|Year : 2021 | Volume
| Issue : 1 | Page : 62-65
Incremental value of three-phase bone scintigraphy and single-photon emission computed tomography–computed tomography in a case of postpartum PUO in the wake of the antibiotic-resistance era
Pramukh Kulkarni, Indirani M Elangoven, A Jaykanth, Shelley Simon
Department of Nuclear Medicine and Molecular Imaging, Apollo Hospitals, Chennai, Tamil Nadu, India
|Date of Submission||24-Jul-2020|
|Date of Acceptance||13-Aug-2020|
|Date of Web Publication||04-Mar-2021|
Dr. Shelley Simon
Department of Nuclear Medicine and Molecular Imaging, No. 21, Greams Lane off Greams Road, Apollo Hospitals, Chennai - 600 006, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Postpartum methicillin-resistant Staphylococcus aureus (MRSA) infection occurs in patients with complicated vaginal delivery or cesarean section. The infection can manifest as mastitis, endometritis, and if untreated may lead to toxic shock syndrome. We report a case of postpartum MRSA osteomyelitis diagnosed by 99mtechnetium-methylene diphosphonate skeletal scintigraphy and single-photon emission computed tomography–computed tomography (CT) that was further confirmed by magnetic resonance imaging and CT-guided biopsy. This multimodal imaging approach helped reach the diagnosis and in further management of the patient.
Keywords: Multimodal approach, postpartum methicillin-resistant Staphylococcus aureus, single-photon emission computed tomography–computed tomography, toxic shock syndrome
|How to cite this article:|
Kulkarni P, Elangoven IM, Jaykanth A, Simon S. Incremental value of three-phase bone scintigraphy and single-photon emission computed tomography–computed tomography in a case of postpartum PUO in the wake of the antibiotic-resistance era. Indian J Nucl Med 2021;36:62-5
|How to cite this URL:|
Kulkarni P, Elangoven IM, Jaykanth A, Simon S. Incremental value of three-phase bone scintigraphy and single-photon emission computed tomography–computed tomography in a case of postpartum PUO in the wake of the antibiotic-resistance era. Indian J Nucl Med [serial online] 2021 [cited 2022 Jan 22];36:62-5. Available from: https://www.ijnm.in/text.asp?2021/36/1/62/310789
| Introduction|| |
Osteomyelitis (OM) is an infectious disease of the bone, which leads to destruction and deterioration of function performed by the affected bone. The occurrence of disease is not high, owing to high resistance to infection. Patients affected are those with risk factors such as diabetes, decubitus ulcers, surgery, trauma, and intravenous drug use.
Staphylococcus aureus has been commonly found to be the causative organism. The majority of these cases involve the methicillin-resistant S. aureus (MRSA) strains acquired through the community. These MRSA strains are ones that are resistant to β-lactam antibiotics including penicillin, cephalosporins, and carbapenems.
The microorganism reaches the bone by hematogenous dissemination, by spread from a contiguous focus of infection, or by a penetrating wound. MRSA infection leads to extraosseous spread of the infection and also increased morbidity. This is attributed to the production of a toxin known as Panton–Valentine leukocidin by MRSA strains.
Mastitis, cellulitis, breast abscess, pelvic thrombophlebitis, pneumonia, septicemia, wound infection (cesarean and episiotomy), and urinary tract infections have been reported in patients with postpartum infection. Cases of pyogenic OM involving femoral heads, pubic symphysis,, and tibia have been reported with sacroiliac joint involvement being a rare entity which the clinician needs to keep in mind to arrive at a diagnosis. It is believed that puerperal sacroiliitis is related to microscopic areas of injury on the joint surfaces produced by the changes during pregnancy.
| Case Report|| |
A 32-year-old female presented with complaints of pain in the lower back for 6 months. The pain was insidious in onset, gradually progressive, radiating to the right gluteal region, and associated with low-grade fever.
The patient had a history of cesarean section after a full-term pregnancy, 6 months before presentation to the clinic. On physical examination, the patient was conscious, normotensive (130/80 mmHg), with elevated heart rate (144 beats/min) and tachypneic (23 breaths/min). Her body temperature was 40.2°C.
Blood investigations revealed the following [Table 1].
