Indian Journal of Nuclear Medicine
Home | About IJNM | Search | Current Issue | Past Issues | Instructions | Ahead of Print | Online submissionLogin 
Indian Journal of Nuclear Medicine
  Editorial Board | Subscribe | Advertise | Contact
Users Online: 263 Print this page  Email this page Small font size Default font size Increase font size


 
 Table of Contents     
LETTER TO THE EDITOR
Year : 2017  |  Volume : 32  |  Issue : 3  |  Page : 251-253  

Utility of three-phase skeletal scintigraphy with single photon emission computed tomography/computed tomography in a case of chronic recurrent multifocal osteomyelitis


1 Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication13-Jun-2017

Correspondence Address:
Ashwani Sood
Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_51_17

Rights and Permissions

How to cite this article:
Radhakrishnan RK, Gorla AK, Sood A, Prakash M, Bhattacharya A, Mittal BR. Utility of three-phase skeletal scintigraphy with single photon emission computed tomography/computed tomography in a case of chronic recurrent multifocal osteomyelitis. Indian J Nucl Med 2017;32:251-3

How to cite this URL:
Radhakrishnan RK, Gorla AK, Sood A, Prakash M, Bhattacharya A, Mittal BR. Utility of three-phase skeletal scintigraphy with single photon emission computed tomography/computed tomography in a case of chronic recurrent multifocal osteomyelitis. Indian J Nucl Med [serial online] 2017 [cited 2017 Jun 24];32:251-3. Available from: http://www.ijnm.in/text.asp?2017/32/3/251/207896



Sir,

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare disease with unknown etiology. It is often considered as an auto-inflammatory disorder and may mimic as bacterial osteomyelitis.[1] CRMO is often reported in the childhood and adolescence. It is characterized by recurrent episodes of unprovoked inflammation of skeletal sites with resultant destruction and painful swelling during its active phase and (often) a painless benign asymptomatic reparative phase. The diagnosis of CRMO is often by exclusion and is usually characterized by (i) absence of features of typical osteomyelitis (such as presence of sequestrum, abscess, or fistula formation); (ii) protracted course with frequent remissions and exacerbations; (iii) atypical and multifocal nature of skeletal involvement; (iv) no pathogenic organisms on tissue culture; (v) nonspecific findings of subacute/chronic osteomyelitis on histological evaluation; (vi) poor response to antimicrobial therapy; and (vii) association with palmoplantar pustulosis, acne, or other inflammatory disorders.[2] The imaging and histological studies can assist in the exclusion of possible alternate diagnoses and establishing the diagnosis of CRMO.

We here present a case of 18-year-old male adolescent presented with progressive swelling over the left lower neck region associated with pain and pruritus for 3 months. Oral nonsteroidal anti-inflammatory drugs relieved the pain briefly with frequent relapse. X-ray and magnetic resonance imaging (MRI) of the upper thoracic region revealed expansile destructive lesion involving the medial third of left clavicle and sternum with periosteal reaction and associated soft tissue changes, suggesting an infective/neoplastic lesion. Biopsy of the lesion for further characterization demonstrated the findings consistent of chronic osteomyelitis, without significant growth of any pathogenic organisms on culture of the biopsied material.

A three-phase skeletal scintigraphy (TPSS) after intravenous injection of 20 mCi of 99m Tc-methylene diphosphonate was performed to assess the activity status of the clavicular lesion and screen the additional skeletal involvement. Mildly increased perfusion, tracer pooling, and tracer avidity were noted in the medial half of the left clavicle and adjacent body of the sternum in all three phases of regional skeletal scintigraphy [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d,[Figure 1]e. Whole-body images [Figure 2]a and [Figure 2]b showed additional focally increased tracer uptake in the left sacroiliac joint, with clinical correlation of recent onset of pain in the same region. The tracer avid mixed lytic-sclerotic expansile lesion of medial two-third of the left clavicle and a sclerotic lesion in sternum near manubriosternal joint were seen on hybrid single photon emission computed tomography/computed tomography (SPECT/CT) of the neck and upper chest region [Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f,[Figure 2]g,[Figure 2]h.
Figure 1: Tc-99m-methylene diphosphonate three-phase skeletal scintigraphy, anterior flow images (a) and anterior and posterior blood pool images of the neck and thoracic regions (b and c) showing increased blood flow and soft tissue blood pooling in the left clavicular region. Delayed anterior and posterior bone static images (d and e) showing increased osteoblastic activity in the medial two-third of the left clavicle and upper body of the sternum. Uptake in the sternum is not conspicuous on flow and blood pool images due to physiological mediastinal blood pool activity

