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Role of Radionuclide Imaging in the Diagnosis of Postoperative Infection¹

¹ From the Division of Nuclear Medicine, Department of Radiology, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040. Recipient of a Certificate of Merit award for a scientific exhibit at the 1999 RSNA scientific assembly. Received April 5, 2000; revision requested April 28 and received June 23; accepted June 26. Address correspondence to C.J.P. (e-mail: palestro@lij.edu).

View larger version (79K): [in a new window]   Figure 1.   Variations in normal distribution of gallium in four different patients. All four images were obtained 72 hours after injection. Gallium image in A demonstrates mild orbital activity with faint bowel uptake. Gallium image in B demonstrates breast uptake that is prominent but still normal. Gallium image in C demonstrates intense linear midline uptake extending from the lower thorax into the upper abdomen, a finding that represents a normally healing surgical incision. The superior mediastinal activity proved to be secondary to nodal involvement by Hodgkin disease. On a gallium image obtained in a child (D), bone marrow uptake is prominent with relatively less soft-tissue activity. Note the gastric uptake, another normal variant, in the left upper quadrant (arrows).

View larger version (161K): [in a new window]   Figure 2a.   Variations in large bowel uptake of gallium. Gallium images obtained 72 hours after injection in four different patients (a-d) demonstrate large bowel activity that is highly variable both in distribution and intensity. None of these patients had colonic disease.

View larger version (169K): [in a new window]   Figure 2b.   Variations in large bowel uptake of gallium. Gallium images obtained 72 hours after injection in four different patients (a-d) demonstrate large bowel activity that is highly variable both in distribution and intensity. None of these patients had colonic disease.

View larger version (150K): [in a new window]   Figure 2c.   Variations in large bowel uptake of gallium. Gallium images obtained 72 hours after injection in four different patients (a-d) demonstrate large bowel activity that is highly variable both in distribution and intensity. None of these patients had colonic disease.

View larger version (149K): [in a new window]   Figure 2d.   Variations in large bowel uptake of gallium. Gallium images obtained 72 hours after injection in four different patients (a-d) demonstrate large bowel activity that is highly variable both in distribution and intensity. None of these patients had colonic disease.

View larger version (136K): [in a new window]   Figure 3a.   Psoas abscess in a 21-year-old woman who presented with left hip pain. The patient had a history of a left femoral fracture requiring surgical intervention. Results of MR imaging performed at another institution were normal, and the patient was referred to the nuclear medicine department for evaluation of suspected osteomyelitis. (a) Anterior gallium image obtained 48 hours after injection demonstrates left lower quadrant activity (arrow), a finding that could easily be misinterpreted as normal bowel activity. (b) Coronal (top) and transverse (bottom) single photon emission CT scans clearly demonstrate that the activity lies outside the bowel (cf Fig 19).

View larger version (91K): [in a new window]   Figure 3b.   Psoas abscess in a 21-year-old woman who presented with left hip pain. The patient had a history of a left femoral fracture requiring surgical intervention. Results of MR imaging performed at another institution were normal, and the patient was referred to the nuclear medicine department for evaluation of suspected osteomyelitis. (a) Anterior gallium image obtained 48 hours after injection demonstrates left lower quadrant activity (arrow), a finding that could easily be misinterpreted as normal bowel activity. (b) Coronal (top) and transverse (bottom) single photon emission CT scans clearly demonstrate that the activity lies outside the bowel (cf Fig 19).

View larger version (137K): [in a new window]   Figure 4.   Normal distribution of In-111-labeled leukocytes. Anterior (left) and posterior (right) labeled leukocyte images obtained about 24 hours after injection demonstrate activity that is confined to the liver, spleen, and bone marrow.

View larger version (176K): [in a new window]   Figure 5.   Normal postoperative accumulation of labeled leukocytes. Anterior labeled leukocyte image obtained about 24 hours after injection shows activity at the sites of a tracheostomy (top arrow) and gastrostomy (bottom arrow). Note also the uptake of labeled cells in the right lung, a finding that represents pneumonia.

