Nuklearmedizinische Diagnostik erregerbedingter Skeletterkrankungen

Zusammenfassung

Grundlage der nuklearmedizinischen Diagnostik erregerbedingter Skeletterkrankungen ist die Drei-Phasen-Skelettszintigraphie. Es handelt sich hierbei um eine sehr sensitive Methode bei der Abklärung akuter und chronischer Osteomyelitiden und septischer Arthrititiden. Eine Normalbefund schließt eine inflammatorische Erkrankung des Skeletts in der Regel aus.
Während die Spezifität der Skelettszintigraphie bei akuten Osteomyelitiden in einem nicht traumatisierten Knochen ebenfalls hoch ist, müssen bei der postraumatischen und bei der chronischen Osteomyelitis entzündungsspezifische Radiopharmezeutika wie markierte Leukozyten zum Einsatz kommen um reparative von florid entzündlichen Veränderungen zu unterscheiden.
Im Achsenskelett-fernen Regionen können hierzu markierte Leukozyten verwendet werden, während im Achsenskelett die F-18-FDG-PET mit einem dedizierten System oder mit einer Koinzidenzkamera eingesetzt werden muss.
Bei der septischen Arthritis bleibt die seit langem etablierte In-111-Leukozytenszintigraphie die Methode der Wahl.

Abstract

The three phase bone scan is still the basic investigation in the evaluation of infective skeletal diseases in nuclear medicine. The bone scan is highly sensitive in the diagnostic work-up of acute and chronic osteomyelitis as well as in septic arthritis. It is well established that a negative scan virtually rules out active disease.
While the specificity of the three phase bone scan is high in acute osteomyelitis in a non violated bone, other tracers like labeled white blood cells have to be used in the postraumatic and postoperative situation in order to differentiate reparative changes from active inflammation.
The diagnostic accuracy of labeled bood cells may be sufficient in the investigation of chronic osteomyelitis in the appendicular skeleton but in the investigation of the central skeleton, F-18-FDG PET either performed with a dedicated system or with a coincidence camera is warranted.
In septic arthritis, In-111- labeled white blood cells scans still remain the procedure of choice.

