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Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 295-296  

99mTc-ethambutol scan with SPECT/CT in knee joint tuberculosis


1 Department of Nuclear Medicine and PET-CT, All India Institute of Medical Sciences, New Delhi, India
2 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
4 Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India

Date of Submission23-Jan-2022
Date of Decision01-Mar-2022
Date of Acceptance16-Mar-2022
Date of Web Publication02-Nov-2022

Correspondence Address:
Dr. Nishikant Avinash Damle
Department of Nuclear Medicine and PET-CT, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_16_22

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   Abstract 


Modalities for in vivo imaging of Mycobacterium tuberculosis are limited and inadequately studied. One such modality is 99mTc-ethambutol scintigraphy which has shown promising results for diagnosis of tuberculosis (TB). Ethambutol, one of the primary antitubercular drugs, is bacteriostatic which acts on the mycolic acid cell wall synthesis of the M. tuberculosis. However, literature on its utility is scarce. The few studies that exist have reported its sensitivity and specificity between 90%– 95% and 71%–85%. We present here a case demonstrating the role of 99mTc-ethambutol scan in knee joint TB.

Keywords: 99mTc-Ethambutol, knee joint, tuberculosis


How to cite this article:
Kalra S, Damle NA, Ranjan P, Sikdar S, Arora G, Goyal A, Gautam D. 99mTc-ethambutol scan with SPECT/CT in knee joint tuberculosis. Indian J Nucl Med 2022;37:295-6

How to cite this URL:
Kalra S, Damle NA, Ranjan P, Sikdar S, Arora G, Goyal A, Gautam D. 99mTc-ethambutol scan with SPECT/CT in knee joint tuberculosis. Indian J Nucl Med [serial online] 2022 [cited 2022 Nov 29];37:295-6. Available from: https://www.ijnm.in/text.asp?2022/37/3/295/360259



Modalities for in vivo imaging of  Mycobacterium tuberculosis Scientific Name Search e limited and inadequately studied. One such modality is 99mTc ethambutol scintigraphy which has shown promising results for diagnosis of tuberculosis (TB). Ethambutol, one of the primary antitubercular drugs, is bacteriostatic which acts on the mycolic acid cell wall synthesis of the M. tuberculosis. However, literature on its utility is scarce. The few studies that exist have reported its sensitivity and specificity between 90%– 95% and 71%–85%.[1],[2],[3],[4],[5],[6] A 48-year-old female with no known comorbidities presented with pain, swelling, and restricted motion of the right knee joint for the past 4 years associated with weight loss and loss of appetite. CRP and ESR were toward higher side. She was treated on analgesics and empirical antibiotics and recommended physiotherapy, all to no avail. The pain gradually increased in intensity, and she was taken to a health facility where magnetic resonance imaging (MRI) was conducted. On MRI scan, a complicated cyst was seen over the lateral aspect of the right knee joint with lateral meniscus tear and degenerative changes. An arthroscopic debridement along with the excision of the cyst was done, and intra-articular viscous supplement was injected. The patient improved, but the symptoms reappeared after 2 months. The patient was referred to our institution where MRI was repeated, and based on radiological findings, diagnosis of knee joint skeletal tuberculosis (TB) was made. The patient was then referred to the nuclear medicine department for further evaluation with 99mTc-ethambutol scintigraphy. 99mTc-Ethambutol was synthesized in-house with radiochemical purity 95%. Dose of 10 mCi 99mTc-ethambutol was injected intravenously, and serial planar whole-body anterior and posterior images were acquired at 15–30-min intervals up to 2 h and at 4 h postinjection. Anterior whole-body image showed radiotracer accumulation in the gallbladder and urinary bladder, depicting normal routes of excretion. No significant (mild) thyroid or splenic uptake was seen, suggesting good radiolabeling. Both kidneys were visualized as shown in [Figure 1].
Figure 1: Maximum intensity projection (a) image of PET revealed increased metabolic activity in the right knee joint. Sagittal T1-weighted (b) and T2-weighted (c) magnetic resonance images showing geographic areas of altered signal intensity in the lateral femoral and tibial condyles, bound by hypointense serpiginous lines, suggestive of epiphyseal bone infarcts. Effusion noted in suprapatellar recess. Coronal STIR (d) and postcontrast T1-weighted (e) images depicting joint effusion, synovial thickening, marked periarthritis, and soft-tissue inflammation consistent with active tuberculosis. Sagittal section of the right knee SPECT/CT (f) showing diffuse increased tracer uptake in the ends of tibia and femur and suprapatellar region. Coronal and axial CT images (g and i) and SPECT/CT (h and j) showing lytic sclerotic changes in the lower end of right femur and upper end of the right tibia with increased uptake

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Based on our diagnosis of TB knee, the patient was put on anti-tubercular therapy (ATT) by the treating physician. After 3 months of ATT, the patient was symptomatically better and was able to perform her daily activities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgement

This study was funded by ITR division ICMR New Delhi as source of funding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Bertram GK, Kruidering-Hall M, Trevor AJ. Katzung & Trevor's Pharmacology: Examination and Board Review. Twelth edition. New York: McGraw-Hill Education; 2019.  Back to cited text no. 1
    
2.
Kartamihardja AH, Kurniawati Y, Gunawan R. Diagnostic value of 99mTc-ethambutol scintigraphy in tuberculosis: Compared to microbiological and histopathological tests. Ann Nucl Med 2018;32:60-8.  Back to cited text no. 2
    
3.
Peets EA, Sweeney WM, Place VA, Buyske DA. The absorption, excretion, and metabolic fate of ethambutol in man. Am Rev Respir Dis 1965;91:51-8.  Back to cited text no. 3
    
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Verma J, Bhatnagar A, Sen S, Singh AK, Bose M. Radio-labeling of ethambutol with technetium-99m and its evaluation for detection of tuberculosis. World J Nucl Med 2005;4:35-46.  Back to cited text no. 4
    
5.
Soeroso NN, Ananda FR, Rahmadhany H, Putra DD. Tuberculosis of the knee: A pitfalls in clinical settings (A case report and literature review). Int J Surg Case Rep 2020;71:14-8.  Back to cited text no. 5
    
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Uboldi FM, Limonta S, Ferrua P, Manunta A, Pellegrini A. Tuberculosis of the knee: A case report and literature review. Joints 2017;5:180-3.  Back to cited text no. 6
    


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