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DOI: 10.1148/rg.263055139
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Combined Labeled Leukocyte and Technetium 99m Sulfur Colloid Bone Marrow Imaging for Diagnosing Musculoskeletal Infection1

Christopher J. Palestro, MD, Charito Love, MD, Gene G. Tronco, MD, Maria B. Tomas, MD and Josephine N. Rini, MD

1 From the Division of Nuclear Medicine, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040. Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received July 5, 2005; revision requested September 2 and received September 27; accepted September 29. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  (a) Infected right hip replacement. WBC image shows mild, diffuse activity around a right hip prosthesis. This activity is less intense than that in the left hip and femur. (b) Aseptically loosened right hip replacement. WBC image shows irregularly increased activity around a right hip prosthesis. Proximally, this activity is more intense than both adjacent activity and activity in the left hip and femur. The intensity of periprosthetic activity on WBC images is not a reliable criterion for determining the presence of infection.

 

Figure 1
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  		Figure 1b.  (a) Infected right hip replacement. WBC image shows mild, diffuse activity around a right hip prosthesis. This activity is less intense than that in the left hip and femur. (b) Aseptically loosened right hip replacement. WBC image shows irregularly increased activity around a right hip prosthesis. Proximally, this activity is more intense than both adjacent activity and activity in the left hip and femur. The intensity of periprosthetic activity on WBC images is not a reliable criterion for determining the presence of infection.

 

Figure 2
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  		Figure 2a.  (a) Anterior (left) and posterior (right) WBC images of a 15-month-old infant show normal findings. In healthy infants and very young children, virtually all of the medullary cavities contain hematopoietically active marrow; thus, labeled WBC activity will be present throughout much of the skeleton. (b) Anterior (left) and posterior (right) WBC images of an adult show normal findings. As a person ages, hematopoietically active marrow recedes and is replaced by fatty marrow. By young adulthood, hematopoietically active marrow is confined to the axial skeleton, proximal femurs, and proximal humeri.

 

Figure 2
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  		Figure 2b.  (a) Anterior (left) and posterior (right) WBC images of a 15-month-old infant show normal findings. In healthy infants and very young children, virtually all of the medullary cavities contain hematopoietically active marrow; thus, labeled WBC activity will be present throughout much of the skeleton. (b) Anterior (left) and posterior (right) WBC images of an adult show normal findings. As a person ages, hematopoietically active marrow recedes and is replaced by fatty marrow. By young adulthood, hematopoietically active marrow is confined to the axial skeleton, proximal femurs, and proximal humeri.

 

Figure 3
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  		Figure 3a.  (a) Generalized marrow expansion. Anterior (left) and posterior (right) WBC images obtained in a patient with metastatic prostate carcinoma show diffuse, irregular activity extending into the distal humeri and femurs. The photopenic regions correspond to areas in which marrow has been replaced by tumor. Sites of apparently increased activity, such as the left sacroiliac region, represent areas of functioning marrow, not infection. (b, c) Localized marrow expansion. (b) Radiograph demonstrates a left femoral fracture. (c) WBC image shows focally increased WBC activity in the uninfected fracture.

 

Figure 3
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  		Figure 3b.  (a) Generalized marrow expansion. Anterior (left) and posterior (right) WBC images obtained in a patient with metastatic prostate carcinoma show diffuse, irregular activity extending into the distal humeri and femurs. The photopenic regions correspond to areas in which marrow has been replaced by tumor. Sites of apparently increased activity, such as the left sacroiliac region, represent areas of functioning marrow, not infection. (b, c) Localized marrow expansion. (b) Radiograph demonstrates a left femoral fracture. (c) WBC image shows focally increased WBC activity in the uninfected fracture.

 

Figure 3
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  		Figure 3c.  (a) Generalized marrow expansion. Anterior (left) and posterior (right) WBC images obtained in a patient with metastatic prostate carcinoma show diffuse, irregular activity extending into the distal humeri and femurs. The photopenic regions correspond to areas in which marrow has been replaced by tumor. Sites of apparently increased activity, such as the left sacroiliac region, represent areas of functioning marrow, not infection. (b, c) Localized marrow expansion. (b) Radiograph demonstrates a left femoral fracture. (c) WBC image shows focally increased WBC activity in the uninfected fracture.

 

Figure 4
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  		Figure 4a.  Osteomyelitis of the left humerus. (a) WBC image shows focally increased activity in the proximal left humerus. (b) Marrow image reveals a photopenic defect in the same region.

