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    RSNA Education Exhibits

    Combined Labeled Leukocyte and Technetium 99m Sulfur Colloid Bone Marrow Imaging for Diagnosing Musculoskeletal Infection

    Published Online:May 1 2006https://doi.org/10.1148/rg.263055139

    Abstract

    The use of labeled leukocyte (white blood cell [WBC]) studies in the diagnosis of osteomyelitis can be problematic. A combined study consisting of WBC imaging and complementary bone marrow imaging performed with technetium 99m (99mTc) sulfur colloid is approximately 90% accurate and is especially useful for diagnosing osteomyelitis in situations involving altered marrow distribution. There are limitations and pitfalls associated with a combined study. If there is no labeled WBC activity in the region of interest, marrow imaging is not useful. The sulfur colloid image becomes photopenic within about 1 week after the onset of infection, so that the study should be interpreted cautiously in the acute setting. Labeled WBC accumulation in lymph nodes can also confound image interpretation, although nodal activity can usually be recognized because it is typically round, discrete, multifocal, linear in distribution, and often bilateral. Furthermore, 99mTc–sulfur colloid that is improperly prepared or is more than about 2 hours old degrades image quality, potentially causing erroneous conclusions. Nevertheless, WBC-marrow imaging is a very accurate technique for diagnosing osteomyelitis. Knowledge of the criteria for image interpretation and of the aforementioned limitations and pitfalls, combined with careful attention to imaging technique, will maximize the value of this study.

