Chronic recurrent multifocal osteomyelitis

On the basis of a preliminary study of antimycobacterial activity of thiobenzanilides a series of eight thiosalicylanilides have been prepared. Synthetized compounds have been examined in vitro against Mycobacterium tuberculosis, Mycobacterium kansasii, Mycobacterium avium and Mycobacterium fortuitum. All compounds have been found very active. The values of minimal inhibitory concentrations are summarized in Table 1. 3',4'-Salicylanilide was selected for the following research. The compound have been found inactive in vivo (on experimental murine tuberculosis).     

Chronic recurrent multifocal osteomyelitis (CRMO). Diaphyseal attack with progressive hyperostosis]

In children, infections involving both the superficial and deep neck spaces are common. Children so affected typically present with fever, neck mass, neck stiffness, and, occasionally, airway compromise. Radiologic modalities used in the evaluation of neck infections include plain lateral neck radiography, ultrasound, computed tomography, and magnetic resonance imaging. All these modalities have proved useful in the treatment of such infections, specifically the decision to perform incision and drainage. The charts of 66 patients-33 with superficial and 33 with deep neck infections-were analyzed with respect to symptoms, signs, computed tomography findings, and need for surgical intervention. Computed tomography was not particularly helpful in superficial neck infections with regard to the decision to perform surgical drainage; however, it did localize and demonstrate the extent of infection. In deep neck infections we found a 92% correlation between computed tomographic evidence of an abscess and surgical confirmation of one. Contrast-enhanced computed tomography remains an excellent tool in the treatment of neck infections in children.     

Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis

The aim of this study was to assess the usefulness of PET with 2-18F-fluoro-2-deoxy-D-glucose (FDG), as compared to immunoscintigraphy (IS) with 99mTc-labeled monoclonal antigranulocyte antibodies (AGAbs), in the detection of chronic osteomyelitis. METHODS: Fifty-one patients suspected of having chronic osteomyelitis in the peripheral (n = 36) or central (n = 15) skeleton were evaluated prospectively with static FDG PET imaging and combined 99mTc-AGAb/99mTc-methylene diphosphonate (MDP) bone scanning within 5 days. FDG PET and IS were evaluated in a blinded and independent manner by visual interpretation, which was graded on a five-point scale of two observers' confident diagnosis of osteomyelitis. Receiver operating characteristic (ROC) curve analysis was performed for both imaging modalities. The final diagnosis was established by means of bacteriologic culture of surgical specimens and histopathologic analysis (n = 31) or by biopsy and clinical follow-up over 2 yr (n = 20). RESULTS: Of 51 patients, 28 had osteomyelitis and 23 did not. According to the unanimous evaluation of both readers, FDG PET correctly identified 27 of the 28 positives and 22 of the 23 negatives (IS identified 15 of 28 positives and 17 of 23 negatives, respectively). The area under the ROC curve was 0.97/0.97 (reader 1/reader 2) for FDG PET and 0.87/0.90 for IS, with a high degree of interobserver concordance (K-values were 0.96 for FDG PET and 0.91 for IS). In the central skeleton, the ROC curve area was 0.98/1.00 for FDG PET and 0.71/0.77 for IS (p<0.05). On the basis of ROC analysis, the overall accuracies of FDG PET and IS in the detection of chronic osteomyelitis were 96%/96% and 82%/ 88%, respectively. With regard to the optimal threshold values, sensitivity and specificity were 100%/97% and 95%/95% with FDG PET, compared to 86%/92% and 77%/82% with IS, respectively. CONCLUSION: In the peripheral skeleton, both FDG PET and combined 99mTc-AGAb/99mTc-MDP scanning are appropriate imaging modalities to diagnose chronic osteomyelitis. FDG PET additionally allows reliable differentiation between osteomyelitis and infection of the surrounding soft tissue. In the central skeleton within active bone marrow, FDG PET is highly accurate and superior to AGAb imaging in the diagnosis of chronic osteomyelitis, which frequently presents as a nonspecific photopenic lesion at scintigraphy with labeled white blood cells.     

Primary multifocal tuberculous osteomyelitis with involvement of the ribs

Day case surgery is an expanding area within the NHS. However, pain following day case procedures remains a constant concern for healthcare professionals. An audit of postoperative pain following a range of day case procedures over a 2-year period at a general hospital in the north of England found that 17-20% of patients experienced unacceptable levels of pain. However, very few of these patients were worried about the pain they experienced and none contacted their GP. This implies that healthcare professionals overestimate the significance of postoperative pain for the patients concerned.     

Bone scintigraphy in screening of torture survivors

BACKGROUND: In most developed countries, survivors of physical torture inflicted for political, religious, or ethnic reasons face ever more stringent review when seeking asylum. In Austria, asylum seekers are required by immigration authorities to undergo medical examination as part of the review. Bone scintigraphy can detect bone lesions that are not detectable clinically or radiologically. We assessed the value of bone scintigraphy as corroboration of alleged injuries. METHODS: Human-rights organisations referred 25 asylum seekers to us from countries where torture is practised. We included patients who claimed to have been beaten by the security forces in their home country because of political or religious conviction or ethnic origin. Injuries had been inflicted 4 months to 5 years earlier. The patients (three women, 22 men) from 12 countries were categorised retrospectively into two groups: group A (n=12), tortured with blows from hard objects, and group B (n=13), tortured with blows from fists and kicks. We also used a control group of 25 individuals with the same age and sex distribution from the same countries who had no history of torture. FINDINGS: In group A, bone scans showed abnormalities in the area of alleged injury in all patients, whereas radiography was positive in only five patients. In group B, bone scans in the alleged areas of damage were positive in seven patients, but radiography yielded no positive outcomes. Among the controls there was one abnormal scan due to a known coxarthrosis. INTERPRETATION: Our preliminary results suggest that bone scintigraphy is a sensitive, non-invasive tool to document trauma some years after the actual injury.     

Bone metastasis with superimposed osteomyelitis in prostate cancer

The following case of a male patient with a history of prostate cancer suffering from pain and swelling in the right mandibular area illustrates the well-known diagnostic problem of a superinfected tumor. Orthopan tomography and CT showed no defects in bone structure or smooth tissue. Whole-body bone scanning showed increased tracer uptake in the mandibular bone and in several other locations in the skeletal system. Antigranulocyte immunoscintigraphy showed increased uptake over the right mandible, whereas the other metastatic sites were visualized as cold spots. A second CT scan depicted a sclerotic lesion with surrounding periostal reaction and soft-tissue swelling and was interpreted as osteomyelitis. Therefore, clinical symptoms, bone scanning, antigranulocyte immunoscintigraphy and follow-up CT resulted in a diagnosis of osteomyelitis, although open needle biopsy revealed the lesion to be prostate cancer metastasis with massive leukocytic invasion.     

Bone scintigraphy in hungry bone syndrome following parathyroidectomy

A 59-yr-old man with chronic renal failure was admitted for evaluation of generalized skeletal pain and frontal bone mass, which was lytic on radiography. Bone scintigraphy demonstrated several foci of moderately increased uptake, without involvement of the skull mass. Radiographs of these lesions were compatible with brown tumors. Serum parathormone level was elevated and CT demonstrated a lower right cervical mass, consistent with parathyroid tumor. Following the removal of the mass and decrease in parathormone levels, the patient suffered from a prolonged period of hypocalcemia and his bone pain worsened. Repeat bone scintigraphy showed an increase in the number and intensity of the areas of focal uptake, consistent with hungry bone syndrome. This flare-up phenomenon is due to an increase in bone metabolism and is an uncommon finding following parathyroidectomy for primary hyperparathyroidism.     

Diagnostic value of myocardial thallium stress scintigraphy in the detection of coronary artery disease in patients undergoing chronic hemodialysis

Atherosclerotic heart disease is the leading cause of death in patients with end stage renal disease, but its non invasive detection remains difficult because of a low efficacy of exercise testing. The aim of the study was to evaluate diagnostic accuracy of thallium myocardial imaging after dipyridamole combined with exercise. Forty two chronic dialysis patients (34 men, 8 women) aged 55 +/- 11 years (range: 36 to 75) without symptom of angina nor myocardial infarction were studied. In each patient, an echocardiography, a myocardial scintigraphy with dipyridamole combined with symptom-limited exercise, and coronarography were performed. A coronary heart disease was diagnosed by coronarography in 10 patients (4.5 and 1 respectively with 1, 2 and 3 vessels diseased). Echocardiography detected a left ventricular hypertrophy (LVH) in 26 patients and a regional asynergia in 14 patients. A positive scintigraphy was present in 11 patients. Three false-positive and 2 false-negative on scintigraphy were noted. Sensibility, specificity, positive predictive value and negative predictive value were respectively evaluated at 80, 73, 73 and 93%. All the five patients with either false-positive or false-negative scintigraphy exhibited a LVH. CONCLUSION. In chronic dialysis patients, coronary heart disease may be detected by thallium myocardial imaging after dipyridamole combined with exercise.     