View larger version (80K): [in a new window]   Figure 6.   Diffuse bilateral pulmonary uptake of labeled leukocytes in a septic patient with no respiratory distress. Repeat sputum cultures and chest radiographs were all negative. Anterior (left) and posterior (right) labeled leukocyte images obtained about 24 hours after injection show increased uptake in the lungs. This uptake is probably related to the release of cytokines, which cause activation of leukocytes and the pulmonary vascular endothelium.

View larger version (162K): [in a new window]   Figure 7.   Antibiotic-associated (pseudomembranous) colitis in a patient who had been treated with multiple antibiotics. Anterior abdominal labeled leukocyte image obtained about 24 hours after injection demonstrates accumulation throughout the colon. Although the cause of this finding is variable, the most likely diagnosis in patients receiving antibiotics is pseudomembranous colitis.

View larger version (186K): [in a new window]   Figure 8.    Increased uptake due to bleeding in a patient who underwent femoral puncture for hemodialysis a few hours after reinjection of labeled leukocytes. Anterior pelvic image obtained about 24 hours after injection shows intense activity in the left groin (arrow) that is due to bleeding rather than infection.

View larger version (84K): [in a new window]   Figure 9a.   Abscess in a 10-year-old girl who was referred to the nuclear medicine department for evaluation of possible right hip osteomyelitis. (a) Anterior and posterior labeled leukocyte images of the abdomen obtained about 24 hours after injection demonstrate intense uptake in the right flank extending from the liver to the pelvis. (b) CT scan obtained a day later demonstrates a large, presumably appendiceal abscess that was subsequently drained. Despite the finding in a, diagnosis and drainage could easily have been accomplished with CT alone. In fact, if the initial clinical impression had been appendicitis rather than osteomyelitis, the patient would never have been referred to the nuclear medicine department. (Reproduced, with permission, from reference 10.)

View larger version (118K): [in a new window]   Figure 9b.   Abscess in a 10-year-old girl who was referred to the nuclear medicine department for evaluation of possible right hip osteomyelitis. (a) Anterior and posterior labeled leukocyte images of the abdomen obtained about 24 hours after injection demonstrate intense uptake in the right flank extending from the liver to the pelvis. (b) CT scan obtained a day later demonstrates a large, presumably appendiceal abscess that was subsequently drained. Despite the finding in a, diagnosis and drainage could easily have been accomplished with CT alone. In fact, if the initial clinical impression had been appendicitis rather than osteomyelitis, the patient would never have been referred to the nuclear medicine department. (Reproduced, with permission, from reference 10.)

View larger version (145K): [in a new window]   Figure 10a.   Pneumonia in a 32-year-old woman who was undergoing hemodialysis. Results of blood cultures were positive. (a) Chest radiograph obtained at the time of admission is negative. (b) Anterior (left) and posterior (right) labeled leukocyte images obtained 24 hours later demonstrate no graft infection, but intense uptake is seen in the right midlung. (c) Chest radiograph obtained 24 hours after b demonstrates a corresponding area of consolidation. (Reproduced, with permission, from reference 10.)

View larger version (91K): [in a new window]   Figure 10b.   Pneumonia in a 32-year-old woman who was undergoing hemodialysis. Results of blood cultures were positive. (a) Chest radiograph obtained at the time of admission is negative. (b) Anterior (left) and posterior (right) labeled leukocyte images obtained 24 hours later demonstrate no graft infection, but intense uptake is seen in the right midlung. (c) Chest radiograph obtained 24 hours after b demonstrates a corresponding area of consolidation. (Reproduced, with permission, from reference 10.)

View larger version (129K): [in a new window]   Figure 10c.   Pneumonia in a 32-year-old woman who was undergoing hemodialysis. Results of blood cultures were positive. (a) Chest radiograph obtained at the time of admission is negative. (b) Anterior (left) and posterior (right) labeled leukocyte images obtained 24 hours later demonstrate no graft infection, but intense uptake is seen in the right midlung. (c) Chest radiograph obtained 24 hours after b demonstrates a corresponding area of consolidation. (Reproduced, with permission, from reference 10.)

