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Radionuclide imaging in patients with fever

Radionuclide imaging in patients with fever. materials for medical students. Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague. Fever . Non-specific reaction of the body (T>38 o C) Most frequent cause inflammation (tumors) Inflammation

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Radionuclide imaging in patients with fever

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  1. Radionuclide imaging in patients with fever materials for medical students Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague

  2. Fever • Non-specific reaction of the body (T>38oC) • Most frequent cause inflammation (tumors) • Inflammation • Infective and non-infective • Usually fever with other signs of imflammation • Clinical picture very important • Other laboratory tests including imaging methods (NM, sono, CT, MRI) are essential

  3. Fever • Probable etiology should be taken into account • Fever in patient post surgery • Fever in patient with renal failure • Fever in patient with HIV positivity • Fever in patient with septicaemia • Fever of unknown origin • Fever for 3 weeks with unknown origin despite 1 week intensive hospital evaluation • Fever in children • Fever in soft tissue inflammation • Fever in bone infection • Fever in patient with abdominal sepsis • Fever in patient with different tumors

  4. Fever • Radiopharmaceuticals • organ specific – show damage of appropriate organ (defect of functioning tissue) • Tc-99m diphosphonates – bone scan • Tc-99m DMSA - kidneys • organ non-specific – accumulates directly in inflammed tissue (little bit tumors, wounds, hematomas) • Ga-67 citrate – infective, non-infective, tumors • labeled leukocytes – pyogenic infection • Tc-99m IgG – non-infective • F-18 FDG

  5. Ga-67 - properties • Used in a form of citrate • Binds to plasmatic proteins, excretion by kidneys (24 h) and then intestinal mucosa • Degree of accumulation correlates with process activity • Basic principles of accumulation: • Complexes with plasma transferrin • Binds to intracellular lactoferrin inside leukocytes • Can binds directly to some parts of bacteria • Patient preparation: • Laxatives - fast elimination from the bowel

  6. Ga-67 - procedure • Injection of 150-180 MBq • high energy, long half-life, high absorbed dose, worse spatial resolution (image qual) • Acquisition 4-6 h p.i., then from 24 h to 3-4 days • Collimator for medium energy • Whole-body study, spot view (larger frame matrix), SPECT

  7. Ga-67 – clinical significance • High sensitivity (90%) but low specificity – used as a locating agent– it locates site of damage so other more specific methods can be used • More suitable for chronic inflammation • Not very good for abdominal inflammation evaluation due to physiological excretion via intestinal mucosa

  8. Ga-67 – clinical indications • Specific inflammation (sarcoidosis, tuberculosis) • Imunocompromised patients (lung inf) • Thoracic inflammation (fibrosis, vasculitis) • Non-infective inflam – process activity (kollagenosis) • Fever of unknown origin • wide spectrum of possible causes • Osteomyelitis • Abdominal and retroperitoneal inflamation (pyelonefritis, absces)

  9. Labeled leucocytesproperties • Basic pinciples of accumulation • positive chemotaxis (no injury during labeling process) • also healing wounds and tumors • Labeling process • in vitro - separation, laboured • in vivo - monoclonal antibodies • Patient preparation • fasted (blood processing)

  10. Labeled leucocytes procedure • Labeling • 60 ml venous blood (kids min. 12 ml) • separation, washing up, labeling – cca 1.5 h • Labeling with Tc-99m HMPAO (300 – 500 MBq) or In-111 oxin (20-40 MBq) • Data acquisition • 30 min, 4-6, 24 (48 In) h post injection • Whole-body study, spot view (larger frame matrix), SPECT

  11. Labeled leucocytes clinical indication • Unspecific bowel disease (Crohn, UC) • Diabetic foot syndroma • Musculosceletal infection • Fever of unknown origin (within 2-3 w) • Imunocompromised patients • Joint prosthesis infection • Acute arthritis • Vascular prosthesis infection

  12. Tc-99m IgG • Non-specific polyclonal • Labeled with In-111 or Tc-99m. • Accumulates predominantly within interstitial space • Physiological accumulation – blood-pool, liver, spleen, kindeys, bone marrow and nasal mucosa • Main indication • Revmatic (non-infective) inflamation

  13. F-18 FDG • Metabolic analog of glucose • enter cells but no metabolism – accumulates according to degree of metabolic turnover • Imaging by PET • Metabolically active processes (inflam, tumors) - more glucose than other tissue • Mainly used as a locating agent (like Ga-67) and mark of activity • PET – much better spatial resolution (better image quality)

  14. New ways • Imaging of bacteria • labeled chemotherapeuticals (chinolony) • dependent on antibiotics therapy • Chemotactic peptides • interleukin 2 – non-infective inflammation (autoimmune) • Combined methods • Streptavidin (tissue senzibilization) and then labeled biotin

  15. Ga-67 citrate physiological distribution male and female

  16. Ga-67 - sarkoidosis

  17. Ga-67 – sarkoidosispanda-sign

  18. Ga-67 – sarkoidosispanda and delta sign

  19. Ga-67 – lung fibrosis

  20. Ga-67 - tuberculosis

  21. Ga-67 - urosepticaemia

  22. Ga-67 – thyroiditiscomparison with Tc-99m pertechnetate

  23. Labeled leucocytesphysiological distribution

  24. Labeled leucocytes ulcerative colitis

  25. Labeled leucocytes ulcerativecolitis or Crohn´s disease?

  26. Labeled leucocytes ulcerative colitis

  27. Labeled leucocytes infection of hip prosthesis

  28. Diabetic foot syndroma

  29. Patient JU 1961, X-ray chron. OM

  30. Patient JU 1961, bone scan posit.

  31. Patient JU 1961, leu scan negative

  32. F-18 FDGphysiological distribution

  33. FUO Fever of unknown origin (all methods failed) PET revealed: - aortitis/vasculitis As a bonus: - Breast cancer (vasculitis as a paraneoplastic sign)

  34. Vascular prosthesis infection PET FDG

  35. Joint prosthesis infection PET FDG

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