Schlüsselwörter

Osteomyelitis - Arthritis - Szintigraphie - PET - markierte Leukozyten

Key words

Osteomyelitis - arthritis - scintigraphy - PET - labeled leucocytes

Literatur

• 1 Al-Sheikh W, Sfakianakis G N, Mnaymneh W, Hourani M, Heal A, Duncan R C, Burnett A, Ashkar F S, Serafini A N. Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography.  Radiology. 1985;  155 501-506
• 2 Becker W. Immunoscintigraphy of infectious lesions. In: v Munz DL, Emrich D (Hrsg). Immunoscintigraphy: facts and fiction, proceedings of the international symposium on immunoscintigraphy. Elsevier Science Publishers BV, Göttingen November 1989; Amsterdam 1990 159-170
• 3 Becker W. Entzündungsdiagnostik mit autologen Leukozyten und murinen monoklonalen Antikörpern.  Nuklearmediziner. 1992;  15 273-286
• 4 Becker W. Entzündungen. In: v Büll U, Schicha H u. a. (Hrsg). Nuklearmedizin. Georg Thieme Verlag, Stuttgart 1994: 404-418
• 5 Becker W. The contribution of nuclear medicine to the patient with infection.  Eur J Nucl Med. 1995;  22 1195-1211
• 6 Becker W. Differentialindikation für verschiedene radioaktive Arzneimittel bei unterschiedlichen entzündlichen Erkrankungen.  Nuklearmedizin. 1999;  38 243
• 7 Becker W, Goldenberg D M, Wolf F. The use of monoclonal antibodies and antibody fragments in the imaging of infectious lesions.  Semin Nucl Med. 1994;  24 142-153
• 8 Becker W, Meller J. The role of nuclear medicine in infection and inflammation.  Lancet Infectious Diseases. 2001;  1 326-333
• 9 Bosslet K, Lüben G, Schwarz A, Hundt E, Harthus H P, Seiler F R, Muhrer C, Kloppel G, Kayser K, Sedlacek H H. Immunohistochemical Localiziation and Molecular Characteristics of three monoclonal Antibody-defined Epitopes detectable on Carcinoembryonic antigen (CEA).  Int J Cancer. 1985;  36 75-84
• 10 Cuckler J M, Star A M, Alavi A, Noto R B. Diagnosis and management of the infected total joint arthroplasty.  Orthop Clin North Am. 1991;  22 523-530
• 11 de Winter D, Van de Wiele C, Vandenberghe S, de Bondt P, de Clercq D, D'Asseler Y, Dierckx R. Coincidence camera FDG imaging for the diagnosis of chronic orthopedic infections: a feasibility study.  J Comput Assist Tomogr. 2001;  25 184-189
• 12 de Winter F, van de Wiele C, Vogelaers D, de Smet K, Verdonk R, Dierckx R A. Fluorine-18 fluorodeoxyglucose-position emission tomography: a highly accurate imaging modality for the diagnosis of chronic musculoskeletal infections.  J Bone Joint Surg [Am]. 2001;  83 651-660
• 13 Delling G. Skelettsystem - Entzündliche Knochenerkrankungen (Osteomyelitis). In: v Remmle SD (Hrsg). Pathologie. Springer, Berlin, Heidelberg, New York 1984: 671-678
• 14 Devillers A, Moisan A, Jean S, Arvieux C, Bourguet P. Technetium-99m hexamethylpropylene amine oxime leucocyte scintigraphy for the diagnosis of bone and joint infections: a retrospective study in 116 patients.  Eur J Nucl Med. 1995;  22 302-307
• 15 el-Desouki M. Skeletal brucellosis: assessment with bone scintigraphy.  Radiology. 1991;  181 415-418
• 16 Fukanaga T, Enomoto K, Okazumi S, Isono K. Analysis of glucose metabolism in patients with esophageal cancer by FDG-PET: estimation of hexokinase activity in the tumor and prediction of prediction of prognosis: clinical PET in Oncology. Proceedings 2nd Intl Symposion on PET in Oncology, Word Scienentific, Singapore 1993: 87-90
• 17 Gilday D L, Paul D J, Paterson J. Diagnosis of osteomyelitis in children by combined blood pool and bone imaging.  Radiology. 1975;  117 331-335
• 18 Gold R H, Tong D JF. Imaging the diabetic foot.  Skeletal Radiology. 1995;  24 563-571