View larger version (81K): [in a new window]   Figure 11a.   Abscess in a 52-year-old woman with left groin pain who had undergone percutaneous femoral angiography. CT performed 5 days after angiography demonstrated normal findings. Because of unrelenting hip pain and an elevated erythrocyte sedimentation rate, a labeled leukocyte study was performed 10 days later. (a) Anterior (left) and left lateral (right) labeled leukocyte images of the pelvis obtained about 24 hours after injection demonstrate intense uptake in the left lower quadrant of the abdomen and extending into the proximal thigh. (b) Repeat CT scan obtained with administration of contrast material helps confirm a large left psoas abscess.

View larger version (106K): [in a new window]   Figure 11b.   Abscess in a 52-year-old woman with left groin pain who had undergone percutaneous femoral angiography. CT performed 5 days after angiography demonstrated normal findings. Because of unrelenting hip pain and an elevated erythrocyte sedimentation rate, a labeled leukocyte study was performed 10 days later. (a) Anterior (left) and left lateral (right) labeled leukocyte images of the pelvis obtained about 24 hours after injection demonstrate intense uptake in the left lower quadrant of the abdomen and extending into the proximal thigh. (b) Repeat CT scan obtained with administration of contrast material helps confirm a large left psoas abscess.

View larger version (142K): [in a new window]   Figure 12a.   Postsurgical abscess in a 52-year-old man with spiking fevers who had undergone appendectomy. (a) CT scan of the abdominopelvic region obtained 5 days after surgery demonstrates only postoperative changes. (b, c) Planar (b) and transverse and coronal tomographic (c) labeled leukocyte images of the pelvis obtained about 24 hours after injection demonstrate abnormal uptake in both the surgical bed (arrowhead) and superficially at the incision site (arrow). Subsequently, pus began draining through the incision. The patient improved with intravenous antibiotic therapy.

View larger version (145K): [in a new window]   Figure 12b.   Postsurgical abscess in a 52-year-old man with spiking fevers who had undergone appendectomy. (a) CT scan of the abdominopelvic region obtained 5 days after surgery demonstrates only postoperative changes. (b, c) Planar (b) and transverse and coronal tomographic (c) labeled leukocyte images of the pelvis obtained about 24 hours after injection demonstrate abnormal uptake in both the surgical bed (arrowhead) and superficially at the incision site (arrow). Subsequently, pus began draining through the incision. The patient improved with intravenous antibiotic therapy.

View larger version (80K): [in a new window]   Figure 12c.   Postsurgical abscess in a 52-year-old man with spiking fevers who had undergone appendectomy. (a) CT scan of the abdominopelvic region obtained 5 days after surgery demonstrates only postoperative changes. (b, c) Planar (b) and transverse and coronal tomographic (c) labeled leukocyte images of the pelvis obtained about 24 hours after injection demonstrate abnormal uptake in both the surgical bed (arrowhead) and superficially at the incision site (arrow). Subsequently, pus began draining through the incision. The patient improved with intravenous antibiotic therapy.

View larger version (106K): [in a new window]   Figure 13a.   Vascular graft infection in a 74-year-old man with a left femoral bypass graft who presented with septicemia. The patient had undergone subtotal colectomy 4 weeks earlier. (a) CT scan depicts only a skin defect extending to the ventral surface of the graft (arrow). The usefulness of CT was limited by metallic hardware in both hips. (b) Anterior labeled leukocyte image obtained about 24 hours after injection demonstrates intense uptake (arrow) representing an infected vascular graft.

View larger version (145K): [in a new window]   Figure 13b.   Vascular graft infection in a 74-year-old man with a left femoral bypass graft who presented with septicemia. The patient had undergone subtotal colectomy 4 weeks earlier. (a) CT scan depicts only a skin defect extending to the ventral surface of the graft (arrow). The usefulness of CT was limited by metallic hardware in both hips. (b) Anterior labeled leukocyte image obtained about 24 hours after injection demonstrates intense uptake (arrow) representing an infected vascular graft.

View larger version (78K): [in a new window]   Hemodialysis graft infection. Labeled leukocyte images obtained about 24 hours after injection show intense uptake in the upper extremity representing an infected arteriovenous hemodialysis graft.