 

Figure 4
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  		Figure 4b.  Osteomyelitis of the left humerus. (a) WBC image shows focally increased activity in the proximal left humerus. (b) Marrow image reveals a photopenic defect in the same region.

 

Figure 5
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  		Figure 5a.  Localized marrow expansion. WBC (a) and marrow (b) images show increased activity in the right hindfoot. There was no obvious reason for this localized marrow expansion.

 

Figure 5
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  		Figure 5b.  Localized marrow expansion. WBC (a) and marrow (b) images show increased activity in the right hindfoot. There was no obvious reason for this localized marrow expansion.

 

Figure 6
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  		Figure 6a.  Infected left hip replacement. (a) Posterior WBC image shows minimal periprosthetic activity in the intertrochanteric region of a left hip prosthesis (arrow), a finding that would be interpreted as normal. (b) Marrow image shows no corresponding activity in the inter-trochanteric region; consequently, the combined study is positive for infection. (Reprinted, with permission, from reference 30.)

 

Figure 6
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  		Figure 6b.  Infected left hip replacement. (a) Posterior WBC image shows minimal periprosthetic activity in the intertrochanteric region of a left hip prosthesis (arrow), a finding that would be interpreted as normal. (b) Marrow image shows no corresponding activity in the inter-trochanteric region; consequently, the combined study is positive for infection. (Reprinted, with permission, from reference 30.)

 

Figure 7
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  		Figure 7a.  Aseptically loosened left knee replacement. WBC (a) and marrow (b) images show intensely increased activity around the femoral and tibial components of a left knee prosthesis. The combined study is negative for infection.

 

Figure 7
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  		Figure 7b.  Aseptically loosened left knee replacement. WBC (a) and marrow (b) images show intensely increased activity around the femoral and tibial components of a left knee prosthesis. The combined study is negative for infection.

 

Figure 8
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  		Figure 8a.  Uninfected orthopedic hardware. (a) Radiograph depicts a left hip dynamic screw. (b, c) WBC (b) and marrow (c) images show two foci of increased activity in the left femur and one focus in the proximal right femur.

 

Figure 8
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  		Figure 8b.  Uninfected orthopedic hardware. (a) Radiograph depicts a left hip dynamic screw. (b, c) WBC (b) and marrow (c) images show two foci of increased activity in the left femur and one focus in the proximal right femur.

 

Figure 8
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  		Figure 8c.  Uninfected orthopedic hardware. (a) Radiograph depicts a left hip dynamic screw. (b, c) WBC (b) and marrow (c) images show two foci of increased activity in the left femur and one focus in the proximal right femur.

 

Figure 9
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  		Figure 9a.  Uninfected fracture of the distal left femur in the same patient as in Figure 3b and 3c. WBC (a) and marrow (b) images show increased activity at the site of the fracture. Labeled WBC uptake in uninfected fractures is probably due, at least in part, to the presence of hematopoietically active marrow, which is part of the reparative process.

 

Figure 9
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  		Figure 9b.  Uninfected fracture of the distal left femur in the same patient as in Figure 3b and 3c. WBC (a) and marrow (b) images show increased activity at the site of the fracture. Labeled WBC uptake in uninfected fractures is probably due, at least in part, to the presence of hematopoietically active marrow, which is part of the reparative process.

 

Figure 10
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  		Figure 10a.  Uninfected neuropathic joint in a diabetic patient. WBC (a) and marrow (b) images show increased activity in the right midfoot.

 

Figure 10
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  		Figure 10b.  Uninfected neuropathic joint in a diabetic patient. WBC (a) and marrow (b) images show increased activity in the right midfoot.

 

Figure 11
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  		Figure 11a.  Gaucher disease in a patient who had previously undergone splenectomy. (a) WBC image shows asymmetric activity in the lower extremities. It would be difficult to exclude osteomyelitis of the proximal left tibia and right ankle. (b) Marrow image demonstrates virtually identical findings. The abnormalities in this case are the areas of decreased activity, which are due to marrow infiltration by Gaucher cells.

 

Figure 11
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  		Figure 11b.  Gaucher disease in a patient who had previously undergone splenectomy. (a) WBC image shows asymmetric activity in the lower extremities. It would be difficult to exclude osteomyelitis of the proximal left tibia and right ankle. (b) Marrow image demonstrates virtually identical findings. The abnormalities in this case are the areas of decreased activity, which are due to marrow infiltration by Gaucher cells.

 

Figure 12
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  		Figure 12a.  Bone infarctions and osteomyelitis in a patient with sickle cell disease. (a) On a WBC image, the most obvious abnormalities are areas of decreased activity in the right hemipelvis, proximal right femur, and proximal right tibia, all of which findings are consistent with infarctions. (b) Marrow image demonstrates similar findings in the right side of the pelvis and the right femur and tibia. Note, however, the absence of activity in the proximal left tibia (arrow). If the marrow image had not been obtained, the proximal left tibial focus of osteomyelitis could easily have gone unrecognized on the WBC image.

 

Figure 12
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  		Figure 12b.  Bone infarctions and osteomyelitis in a patient with sickle cell disease. (a) On a WBC image, the most obvious abnormalities are areas of decreased activity in the right hemipelvis, proximal right femur, and proximal right tibia, all of which findings are consistent with infarctions. (b) Marrow image demonstrates similar findings in the right side of the pelvis and the right femur and tibia. Note, however, the absence of activity in the proximal left tibia (arrow). If the marrow image had not been obtained, the proximal left tibial focus of osteomyelitis could easily have gone unrecognized on the WBC image.

 

Figure 13
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  		Figure 13a.  Infected vascular graft in a hemodialysis patient. (a) Anterior (left) and posterior (right) WBC images show increased activity in an infected left femoral vascular graft. Generalized marrow expansion is also present. Note the asymmetric activity in the long bones of the lower extremities. (b, c) WBC (b) and marrow (c) images show a virtually identical distribution of activity in the distal femurs and proximal tibias. The distal distributions of the two radiotracers were also identical.

 

Figure 13
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  		Figure 13b.  Infected vascular graft in a hemodialysis patient. (a) Anterior (left) and posterior (right) WBC images show increased activity in an infected left femoral vascular graft. Generalized marrow expansion is also present. Note the asymmetric activity in the long bones of the lower extremities. (b, c) WBC (b) and marrow (c) images show a virtually identical distribution of activity in the distal femurs and proximal tibias. The distal distributions of the two radiotracers were also identical.

 

Figure 13
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  		Figure 13c.  Infected vascular graft in a hemodialysis patient. (a) Anterior (left) and posterior (right) WBC images show increased activity in an infected left femoral vascular graft. Generalized marrow expansion is also present. Note the asymmetric activity in the long bones of the lower extremities. (b, c) WBC (b) and marrow (c) images show a virtually identical distribution of activity in the distal femurs and proximal tibias. The distal distributions of the two radiotracers were also identical.

 

Figure 14
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  		Figure 14a.  Nodal uptake of labeled WBCs. (a) WBC image shows multiple small, punctate foci in a linear distribution along the medial aspects of both hips (arrows). (b) Marrow image shows no corresponding foci, and the combined study could erroneously be interpreted as consistent with infection. An aseptically loosened right hip replacement was revised. There was no evidence of infection.

 

Figure 14
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  		Figure 14b.  Nodal uptake of labeled WBCs. (a) WBC image shows multiple small, punctate foci in a linear distribution along the medial aspects of both hips (arrows). (b) Marrow image shows no corresponding foci, and the combined study could erroneously be interpreted as consistent with infection. An aseptically loosened right hip replacement was revised. There was no evidence of infection.

 

Figure 15
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  		Figure 15a.  Septic arthritis. (a, b) WBC (a) and marrow (b) images show diffusely increased activity in the left knee. The study could be interpreted as negative for infection. (c) Pelvic marrow image shows considerable bladder activity, which indicates presence of unbound pertechnetate, rendering b uninterpretable. Use of bladder imaging with the routine marrow imaging protocol is a simple quality control procedure.

 

Figure 15
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  		Figure 15b.  Septic arthritis. (a, b) WBC (a) and marrow (b) images show diffusely increased activity in the left knee. The study could be interpreted as negative for infection. (c) Pelvic marrow image shows considerable bladder activity, which indicates presence of unbound pertechnetate, rendering b uninterpretable. Use of bladder imaging with the routine marrow imaging protocol is a simple quality control procedure.

 

Figure 15
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  		Figure 15c.  Septic arthritis. (a, b) WBC (a) and marrow (b) images show diffusely increased activity in the left knee. The study could be interpreted as negative for infection. (c) Pelvic marrow image shows considerable bladder activity, which indicates presence of unbound pertechnetate, rendering b uninterpretable. Use of bladder imaging with the routine marrow imaging protocol is a simple quality control procedure.

 




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