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Year : 2015  |  Volume : 30  |  Issue : 1  |  Page : 80-81  

An uncommon case showing three different pathologies on 99m technetium-methylene diphosphonate bone scintigraphy


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication23-Dec-2014

Correspondence Address:
Dr. Madhavi Tripathi
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.147555

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   Abstract 

99m Technetium-methylene diphosphonate bone scintigraphy (BS) has an important role in evaluating skeletal pathology, especially its extent. Incidental extra-osseous uptake may sometimes be seen in soft-tissue pathologies. We present a 64-year-old female with skull base osteomyelitis referred for BS which revealed involvement of the skull base on the left side, uptake was also noted in bilateral lungs secondary to hypercalcemia of renal failure and in the D12-L1 vertebrae as the patient had a history of Pott's spine. This is perhaps a unique case showing three findings each of a different etiology in the same scan.

Keywords: 99m Technetium methylene diphosphonate bone scan, extra-osseous uptake, hypercalcemia, Pott′s spine, skull base osteomyelitis


How to cite this article:
Chakraborty PS, Karunanithi S, Dhull VS, Kumar K, Gupta R, Tripathi M. An uncommon case showing three different pathologies on 99m technetium-methylene diphosphonate bone scintigraphy. Indian J Nucl Med 2015;30:80-1

How to cite this URL:
Chakraborty PS, Karunanithi S, Dhull VS, Kumar K, Gupta R, Tripathi M. An uncommon case showing three different pathologies on 99m technetium-methylene diphosphonate bone scintigraphy. Indian J Nucl Med [serial online] 2015 [cited 2019 Dec 15];30:80-1. Available from: http://www.ijnm.in/text.asp?2015/30/1/80/147555

A 64-year-old female was referred to our department for a three phase 99m technetium ( 99m Tc)-methylene diphosphonate bone scintigraphy (BS) for evaluation of skull base osteomyelitis. Co-morbidities included diabetes mellitus and renal failure. Planar BS was equivocal in showing mildly increased uptake on the skull base left side [Figure 1]a, dotted arrow] which when corroborated with single photon emission computed tomography/computed tomography (SPECT/CT) revealed involvement of the left mastoid [Figure 1]b-d, arrow] and petrous temporal thus confirming skull base osteomyelitis. SPECT/CT had an incremental value over planar imaging in evaluating the bones involved. Diffuse radiotracer uptake was also noted in bilateral lung fields [Figure 1]a, thin arrows] along with another area of increased uptake in dorso (D12) - lumbar (L1) spine [Figure 1]a, thick arrow]. Her serum urea was 74 mmol/l; serum creatinine - 2.4 mmol/l; serum calcium - 13 mg/dl; serum phosphate - 7.0 mg/dl and alkaline phosphatase - 247 IU/l, thus confirming lung uptake secondary to hypercalcemia of renal failure. The patient had a history of Pott's spine 2 years ago for which she had taken antitubercular treatment followed by pedicle screw fixation of D12-L1 vertebrae. So BS basically revealed all three aspects of disease pathology in the same scan.
Figure 1: 99mTechnetium-methylene diphosphonate bone scan planar (a) and Single photon emission tomography (SPECT) (b), computed tomography (CT) (c) and hybrid SPECT/CT (d) images. SPECT/CT showed an incremental value over planar imaging in diagnosis of skull base osteomyelitis (a, dotted arrow; b-d, arrow). Also diffuse radiotracer uptake was noted in bilateral lung fields (a, thin arrows) due to hypercalcaemia, along with another focal area of increased uptake in lower dorso (D12) - lumbar (L1) spine region (a, thick arrow) due to Pott's spine

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A positive uptake on a 99m Tc-MDP or gallium-67 scan is said to be diagnostic of skull base osteomyelitis in the appropriate clinical scenario. [1] SPECT/CT has been found to be useful for the diagnosis of skull base osteomyelitis. [2] Radioisotope scans are also useful for follow-up and treatment monitoring. [3] Lung is the most common site of metastatic calcification as relatively low carbon dioxide tension of the extra-cellular fluid surrounding the alveoli causes an alkaline environment that favors the deposition of calcium. [4] Metastatic calcium deposition has been reported in hyperparathyroidism, parathyroid carcinoma, chronic renal failure among other diseases associated with a calcium-phosphate ion-product >5 mmol 2 /l 2 . [5] Extra-osseous calcium deposition has also been reported in kidney and stomach. [6] BS has emerged as an important tool in the diagnosis and management of Pott's spine [7] with sensitivity approaching 75%. [8] To our knowledge this is a unique case in literature showing three different findings from different etiologies in the same BS.

 
   References Top

1.
Singh A, Al Khabori M, Hyder MJ. Skull base osteomyelitis: Diagnostic and therapeutic challenges in atypical presentation. Otolaryngol Head Neck Surg 2005;133:121-5.  Back to cited text no. 1
    
2.
Sharma P, Agarwal KK, Kumar S, Singh H, Bal C, Malhotra A, et al. Utility of (99m) Tc-MDP hybrid SPECT-CT for diagnosis of skull base osteomyelitis: Comparison with planar bone scintigraphy, SPECT, and CT. Jpn J Radiol 2013;31:81-8.  Back to cited text no. 2
    
3.
Illing E, Zolotar M, Ross E, Olaleye O, Molony N. Malignant otitis externa with skull base osteomyelitis. J Surg Case Rep 2011;2011:6.  Back to cited text no. 3
    
4.
Strain JP, Hill TC, Parker JA, Donohoe KJ, Kolodny GM. Diffuse, intense lung uptake on a bone scan: A case report. Clin Nucl Med 2000;25:608-10.  Back to cited text no. 4
    
5.
Wheat D, McCarthy P. Metastatic pulmonary, gastric, and renal calcification demonstrated on bone scintigraphy in a patient with malignant melanoma and renal failure. Clin Nucl Med 1998;23:824-7.  Back to cited text no. 5
    
6.
Sonavane ST, Marwah A, Shah H, Jaiswar R. Abnormal extraosseous activity in both lungs and stomach in pre-transplant 99mTc-MDP bone scan disappearing after renal transplant. Indian J Nucl Med 2013;28:165-7.  Back to cited text no. 6
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7.
Kim SJ, Seok JW, Kim IJ, Kim YK, Kim DS. Multifocal Pott's disease (tuberculous spondylitis) incidentally detected on Tc-99m MDP bone and Ga-67 citrate scintigraphy in a patient with diabetes. Clin Nucl Med 2003;28:286-9.  Back to cited text no. 7
    
8.
Lin WY, Wang SJ, Cheng KY, Shen YY, Changlai SP. Diagnostic value of bone and Ga-67 imaging in skeletal tuberculosis. Clin Nucl Med 1998;23:743-6.  Back to cited text no. 8
    


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