She was then referred for a 99mtechnetium-methylene diphosphonate (99mTc-MDP) three-phase skeletal scintigraphy with single-photon emission computed tomography–computed tomography (SPECT-CT) after the regular investigations, 20 mCi of 99mTc-MDP was injected after securing an intravenous line. The scan revealed increased perfusion in the first pass and mild tracer pooling on the second pass in the right sacroiliac region [Figure 1]a and [Figure 1]b. The static study [Figure 1]c and delayed whole-body sweep [[Figure 1]d] showed increase in tracer concentration in the sacroiliac joints (R > L), and mildly increased tracer concentration was seen in the symphysis pubis.
|Figure 1: (a) 99mtechnetium-methylene diphosphonate three-phase perfusion-phase skeletal scintigraphy in posterior view shows abnormal perfusion in the region corresponding to the right sacroiliac joint. (b) 99mtechnetium-methylene diphosphonate blood-pool phase scintigraphy in posterior view shows mild tracer pooling in the right sacroiliac region. (c) Increased tracer uptake in the delayed phase seen in the region corresponding to the right sacroiliac region (bold arrow) and symphysis pubis (arrow). (d) 99mtechnetium-methylene diphosphonate delayed whole-body sweep showing increased tracer concentration in the sacroiliac joints (R > L, marked by bold arrow) and mildly increased tracer concentration was seen in the symphysis pubis (arrow). Injection site is noted near the right elbow|
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SPECT-CT with low-dose nondiagnostic CT of the pelvic region was done for localization. It showed increased tracer concentration in the articular margin erosions with adjoining sclerosis in bilateral sacroiliac joints (Right > Left) with minimal soft-tissue component on the right side [Figure 2]a and [Figure 2]b. Subchondral erosions were seen in the pubic symphysis with mild tracer concentration. Old healed fracture was noted in the left inferior pubic ramus [Figure 2]c.
|Figure 2: (a) Single-photon emission computed tomography with low-dose screening computed tomography of the pelvic region showing increased tracer concentration in the articular margin erosions with adjoining sclerosis in bilateral sacroiliac joints. (b) Computed tomography scan acquired with single-photon emission computed tomography for attenuation correction showing soft-tissue involvement in the right sacroiliac joint. (c) Single-photon emission computed tomography with low-dose screening computed tomography of the pelvic region showing increased tracer concentration corresponding to healed fracture in the left inferior pubic ramus|
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Magnetic resonance imaging (MRI) of the spine and pelvis was performed, which revealed bilateral sacroiliitis with small amount of peripherally enhancing collection around both the sacroiliac joints, right joint affected more than the left [Figure 3]a and [Figure 3]b.
|Figure 3: (a) STIR coronal section of the pelvis showing bilateral sacroiliitis with peripherally enhancing collection around bilateral sacroiliac joints (Right > Left). (b) T1-weighted magnetic resonance imaging image showing bilateral sacroiliitis with peripherally enhancing collection around bilateral sacroiliac joints (Right > Left)|
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MRI of the right thigh revealed edema in the right iliopsoas muscle, extending into the upper thigh along with the iliacus muscle [Figure 4].
|Figure 4: T2 SPAIR axial section showing hyperintensity in the right iliopsoas muscle|
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The patient underwent a CT-guided fine-needle aspiration cytology of the right sacroiliac joint collection. Microscopy revealed a predominantly disperse population of intact and degenerated polymorphs against the background containing scanty chronic inflammatory cells and necrotic material. No evidence of granuloma or malignancy was observed. Ziehl–Neelsen staining showed no evidence of acid-fast bacilli. Pus collected was subjected to culture and sensitivity using colorimetric VITEK-2 method showed growth of S. aureus after 24 h of the incubation period. The organism was found to be resistant to benzyl penicillin and oxacillin and sensitivity to teicoplanin.
Blood culture and sensitivity under aerobic conditions using colorimetric VITEK-2 method revealed the growth of S. aureus after 48 h of incubation period. The organism was found to be resistant to benzylpenicillin. Urine culture and sensitivity showed no growth after 48 h of incubation.
The patient was started on intravenous teicoplanin 400 mg twice a day. The patient responded to a long course of intravenous antibiotic treatment.
| Discussion and Review of Literature|| |
Postpartum OM is a rare disease with few case reports in literature. Pyogenic sacroiliitis is an uncommon condition with a reported incidence rate varying from 1.5% to 10% of all pyogenic joint infections.
The radiologic diagnosis in OM includes techniques such as plain radiography, CT, MRI, and nuclear medicine techniques such as triple-phase scan, SPECT-CT, and 18fluorodeoxyglucose-positron emission tomography combined with CT.
Triple-phase bone scan provides information regarding the blood flow, abnormal pooling of blood in the immediate images, and persistence of tracer activity in the delayed images. OM is an infectious disease of the bone; the tracer activity is related to both osteoblastic and vascular activity leading to focal increased uptake in all three phases.
SPECT combined with a CT scan for the purpose of attenuation correction helps in the localization of additional regions of disease that would otherwise have missed on planar scintigraphy. SPECT-CT will also be able to provide clues regarding the involvement of soft tissues, which will guide the clinician to confirm the same by investigating further, which in our case was by MRI and CT-guided biopsy.
