium labeled white blood cell scan of the feet of a diabetic patient with infection in the great toe of the left foot. Notice the dark spot at the site of infection.

99m99mTcWBC ScanTcWBC Scan

Male Patient 1 month Male Patient 1 month post distal post distal pancreatectomy and pancreatectomy and splenectomy. The splenectomy. The patient was febrile at patient was febrile at time of study.time of study.

Images consistent Images consistent with inflammation in with inflammation in surgical wound and surgical wound and pelvic abscess.pelvic abscess.

LUQ

Incision

Pelvic Abscess

Inflammatory Bowel With Inflammatory Bowel With 99m99mTcWBCTcWBC

Diffuse uptake Diffuse uptake throughout the throughout the colon. No small colon. No small bowel uptake bowel uptake identified. identified.

When the disease When the disease involves the entire involves the entire colon and there is colon and there is no small bowel no small bowel activity, total activity, total colectomy may be colectomy may be considered.considered.

24 Year old female, known IBD

99m99mTc WBC Liver AbscessTc WBC Liver Abscess

WBC Scan WBC Scan demonstrates 5 demonstrates 5 abscesses.abscesses.

4 located in the right 4 located in the right lobe of the liver and a lobe of the liver and a single abscess was single abscess was noted in the left noted in the left (quadrate) lobe of the (quadrate) lobe of the liver. liver.

48 Year old male, FUO and abdominal pain.

In111 Vs. Tc99mIn111 Vs. Tc99m In111 LeukocytesIn111 Leukocytes

Dose 200-500uCiDose 200-500uCi Image 10 minutes per viewImage 10 minutes per view 20% window20% window Medium or High energy Medium or High energy

collimatorcollimator Dual energiesDual energies

173 keV and 247 keV173 keV and 247 keV

Normal uptake Normal uptake spleenspleen, Liver , Liver and bone marrowand bone marrow 0-4 hours post injection shows 0-4 hours post injection shows

transient pulmonary distributiontransient pulmonary distribution

Image 24 hours post injectionImage 24 hours post injection Possibly 3-4 hours for abdominal Possibly 3-4 hours for abdominal

imagingimaging

Tc99m Ceretec Tc99m Ceretec LeukocytesLeukocytes Dose 20-25 mCiDose 20-25 mCi Image 5 minutes per viewImage 5 minutes per view 20% window20% window Low energy-high Low energy-high

resolutionresolution Energy setting 140keVEnergy setting 140keV Normal uptake: liver, Normal uptake: liver, spleenspleen, bone marrow, , bone marrow, kidneys and bladderkidneys and bladder Post 4 hours intestinal Post 4 hours intestinal

excretion may be evidentexcretion may be evident

Image at 1-4 hours post Image at 1-4 hours post injectioninjection