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Dr. Manish Thangaraj delivered this lecture at Alagappa University. Its related to Bones course in Medical Science. Its main points are: Osteomyelitis, Case, Limp, Painful, Ankle, Afebrile, Local, Erythema, Swelling, Tibial, Metaphysis
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Osteomyelitis (Case 1)
5-year-old boy with a 3-day history of limp and painful right ankle. He is afebrile, and examination shows no local erythema or swelling. ESR was raised.
Increased activity on all phases in the distal right tibial metaphysis. Consistent with osteomyelitis of that region
Flow
Pool
Delayed
The patient is status post gunshot wound several years ago, and is a paraplegic. He has sacral ulcers and heel ulcerations, and the study is obtained to evaluate for osteomyelitis.
Increased activity in blood flow and pool images in both feet.
Flow & Pool
63-year old woman with sudden onset of lower back pain one month ago
Intensely increased uptake at L2-3.
Previous lumbar spine radiographs were normal except for degenerative change.
Biospy showed growth of Streptococcus viridans
This picture is highly suggestive of discitis
Case 4
55 year-old diabetic man with left heal pain. Increased blood flow and delayed uptake on bone scintigraphy in the left calcaneous There is also increased activity in the 1st^ and 2 nd^ metatarsal heads
Flow
Delayed
52 year-old diabetic man right plantar ulcer over the 3rd digit for 3 months.
Recently low grade fever and worsening foot pain.
Increased blood flow and blood pool activity to the right forefoot.
Defused activity is also noted in surrounding tissue
Flow
Pool
Flow
Pool
Case 5
Marked uptake at the right third distal metatarsal and proximal phalanx
These findings are consistent with osteomyelitis of the third metatarsal and possibly third metatarsal-phalangeal joint infection.
Soft tissue activity is due to accompanying cellulitis in the surrounging tissue.
Radiograph is normal
Delayed images Radiograph
24 hours delayed In-111 labelled WBC images show a single focal area of increased acitivity in the distal left foot.
Case 7
53 year old man with recent onset of left shoulder pain. He has advanced diabetes and a prior history of septic arthritis of the right shoulder. Bone scintigraphy (not shown) demonstrated non-specific mildly increased activity in the left shoulder on the flow and delayed images.
On 111 In-WBCs a focus of increased leukocyte accumulation is identified in the left acromioclavicular joint most consistent with pyogenic arthritis.
Cultures were positive for staphylococcus (^111) In-oxine WBC scan
Gallium scintigraphy obtained 72 hours post injection reveals increased activity in the soft tissues about the right hip joint suggesting osteomyelitis.
CT scan confirmed the diagnosis
Case 9
19 year old man with a 6 month history of Hodgkins Disease. Being evaluated after chemotherapy.
Prominent soft tissue uptake is seen in the pectoralis muscles, bilaterally. Otherwise, the examination showed only physiologic distribution of activity.
Delayed WB
Spot views
This patient is a body builder. Two day prior to examination, he had an extensive workout focusing his chest muscle. This is exercised-induced myositis.
Lt Lat
Planter
Rt Med Delayed MDP images:
Increased activity in the right great toe, right lateral foot, left great toe, left lateral foot and left midfoot on delayed images
Planter
Rt medial.
Gallium-67:
Hyperintense uptake in the right great toe consistent with osteomyelitis. Some increased uptake in the left mid foot.
73-year old woman with end- stage renal disease had a left total knee replacement approximately one year ago. Two month following the surgery, the patient had aseptic arthritis of the left knee, which was treated with intravenous antibiotics and debridement. The patient now presents with fevers and an elevated white blood cell count.
The plain radiographs demonstrate the left knee prosthesis and no frank evidence of osteomyelitis
Case 11
24-hour delayed whole body scintigraphy with In-111 white blood cells. There is no abnormality in the left knee. However, additional images over the lower extremities demonstrate increased activity in the left tibia just beyond the level of the prosthesis. It was also demonstrated by MRI.