View larger version (104K): [in a new window]   Figure 15a.   Increased bone marrow uptake in an 86-year-old woman who was referred for evaluation of possible osteomyelitis. The patient had sustained right lower extremity fractures 1 month earlier. (a) Radiograph reveals multiple fractures of the right tibia and fibula. An internal fixation device is seen in the tibia. (b) Labeled leukocyte image obtained about 24 hours after injection (left) shows intense uptake in the right tibia, a finding that could easily be misinterpreted as osteomyelitis. However, this same uptake pattern is also present on a bone marrow scan (right), which indicates that the labeled leukocyte uptake represents marrow (albeit atypical in location) rather than infection. Thus, when taken together, the two images are negative for infection.

View larger version (71K): [in a new window]   Figure 15b.   Increased bone marrow uptake in an 86-year-old woman who was referred for evaluation of possible osteomyelitis. The patient had sustained right lower extremity fractures 1 month earlier. (a) Radiograph reveals multiple fractures of the right tibia and fibula. An internal fixation device is seen in the tibia. (b) Labeled leukocyte image obtained about 24 hours after injection (left) shows intense uptake in the right tibia, a finding that could easily be misinterpreted as osteomyelitis. However, this same uptake pattern is also present on a bone marrow scan (right), which indicates that the labeled leukocyte uptake represents marrow (albeit atypical in location) rather than infection. Thus, when taken together, the two images are negative for infection.

View larger version (80K): [in a new window]   Figure 16.   Increased uptake due to infection in an 84-year-old man with an infected right hip prosthesis. Labeled leukocyte image obtained about 24 hours after injection (left) appears negative for infection of the right hip (arrow). However, a bone marrow scan (right) clearly demonstrates the absence of uptake in the right hip (arrow). Thus, when taken together, the two images are positive for infection. Intensity of uptake is not a reliable criterion for determining whether infection is present.

View larger version (73K): [in a new window]   Figure 17.   Arteriovenous dialysis graft infection in a 70-year-old woman. Peptide image of the left forearm obtained about 90 minutes after injection (left) demonstrates excellent resolution. A corresponding labeled leukocyte image (right) was obtained about 24 hours after injection. Both images demonstrate uptake in the infected graft.

View larger version (115K): [in a new window]   Figure 18a.   Diverticulitis in a 75-year-old woman who was referred to the nuclear medicine department because of persistent hip pain. The patient had recently undergone left hip replacement surgery. A monoclonal antibody study was performed to rule out infection. (a) Anterior (left) and posterior (right) antibody images obtained about 24 hours after injection demonstrate intense uptake within the pelvic midline (arrow), despite the fact that the left hip prosthesis was normal. (b) Subsequent CT scan reveals diverticulitis.

View larger version (150K): [in a new window]   Figure 18b.   Diverticulitis in a 75-year-old woman who was referred to the nuclear medicine department because of persistent hip pain. The patient had recently undergone left hip replacement surgery. A monoclonal antibody study was performed to rule out infection. (a) Anterior (left) and posterior (right) antibody images obtained about 24 hours after injection demonstrate intense uptake within the pelvic midline (arrow), despite the fact that the left hip prosthesis was normal. (b) Subsequent CT scan reveals diverticulitis.

View larger version (66K): [in a new window]   Figure 19a.   Psoas abscess in the same patient as in (a) Labeled leukocyte image obtained about 24 hours after injection (left) demonstrates normal findings, whereas abnormal activity is seen in the left lower quadrant on a gallium image (right) (arrow). (b) Transverse and coronal tomographic gallium images more clearly demonstrate the abnormality (arrows). (c) CT scan reveals a left psoas abscess.

View larger version (29K): [in a new window]   Figure 19b.   Psoas abscess in the same patient as in (a) Labeled leukocyte image obtained about 24 hours after injection (left) demonstrates normal findings, whereas abnormal activity is seen in the left lower quadrant on a gallium image (right) (arrow). (b) Transverse and coronal tomographic gallium images more clearly demonstrate the abnormality (arrows). (c) CT scan reveals a left psoas abscess.

View larger version (111K): [in a new window]   Figure 19c.   Psoas abscess in the same patient as in (a) Labeled leukocyte image obtained about 24 hours after injection (left) demonstrates normal findings, whereas abnormal activity is seen in the left lower quadrant on a gallium image (right) (arrow). (b) Transverse and coronal tomographic gallium images more clearly demonstrate the abnormality (arrows). (c) CT scan reveals a left psoas abscess.