• 19 Gratz S, Behr T, Schmitt H A, Wüstner M, Morguet A, Meller J, Becker W. ^99mTl labeled antigranulocyte monoclonal antibody Fab' fragments (LeukoScan®) for diagnostic imaging of bone and soft tissue infections.  J Nucl Med. 1998;  39 34
• 20 Gratz S, Dörner J, Oestmann J W, Opitz M, Meller J, Grabbe E, Becker W. ⁶⁷ Ga-citrate and ^99mTc-MDP for estimating the severity of vertebral osteoyelitis.  Nucl Med Comm. 2000;  21 111-120
• 21 Guhlmann A, Brecht Krauss D, Suger G, Glatting G, Kotzerke J, Kinzl L, Reske S N. Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis.  J Nucl Med. 1998;  39 2145-2152
• 22 Handmaker H, Leonards R. The bone scan in inflammatory osseous disease.  Semin Nucl Med. 1976;  6 95-105
• 23 Handmaker H, Giammona S T. Improved early diagnosis of acute inflammatory skeletal-articular diseases in children: a two-radiopharmaceutical approach.  Pediatrics. 1984;  73 661-669
• 24 Heyman S, Goldstein H A, Crowley W, Treves S. The scintigraphic evaluation of hip pain in children.  Clin Nucl Med. 1980;  5 109-115
• 25 Hoffer P. Gallium: Mechanisms.  J Nucl Med. 1980;  21 282-285
• 26 Howie D W, Savage J P, Wilson T G. The technetium phosphate bone scan in the diagnosis of osteomyelitis in childhood.  J Bone Joint Surg. 1983;  65 431-437
• 27 Ichiya Y, Kuwabara Y, Sasaki Y, Yoshida T, Akashi Y, Murayama S, Nakamura K, Fukumura T, Masuda K. FDG-PET in infectious lesions: detection and assessment of lesion activity.  Ann Nucl Med. 1996;  10 185-191
• 28 Ivancevic V, Mastrovic Z, Ivancevic D, Hancevic J, Davila S, Turcic J. Labelling leukocytes with 99m- Tc HMPAO: contribution to the diagnosis of osteomyelitis.  Acta Chir Iugosl. 1989;  36 (Suppl 2) 740-742
• 29 Jones H A, Isriskandan S, Peters A M, Pride N B, Krausz T, Boobis A R, Haslett C. Dissociation of neutrophil emigration and metabolic activity in lobar pneumonia and bronchiectasis.  Eur Respir J. 1997;  10 795-803
• 30 Kälicke T, Schmitz A, Risse J H, Arens S, Keller E, Hansis M, Schmitt O, Biersack H J, Grünwald F. Fluorine-18 fluorodeoxyglucose PET in infectious bone diseases: results of histologically confirmed cases.  Eur J Nucl Med. 2000;  27 524-528
• 31 Keenan A M, Tindel N L, Alavi A. Diagnosis of pedal osteomyelitis in diabetic patients using current scintigraphic techniques.  Arch Intern Med. 1989;  149 2262-2266
• 32 Kim E E, Haynie T P, Podolof D A, Lowry P A, Harle T S. Radionuclide imaging in the evaluation of osteomyelitis and septic arthritis.  Crit Rev Diagn Imaging. 1989;  29 257-305
• 33 Kloiber R, Pavlosky W, Portner O, Gartke K. Bone scintigraphy of hip joint effusions in children.  AJR. 1983;  140 995-999
• 34 Krznaric E. Roo MD, Verbruggen A, Stuyck J, Mortelmans L. Chronic osteomyelitis: diagnosis with technetium-99m-d, l- hexamethylpropylene amine oxime labelled leucocytes.  Eur J Nucl Med. 1996;  23 792-797
• 35 Larcos G, Brown M L, Sutton R T. Diagnosis of osteomyelitis of the foot in diabetic patients: value of 111In-leukocyte scintigraphy.  AJR. 1991;  157 527-531
• 36 Lew D P, Waldvogel F A. Osteomyelitis.  N Eng J Med. 1997;  336 999-1007
• 37 Mader J T, Shirtliff M, Calhoun J H. Staging and staging applications in osteomyelitis.  Clin Infect Dis. 1997;  25 1303-1309
• 38 Magnuson J E, Brown M L, Hauser M F, Berquist T H, Fitzgerald R H, Klee G G. In-111-labeled leukocyte scintigraphy in In-111- labeled leukocyte scintigraphy in suspected orthopedic prosthesis infection: comparison with other imaging modalities.  Radiology. 1988;  168 235-239
