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LETTER TO EDITOR
Year : 2015  |  Volume : 14  |  Issue : 2  |  Page : 142

Increasing Specificity of 99m Tc-HDP Three-phase bone Scintigraphy and 99m Tc Besilesomab Scan in Case of Osteomyelitis Complicated with Necrotizing Fasciitis


Department of Nuclear Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication15-May-2015

Correspondence Address:
Madhur Kumar Srivastava
Department of Nuclear Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
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DOI: 10.4103/1450-1147.153907

PMID: 26097429

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How to cite this article:
Srivastava MK, Ponnusamy M, Halanaik D, Pandit N. Increasing Specificity of 99m Tc-HDP Three-phase bone Scintigraphy and 99m Tc Besilesomab Scan in Case of Osteomyelitis Complicated with Necrotizing Fasciitis. World J Nucl Med 2015;14:142

How to cite this URL:
Srivastava MK, Ponnusamy M, Halanaik D, Pandit N. Increasing Specificity of 99m Tc-HDP Three-phase bone Scintigraphy and 99m Tc Besilesomab Scan in Case of Osteomyelitis Complicated with Necrotizing Fasciitis. World J Nucl Med [serial online] 2015 [cited 2019 Nov 19];14:142. Available from: http://www.wjnm.org/text.asp?2015/14/2/142/153907

Dear Editor,

We studied with great interest the case report "False Negative 99m Tc Hydroxymethane Disphosphonate Three-phase Bone scintigraphy and 99m Tc Besilesomab Scan in detecting Tibia osteomyelitis concomitant with necrotizing fasciitis." [1] The author has nicely described the case and is correct in saying that due to necrotizing fasciitis, underlying osteomyelitis (OM) is difficult to image and that pericortical tracer accumulation can be an early sign of OM. The mechanism of uptake of 99m Tc-besilesomab in infection is also well described. However, we want to focus on a few techniques that can increase the specificity of the above tests. The fourth phase of bone scanning, that is, delayed static scan at 24 h, increases the specificity of the bone scan in diagnosing OM. [2] In 99m Tc-besilesomab, a delayed image at 24 h showing increase in tracer activity or increase in the size of uptake in the lesion favors OM. [3] The uptake of 99m Tc-besilesomab in the right tibia at 5 h would have been better visualized, had the adjoining areas of increased uptake in skin and soft tissue been masked. The masking of area with high tracer concentration is widely used method to see adjacent region of reduced tracer concentration. During image formation, pixel with highest tracer concentration is taken as 100% and other areas are normalized accordingly. If that pixel is masked, the image processing software will take next highest tracer concentration area and normalize rest of the image accordingly. In true terms the uptake will increase in rest of the region. This can be done by οmage masking tool like ?series reformat processing activity? in Siemens Syngo MI® application by Siemens AG, Erlangen, Germany. Lastly, in cases of diabetic status with no history of trauma, infection by Gram-negative bacilli such as Acinetobacter sp. should be considered, which are of low virulence and thus produce not enough bony changes to be strongly positive on bone scan. Tracer uptake in bone scan depends on bone turnover which, in turn, depends on the virulence of bacteria. In Staph. aureus (highly virulent bacteria) osteomyelitis, like in open wound infection, tracer uptake is more as osteoblastic activity in bone is more, than in low virulent organism like acinetobacter. This point also reflects the importance of history taking like in this particular case history of trauma and diabetic status is important. [4],[5] This should be considered while reporting the case. The pericortical accumulation of the tracer as an early sign of OM needs to be further evaluated.

 
   References Top

1.
Tan TH, Lee BN. False negative 99m Tc-hydroxymethane disphosphonate three-phase bone scintigraphy and 99m Tc-besilesomab scan in detecting tibia osteomyelitis concomitant with necrotizing fasciitis. World J Nucl Med 2014;13:190-2.  Back to cited text no. 1
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2.
Elgazzar AH, Shehab D. Musculoskeletal system. In: Elgazzar AH, editor. The Pathophysiologic Basis of Nuclear Disease. 2 nd ed. Berlin, Germany: Springer; 2006. p. 132-208.  Back to cited text no. 2
    
3.
Richter WS, Ivancevic V, Meller J, Lang O, Le Guludec D, Szilvazi I, et al. 99m Tc-besilesomab (Scintimun) in peripheral osteomyelitis: Comparison with 99m Tc-labelled white blood cells. Eur J Nucl Med Mol Imaging 2011;38:899-910.  Back to cited text no. 3
    
4.
Chiu LQ, Wang W. A case of unusual Gram-negative bacilli septic arthritis in an immunocompetent patient. Singapore Med J 2013;54:e164-8.  Back to cited text no. 4
    
5.
Collinet-Adler S, Castro CA, Ledonio CG, Bechtold JE, Tsukayama DT. Acinetobacter baumannii is not associated with osteomyelitis in a rat model: A pilot study. Clin Orthop Relat Res 2011;469:274-82.  Back to cited text no. 5
    




 

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