    © RSNA, 2006

    References

    • 1 LipskyBA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis1997; 25: 1318–1326. Crossref, Medline, Google Scholar
    • 2 PalestroCJ, Torres MA. Radionuclide diagnosis of orthopedic infections. Semin Nucl Med1997; 27: 334–345. Crossref, Medline, Google Scholar
    • 3 Propst-ProctorSL, Dillingham MF, McDougall IR, Goodwin D. The white blood cell scan in orthopedics. Clin Orthop Relat Res1982; 168: 157–165. Medline, Google Scholar
    • 4 McKillopJH, McKay I, Cuthbert GF, Fogelman I, Gray HW, Sturrock RD. Scintigraphic evaluation of the painful prosthetic joint: a comparison of gallium-67 citrate and indium-111 labelled leukocyte imaging. Clin Radiol1984; 35: 239–241. Crossref, Medline, Google Scholar
    • 5 WukichDK, Abreu SH, Callaghan JJ, et al. Diagnosis of infection by preoperative scintigraphy with indium-labeled white blood cells. J Bone Joint Surg Am1987; 69: 1353–1360. Crossref, Medline, Google Scholar
    • 6 JohnsonJA, Christie MJ, Sandler MP, Parks PF, Homra L, Kaye JJ. Detection of occult infection following total joint arthroplasty using sequential technetium-99m HDP bone scintigraphy and indium-111 WBC imaging. J Nucl Med1988; 29: 1347–1353. Medline, Google Scholar
    • 7 SchauweckerDS, Park HM, Mock BH, et al. Evaluation of complicating osteomyelitis with Tc-99m MDP, In-111 granulocytes, and Ga-67 citrate. J Nucl Med1984; 25: 849–853. Medline, Google Scholar
    • 8 Al-SheikhW, Sfakianakis GN, Mnaymneh W, et al. Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography. Radiology1985; 155: 501–506. Link, Google Scholar
    • 9 PrchalCL, Kahen HL, Blend MJ, Barmada R. Detection of musculoskeletal infection with the indium-111 leukocyte scan. Orthopedics1987; 10: 1253–1257. Medline, Google Scholar
    • 10 PalestroCJ, Kim CK, Swyer AJ, Capozzi JD, Solomon RW, Goldsmith SJ. Total-hip arthroplasty: periprosthetic indium-111-labeled leukocyte activity and complementary technetium-99m-sulfur colloid imaging in suspected infection. J Nucl Med1990; 31: 1950–1955. Medline, Google Scholar
    • 11 PalestroCJ, Swyer AJ, Kim CK, Goldsmith SJ. Infected knee prosthesis: diagnosis with In-111 leukocyte, Tc-99m sulfur colloid, and Tc-99m MDP imaging. Radiology1991; 179: 645–648. Link, Google Scholar
    • 12 RyanDH, Cohen HJ. Bone marrow examination. In: Hoffman R, Benz EJ Jr, Shattil SJ, et al, eds. Hematology: basic principles and practice. 4th ed. Philadelphia, Pa: Elsevier Churchill Livingstone, 2005; 2556–2672. Google Scholar
    • 13 CompstonJE. Bone marrow and bone: a functional unit. J Endocrinol2002; 173: 387–394. Crossref, Medline, Google Scholar
    • 14 AsterJC. Red blood cell and bleeding disorders. In: Kumar V, Abbas AK, Fausto N, eds. Robbins and Cotran pathologic basis of disease. 7th ed. Philadelphia, Pa: Elsevier Saunders, 2005; 619–660. Google Scholar
    • 15 PalestroCJ, Mehta HH, Patel M, et al. Marrow versus infection in the Charcot joint: indium-111 leukocyte and technetium-99m sulfur colloid scintigraphy. J Nucl Med1998; 39: 346–350. Medline, Google Scholar
    • 16 PalestroCJ, Roumanas P, Swyer AJ, Kim CK, Goldsmith SJ. Diagnosis of musculoskeletal infection using combined In-111 labeled leukocyte and Tc-99m SC marrow imaging. Clin Nucl Med1992; 17: 269–273. Crossref, Medline, Google Scholar
    • 17 TorresMA, Palestro CJ. Leukocyte-marrow scintigraphy in hyperostosis frontalis interna. J Nucl Med1997; 38: 1283–1285. Medline, Google Scholar
    • 18 HayashidaK, Ochi T, Fujimoto M, et al. Bone marrow changes in adjuvant-induced and collagen-induced arthritis: interleukin-1 and interleukin-6 activity and abnormal myelopoiesis. Arthritis Rheum1992; 35: 241–245. Crossref, Medline, Google Scholar
    • 19 FeiginDS, Strauss HW, James HW. The bone marrow scan in experimental osteomyelitis. Skeletal Radiol1976; 1: 103–108. Crossref, Google Scholar
    • 20 PalestroCJ, Charallel J, Vallabhajosula S, Greenberg M, Goldsmith SJ. In-WBC as a bone marrow imaging agent [abstract]. J Nucl Med1987; 27(P): 574. Google Scholar
    • 21 MulambaL, Ferrant A, Leners N, de Nayer P, Rombouts JJ, Vincent A. Indium-111 leucocyte scanning in the evaluation of painful hip arthroplasty. Acta Orthop Scand1983; 54: 695–697. Crossref, Medline, Google Scholar
    • 22 KingAD, Peters AM, Stuttle AW, Lavender JP. Imaging of bone infection with labelled white blood cells: role of contemporaneous bone marrow imaging. Eur J Nucl Med1990; 17: 148–151. Crossref, Medline, Google Scholar
    • 23 SeaboldJE, Nepola JV, Marsh JL, et al. Postoperative bone marrow alterations: potential pitfalls in the diagnosis of osteomyelitis with In-111–labeled leukocyte scintigraphy. Radiology1991; 180: 741–747. Link, Google Scholar
    • 24 AchongDM, Oates E. The computer-generated bone marrow subtraction image: a valuable adjunct to combined In-111 WBC/Tc-99m in sulfur colloid scintigraphy for musculoskeletal infection. Clin Nucl Med1994; 19: 188–193. Crossref, Medline, Google Scholar
    • 25 JosephTN, Mujitaba M, Chen AL, et al. Efficacy of combined technetium-99m sulfur colloid/indium-111 leukocyte scans to detect infected total hip and knee arthroplasties. J Arthroplasty2001; 16: 753–758. Crossref, Medline, Google Scholar
    • 26 LoveC, Marwin SE, Tomas MB, et al. Diagnosing infection in the failed joint replacement: a comparison of coincidence detection fluorine-18 FDG and indium-111-labeled leukocyte/technetium-99m-sulfur colloid marrow imaging. J Nucl Med2004; 45: 1864–1871. Medline, Google Scholar
    • 27 MaderJT, Calhoun J. Osteomyelitis. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone, 2000; 1183–1196. Google Scholar
    • 28 MaderJT, Brown GL, Guckian JC, Wells CH, Reinarz JA. A mechanism for the amelioration by hyperbaric oxygen of experimental staphylococcal osteomyelitis in rabbits. J Infect Dis1980; 142: 915–922. Crossref, Medline, Google Scholar
    • 29 LoveC, Palestro CJ. Radionuclide imaging of infection. J Nucl Med Technol2004; 32: 47–57. Medline, Google Scholar
    • 30 LoveC, Tomas MB, Marwin SE, Pugliese PV, Palestro CJ. Role of nuclear medicine in diagnosis of the infected joint replacement. RadioGraphics2001; 21: 1229–1238. Link, Google Scholar
    • 31 BosettiM, Cannas M. The effect of bioactive glasses on bone marrow stromal cells differentiation. Biomaterials2005; 26: 3873–3879. Crossref, Medline, Google Scholar
    • 32 Van NostrandD, Abreu SH, Callaghan JJ, Atkins FB, Stoops HC, Savory CG. In-111–labeled white blood cell uptake in noninfected closed fracture in humans: prospective study. Radiology1988; 167: 495–498. Link, Google Scholar
    • 33 RosenbergAE. Bones, joints, and soft tissue tumors. In: Kumar V, Abbas AK, Fausto N, eds. Robbins and Cotran pathologic basis of disease. 7th ed. Philadelphia, Pa: Elsevier Saunders, 2005; 1273–1324. Google Scholar
    • 34 PalestroCJ, Tomas MB. Scintigraphic evaluation of the diabetic foot. In: Freeman LM, ed. Nuclear medicine annual 2000. Philadelphia, Pa: Lippincott Williams & Wilkins, 2000; 143–172. Google Scholar
    • 35 BuringK. On the origin of cells in heterotopic bone formation. Clin Orthop Relat Res1975; 110: 293–302. Crossref, Medline, Google Scholar
    • 36 PalestroCJ, Kim CK, Swyer AJ, Vallabhajosula S, Goldsmith SJ. Radionuclide diagnosis of vertebral osteomyelitis: indium-111-leukocyte and technetium-99m-methylene diphosphonate bone scintigraphy. J Nucl Med1991; 32: 1861–1865. Medline, Google Scholar

    Article History

    Published in print: May 2006