Bone scintigraphy in osteodystrophia deformans (Paget's disease)

The value of combined investigations using both scintiscanning and radiological procedures has been proved for the disease's extension and activity in 28 patients suffering from osteodystrophia deformans (Pagets disease). It was seen that such a method leads to more precise results concerning the patient's condition. Special therapy indications were set up, based on these summarized findings. A further advantage of bones scanning alone is the lower radiation dose, which is mainly indicated for control tests in Paget's course. At present, we have no experience of malignant forms of this disease among our group of patients.     

Use of somatostatin analogue scintigraphy in the localization of recurrent medullary thyroid carcinoma

Detection of recurrence of medullary thyroid carcinoma (MTC) remains a diagnostic problem. Increased serum tumour marker levels frequently indicate recurrence while conventional imaging techniques (CIT) are non-diagnostic. In this study, we performed indium-111 octreotide scintigraphy and CIT in a series of 20 patients with MTC presenting with elevated serum tumour markers after surgery. 111In-octreotide whole-body studies detected 15 pathological uptake foci in 11 of the 20 patients studied and CIT detected 17 lesions in 11 of the 20 patients. Ten patients underwent reoperation, five of them with positive 111In-octreotide scintigraphy and CIT and two with positive isotopic exploration and negative CIT. Surgical findings demonstrated that the results of isotopic study and CIT had been false-positive for MTC in one case (sarcoidosis). The six patients with true-positive 111In-octreotide studies had significantly higher basal calcitonin (CT) and carcinoembryonic antigen (CEA) levels than the patients with negative isotopic studies. The expression of somatostatin receptor (SSTR) subtypes by PC-PCR could be investigated in four cases with a positive isotopic study. Among the three cases with a true-positive study, SSTR2, the SSTR subtype that preferentially binds to the somatostatin analogue octreotide, was detected in two, SSTR5 was demonstrated in the three, and SSTR3 was detected in one. No subtype of SSTR was detected in the case with a final diagnosis of sarcoidosis. We conclude that 111In-octreotide has limited sensitivity in detecting recurrence in patients with MTC, although its sensitivity may improve with high serum CT levels. This radionuclide imaging technique should be employed when conventional imaging techniques are negative or inconclusive or when the presence of somatostatin receptors may provide the basis for treatment with somatostatin analogues.     

Chronic recurrent multifocal hyperostosis of the long bones associated with hyperphosphatemia--a case report

BACKGROUND: JM216 is a new oral platinum complex with dose-limiting toxicity myelosuppression, now undergoing phase II evaluation. PATIENTS AND METHODS: JM216 was evaluated as first line therapy in non-small-cell lung cancer. Seventeen patients received 120 mg/m2/day for five days repeated every three weeks. RESULTS: Toxicity was manageable, the commonest side-effects being nausea, vomiting, diarrhoea, constipation and asthenia. Myelososuppression was generally grade < 2 and there were no cases of neutropenic sepsis or bleeding. Thirteen patients were fully evaluable for response. No sustained objective responses were reported. One patient was reported as stable disease had a partial response after three courses but was progressing again after four. An additional five patients had stable disease (46.2%). CONCLUSIONS: Although some patients may have had useful palliation, JM216 did not appear to have significant antitumour activity in non-small-cell lung cancer.     

Discordance of sialography and scintigraphy in unilateral chronic sialadenitis

A Tc-99m pertechnetate salivary gland scintigraphy, digital subtraction sialography (DSS) and cytological findings of a 48-year-old female who received I-131 therapy for the treatment of follicular carcinoma of thyroid are presented. Post radioiodine therapy sialoscintigraphy showed increased blood flow and uptake with decreased secretion in the left parotid gland suggesting acute inflammation. In contrast, DSS and fine needle aspiration biopsy (FNAB) findings were consistent with chronic sialoadenitis. Follow-up scintigraphy one month later showed normal blood flow and decreased uptake and confirmed the diagnosis of chronic sialoadenitis. In right of this case, we conclude that since management of sialoadenitis depends on the stage of inflammation scintigraphic findings should be interpreted together with radiology and FNAB findings if necessary. When chronic sialoadenitis is followed by acute exacerbations, diagnosis based exclusively on sialoscintigraphic findings may result in inadequate patient management.