• 39 Majd M, Frankel R S. Radionuclide imaging in skeletal inflammatory and ischemic diseases in children.  AJR. 1976;  126 832-841
• 40 Mandell G A. Nuclear medicine in pediatric orthopedics.  Semin Nucl Med. 1998;  28 95-115
• 41 Maurer A H, Chen D C, Camargo E E, Wong D F, Wagner H N, Alderson P O. Utility of three-phase skeletal scintigraphy in suspected osteomyelitis: concise communication.  J Nucl Med. 1981;  22 941-949
• 42 Maurer A H, Millmond S H, Knight L C. Infection in diabetic osteoarthropathy: use of indium-labeled leucocytes for diagnosis.  Radioloogy. 1986;  161 221-225
• 43 Meller J, Altenvoerde G, Munzel U, Jauho A, Behe M, Gratz S, Luig H, Becker W. Fever of unknown origin- prospective comparison of 18 FDG-imaging with a double head coincidence camera (DHCC) and Ga-67 citrate SPECT.  Eur J Nucl Med. 2000;  27 1617-1625
• 44 Meller J, Lehmann K, Altenvoerde G, Jauho A, Becker W. 18- FDG Uptake bei einer Patientin mit fibröser Thyreoiditis (Riedel- Thyreoiditis).  Nuklearmedizin. 2000;  39 115
• 45 Meller J, Köster G, Liersch T, Siefker U, Lehmann K, Meyer I, Schreiber K, Altenvoerde G, Becker W. Chronic bacterial osteomyelitis - prospective comparison of 18 FDG- imaging with a double head coincidence camera (DHCC) and In-111 labeled autologous leucocytes.  Eur J Nucl Med. 2002;  29 53-60
• 46 Meller J, Sahlmann C O, Lehmann K, Siefker U, Meyer I, Schreiber K, Altenvoerde G, Becker W. FDG-Hybrid-Kamera-PET bei Patienten mit postoperativem Fieber.  Nuklearmedizin. im Druck; 
• 47 Meller Y, Yagupsky P, Elitsur Y, Inbar-Ianay I, Bar-Ziv J. Chronic multifocal symmetrical osteomyelitis. Report of two cases in Bedouin infants.  Am J Dis Child. 1984;  138 349-351
• 48 Merkel K D, Brown M L, Dewanjee M K, Fitzgerald RH J r. Comparison of indium-labeled-leukocyte imaging with sequential technetium-gallium scanning in the diagnosis of low-grade musculoskeletal sepsis. A prospective study.  Bone Joint Surg Am. 1985;  67 465-476
• 49 Newman L G, Waller J, Palestro C J, Schwartz M, Klein M J, Hermann G, Harrington E, Harrington M, Roman S H, Stagnaro-Green A. Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline.  JAMA. 1991;  266 1246-1251
• 50 Palestro C J, Kim C K, Swyer A J, Vallabhajosula S, Goldsmith S J. Radionuclide diagnosis of vertebral osteomyelitis: indium-111-leukocyte and technetium-99m-methylene diphosphonate bone scintigraphy.  J Nucl Med. 1991;  32 1861-1865
• 51 Palestro C J, Swyer A J, Kim C K, Goldsmith S J. Infected knee prosthesis: diagnosis with In-111 leukocyte, Tc-99m sulfur colloid, and Tc-99m MDP imaging.  Radiology. 1991;  179 645-648
• 52 Park H M, Wheat L J, Siddiqui A R, Burt R W, Robb J A, Ransburg R C, Kernek C B. Scintigraphic evaluation of diabetic osteomyelitis: concise communication.  J Nucl Med. 1982;  23 569-573
• 53 Pennington W T, Mott M P, Thometz J G, Sty J R, Metz D. Photopenic bone scan osteomyelitis: a clinical perspective.  J Pediatr Orthop. 1999;  19 695-698
• 54 Rennen H J, Boerman O C, Oyen W J, Corstens F H. Imaging infection/inflammation in the new millennium.  Eur J Nucl Med. 2001;  28 241-252
• 55 Reuland P. Winker KH, Heuchert T, Ruck R, Müller- Schauenburg W, Weller S, Feine U. Detection of Infection in Postoperative Orthopedic Patients with Technetium-99m-Labeled Monoclonal Antibodies against Granulocytes.  J Nucl Med. 1991;  32 2209-2214
• 56 Roddie M E, Peters A M, Danpure H J, Osman S, Henderson B L, Lavender J, Carroll M J, Neirinckx R D, Kelly J D. Inflammation: imaging with Tc-99m HMPAO-labeled leukocytes.  Radiology. 1988;  166 767-772