Click here to view
Figure 2: Tc-99m-methylene diphosphonate skeletal scintigraphy (a and b) anterior and posterior whole-body images showing increased osteoblastic activity in medial two-third of the left clavicle, body of the sternum, and left sacroiliac joint; coronal CT (c and d), SPECT (e and f), and SPECT/CT (g and h) of the thorax showing increased osteoblastic activity in mixed lytic-sclerotic expansile lesion and in the medial two-third of the left clavicle and sclerotic lesion in the upper body of the sternum near manubriosternal joint. SPECT/CT: Single photon emission computed tomography/computed tomography

Click here to view


Auto-inflammatory skeletal disorders such as CRMO often result from the dysregulation of innate immunity, leading to immune cell infiltration of the bone and consequent osteoclastic activation, osteolysis, and reparative bone remodeling, though exact molecular event inciting this is not fully understood.[3] Strong association of CRMO with various other inflammatory disorders such as palmoplantar pustulosis, acne, psoriasis, sweet syndrome, and inflammatory bowel disease is well established. Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome is a similar auto-inflammatory disorder and often considered as the adult counterpart of CRMO. Patients with CRMO usually present with insidious onset of pain and swelling of the involved bones.[4] The commonly involved sites include the medial ends of the clavicles and metaphyses of long tubular bones of lower limbs, followed by flat bones such as pelvis and sternum.[5] Typically, the course of the disease is prolonged with alternating exacerbations and remissions. Recurrence may involve previously involved sites or new sites. Flare-ups of the associated auto-inflammatory disorders are noted simultaneous to the osseous exacerbations, suggesting common etiological basis.[2]

Conventional radiography is the first-line investigation in providing the site and nature of the involvement followed by CT and MRI, facilitating the better characterization of the lesions. TPSS is a widely established nuclear medicine imaging modality for the evaluation of suspected osteomyelitis with high sensitivity in unviolated bones. Active osteomyelitis is often characterized by the presence of increased flow; blood pooling and tracer uptake on TPSS.[6] Whole-body imaging detects clinically silent distant diseased sites. Mandell et al. demonstrated the utility of whole-body bone scan in 14 patients with CRMO in detecting the multifocality and in selection of biopsy sites.[7] SPECT/CT allows for precise anatomical localization, extent of the disease, and characterization of the lesions. In the present case, TPSS with SPECT/CT revealed bony lesions at primary site and additional site of involvement in the left sacroiliac joint correlating with the recent onset of pain at the same site. TPSS with SPECT/CT has potential role in accurate assessment of disease activity, detection of additional occult sites of involvement with better characterization of the lesions, and anatomical identification of optimal sites for biopsy evaluation, thus furnishing as a one-stop-shop imaging technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Khanna G, Sato TS, Ferguson P. Imaging of chronic recurrent multifocal osteomyelitis. Radiographics 2009;29:1159-77.  Back to cited text no. 1
    
2.
Iyer RS, Thapa MM, Chew FS. Chronic recurrent multifocal osteomyelitis: Review. AJR Am J Roentgenol 2011;196 6 Suppl: S87-91.  Back to cited text no. 2
    
3.
Hedrich CM, Hofmann SR, Pablik J, Morbach H, Girschick HJ. Autoinflammatory bone disorders with special focus on chronic recurrent multifocal osteomyelitis (CRMO). Pediatr Rheumatol Online J 2013;11:47.  Back to cited text no. 3
    
4.
Kaiser D, Bolt I, Hofer M, Relly C, Berthet G, Bolz D, et al. Chronic nonbacterial osteomyelitis in children: A retrospective multicenter study. Pediatr Rheumatol Online J 2015;13:25.  Back to cited text no. 4
    
5.
Fritz J, Tzaribatchev N, Claussen CD, Carrino JA, Horger MS. Chronic recurrent multifocal osteomyelitis: Comparison of whole-body MR imaging with radiography and correlation with clinical and laboratory data. Radiology 2009;252:842-51.  Back to cited text no. 5
    
6.
Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ. Radionuclide bone imaging: An illustrative review. Radiographics 2003;23:341-58.  Back to cited text no. 6
    
7.
Mandell GA, Contreras SJ, Conard K, Harcke HT, Maas KW. Bone scintigraphy in the detection of chronic recurrent multifocal osteomyelitis. J Nucl Med 1998;39:1778-83.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed22    
    Printed0    
    Emailed0    
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal