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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