• 57 Rüther W, Hotze A, Moller F, Bockisch A, Heitzmann P, Biersack H J. Diagnosis of bone and joint infection by leucocyte scintigraphy. A comparative study with 99mTc-HMPAO-labelled leucocytes, 99mTc-labelled antigranulocyte antibodies and 99mTc-labelled nanocolloid.  Arch Orthop Trauma Surg. 1990;  110 26-32
• 58 Salomon C G, Ali A, Fordham E W. Bone scintigraphy in tuberculous sacroiliitis.  Clin Nucl Med. 1986;  11 407-408
• 59 Sasaki M, Ichiya Y, Kuwabara Y, Otsuka M, Tahara T, Fukumura T, Gunasekera R, Masuda K. Ringlike uptake of [18F]-FDG in brain abscess: a PET study.  J Comput Assist Tomogr. 1990;  14 486-487
• 60 Schauwecker D S. et al . Evaluation of complicating osteomyelitis with Tc-99m MDP, In-11 granulocytes and Ga-67 citrate.  Diagnostic Nuclear Medicine. 1984;  25 849-853
• 61 Schauwecker D S. Osteomyelitis: Diagnosis with in-111-labeled leucocytes.  Radiology. 1989;  171 141-146
• 62 Schauwecker D S. The scintigraphic diagnosis of osteomyelitis.  AJR. 1992;  158 9-18
• 63 Schilling F, Kessler S. SAPHO syndrome: clinico-rheumatologic and radiologic differentiation and classification of a patient sample of 86 cases.  Z Rheumatol. 2000;  59 1-28
• 64 Seabold J E, Nepola J V, Marsh J L, Hawes D R, Justin E P, Ponto J A, Pettit W A, el-Khoury G Y, Kirchner P T. Postoperative bone marrow alterations: potential pitfalls in the diagnosis of osteomyelitis with In-111-labeled leukocyte scintigraphy.  Radiology. 1991;  180 741-747
• 65 Shepherd P R, Kahn B B. Glucose transporters and insulin action: Implications for insulin resistance and diabetes mellitus.  N Engl J Med. 1999;  341 248-257
• 66 Tahara T, Ichiya Y, Kuwabara Y, Otsuka M, Miyake Y, Gunasekera R, Masuda K. High [18F]-fluorodeoxyglucose uptake in abdominal abscesses: a PET study.  J Comput Assist Tomogr. 1989;  13 829-831
• 67 Tsuchimochi M, Higashino N, Okano A, Kato J. Study of combined technetium 99m methylene diphosphonate and gallium 67 citrate scintigraphy in diffuse sclerosing osteomyelitis of the mandible: case reports.  J Oral Maxillofac Surg. 1991;  49 887-897
• 68 Tumeh S S, Aliabadi P, Weissman B N, McNeil B J. Chronic osteomyelitis: bone and gallium scan patterns associated with active disease.  Radiology. 1986;  158 68-72
• 69 Tumeh S S, Tohmeh A G. Nuclear medicine techniques in septic arthritis and osteomyelitis.  Rheum Dis Clin North Am. 1991;  17 559-583
• 70 Tuson C E, Hoffman E B, Mann M D. Isotope bone scanning for acute osteomyelitis and septic arthritis in children.  J Bone Joint Surg. 1994;  76 306-310
• 71 Tzen K Y, Oster Z H, Wagner H N, Tsan M F. Role of ironbinding proteins and enhanced capillary permeability on the accumulation of gallium-67.  J Nucl Med. 1980;  21 31-35
• 72 Unger E, Moldofsky P, Gatenby R, Hartz W, Broder G. Diagnosis of osteomyelitis by MR imaging.  AJR. 1988;  150 605-610
• 73 Uren R F, Howman-Giles R. The ‘cold hip’ sign on bone scan. A retrospective review.  Clin Nucl Med. 1991;  16 553-556
• 74 Waki A, Kato H, Yano R, Sadato N, Yokoyama A, Ishii Y, Yonekura Y, Fujibayashi Y. The importance of glucose transport activity as the rate-limiting step of 2-deoxyglucose uptake in tumor cells in vitro.  Nucl Med Bio. 1998;  25 593-597
• 75 Waldvogel F A, Medoff G, Swartz M N. Osteomyelitis: A review of clinical features, therapeutic considerations and unusual aspects.  N Eng J Med. 1970;  282 316-322
• 76 Warburg O. The metabolism of tumors. Richard R Smith, New York 1931
• 77 Zhuang H, Duarte P S, Pourdehand M, Shnier D, Alavi A. Exclusion of chronic osteomyelitis with F-18 fluorodeoxyglucose positron emission tomographic imaging.  Clin Nucl Med. 2000;  25 281-284