Σπινθηρογραφική διάγνωση και παρακολούθηση οστεομυελίτιδας σε διαβητική ασθενή με την μέθοδο των επισημασμένων με 99mTc-HMPAO αυτόλογων λευκών αιμοσφαιρίων
Καραμήτσος, Δημήτριος - Σπυρίδων - Έριχ
Introduction-Aim: Pedal ulcers are common complications in diabetic patients and are often portals of bacterial entry and infection. The diagnosis of osteomyelitis may be difficult due to the concomitant soft tissue infection and plain film radiographs are often without findings or inconclusive during early sta- ges of the disease. The aim of this publication is to demonstrate the contribution of 99m Tc-HMPAO labelled leucocyte scintigraphy in diagnosis and follow-up of pedal osteomyelitis in a diabetic patient with a pedal neurotrophic ulcer and initial radiograph negative for osteomyelitis. Patient and methods: A 55 year old female with a history of type 2 diabetes mellitus and peripheral neuropathy presented with a 3-month-old, 4 cm-diameter, deep plantar ulcer over left calcaneus and clinical signs of infection. Initial radiographs of the left foot were negative for osteomyelitis. Pseudomonas aeruginosa isolated from material collected from the base of the ulcer. The patient had three-phase 99m Tc-MDP bone scintigraphy (perfusion phase, blood pool images and delayed images of the feet) followed, 5 days later, by 99m Tc-HMPAO-labelled leucocyte scintigraphy. The later was repeated 2 and 4 months after initial diagnosis in order to evaluate response to treatment. Results: Three-phase bone scintigraphy demonstrated increased blood flow, focal hyperemia and intense focal uptake on delayed images, at the calcaneus of the left foot. 99m Tc-HMPAO-labelled leucocyte scintigraphy showed focal leucocytes accumulation concordant with bone scintigraphy findings, and also uptake by soft tissue infection area. Thus, the diagnosis of osteomyelitis was established by combination of radionuclide studies, in the absence of radiographic findings, and the patient was properly treated. Two months later, a follow-up leucocyte scintigraphy demonstrated partial response of the left calcaneus lesion and revealed a new site of bone infection in the right foot. A third leucocyte scintigraphy performed 4 months after the initial diagnosis, showed deterioration of left calcaneus osteomyelitis and the patient underwent a below-knee amputation. Conclusion: Foot imaging by 99m Tc-HMPAO-labelled leucocyte scintigraphy, combined with bone scintigraphy, plays a decisive role in early and accurate diagnosis of pedal osteomyelitis with coexisting neurotrophic ulcer in diabetic patients and should be performed despite negative initial radiographs. Furthermore, leucocyte scintigraphy is a useful method for evaluation of response to treatment and can thus influence therapeutic decisions.
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