The triple-phase skeletal scintigraphy with SPECT-CT helped clinch the diagnosis by being able to locate the foci of interest, rule out the involvement of other joints in the delayed whole-body sweep study, and help confirm the diagnosis with the aid of biopsy.
Lee et al. in their study have described the key imaging findings in OM with various imaging modalities. The authors concluded that MRI is the imaging modality of choice for establishing the diagnosis of OM in view of better soft-tissue delineation, whereas the triple-phase bone scan has high sensitivity for detecting acute OM in a nonviolated bone.
Arican et al. in their retrospective study involving 85 patients with suspicion of OM evaluated the contribution of SPECT/CT to three-phase bone scintigraphy for the assessment of OM and patient's management. Their statistical analysis confirmed the superiority of SPECT/CT over planar scan in not only helping in the diagnosis and management of the study population but also differentiating acute from chronic OM.
Cornejo and Mandell described the distribution of MRSA OM mentioning the multifocal and long segment distribution of the disease on bone scintigraphy. These findings correlated well with the MRI scan.
| Conclusion|| |
99mTc-methylene diphosphonate planar triple-phase bone scintigraphy along with a SPECT-CT scan forms an integral part of the diagnostic workup in a case of postpartum low back pain associated with fever. The modality aids in providing a differential diagnosis and confirms the presence of polyarthritis in addition to the primary suspected pathology.
Planar triple-phase bone scintigraphy helps locate the foci of infection and rule out the involvement of other joints. A SPECT-CT scan done along with bone scintigraphy helps confirm the diagnosis by planning a CT-guided biopsy to accurately localize the site of biopsy.
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Conflicts of interest
| References|| |
Chihara S, Segreti J. Osteomyelitis. Dis Mon 2010;56:5-31.
Chambers HF, Deleo FR. Waves of resistance: Staphylococcus aureus
in the antibiotic era. Nat Rev Microbiol 2009;7:629-41.
Zimmerli W, Harrison's Principles of Internal Medicine, 20th
Edition. Osteomyelitis, Chapter 126. p. 945.
Gafur OA, Copley LA, Hollmig ST, Browne RH, Thornton LA, Crawford SE. The impact of the current epidemiology of pediatric musculoskeletal infection on evaluation and treatment guidelines. J Pediatr Orthop 2008;28:777-85.
Arnold SR, Elias D, Buckingham SC, Thomas ED, Novais E, Arkader A, et al
. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus
. J Pediatr Orthop 2006;26:703-8.
Lee KS, Kong S, Kim J, Kim T, Choi CB, Kim YS, et al
. Osteomyelitis of bilateral femoral heads after childbirth: A case report. Ann Rehabil Med 2015;39:498-503.
Gamble K, Dardarian TS, Finstein J, Fox E, Sehdev H, Randall TC. Osteomyelitis of the pubic symphysis in pregnancy. Obstet Gynecol 2006;107:477-81.
Cosma S, Borella F, Carosso A, Ingala A, Fassio F, Robba T, et al
. Osteomyelitis of the pubic symphysis caused by methicillin-resistant Staphylococcus aureus
after vaginal delivery: A case report and literature review. BMC Infect Dis 2019;19:952.
Lee R, How E. Postpartum haematogenous osteomyelitis of the tibia: A case report and review of literature. Internet J Orthop Surg 2009;18:1.
Haq I, Morris V. Post-partum septic sacroiliitis. Rheumatology 2001;40:1191-2.
Vyskocil JJ, McIlroy MA, Brennan TA, Wilson FM. Pyogenic infection of the sacroiliac joint. Case reports and review of the literature. Medicine (Baltimore) 1991;70:188-97.
Keith L. Moore, Arthur F. Dalley, Anne MR, Agur. Clinically oriented anatomy. Baltimore, MD: Lippincott, Williams and Wilkins; Rheumatology 2001;40:1191-2.
Linnet KM, Gammelgaard L, Johansen M, Krarup N, Rasmussen KL. Bilateral pyogenic sacroiliitis following uncomplicated pregnancy and labor. Acta Obstet Gynecol Scand 1996;75:950-1.
Lee YJ, Sadigh S, Mankad K, Kapse N, Rajeswaran G. The imaging of osteomyelitis. Quant Imaging Med Surg 2016;6:184-98.
Arıcan P, Okudan B, Şefizade R, Naldöken S. Diagnostic value of bone SPECT/CT in patients with suspected osteomyelitis. Mol Imaging Radionucl Ther 2019;28:89-95.
Cornejo P, Mandell GA. Bone scintigraphic findings in MRSA osteomyelitis. Clin Nucl Med 2016;41:153-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]