![Page 1: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/1.jpg)
Radionuclide imaging in patients with fever
Otto Lang MDDept Nucl Med
3rd School of MedicineCharles University
Prague
materials for medical students
![Page 2: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/2.jpg)
Fever
• Non-specific reaction of the body (T>38oC)
• Most frequent cause inflammation (tumors)
• Inflammation – Infective and non-infective
• Usually fever with other signs of imflammation
• Clinical picture very important
• Other laboratory tests including imaging methods (NM, sono, CT, MRI) are essential
![Page 3: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/3.jpg)
Fever • Probable etiology should be taken into account
– Fever in patient post surgery
– Fever in patient with renal failure
– Fever in patient with HIV positivity
– Fever in patient with septicaemia
– Fever of unknown origin• Fever for 3 weeks with unknown origin despite 1 week intensive hospital
evaluation
– Fever in children
– Fever in soft tissue inflammation
– Fever in bone infection
– Fever in patient with abdominal sepsis
– Fever in patient with different tumors
![Page 4: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/4.jpg)
Fever • Radiopharmaceuticals
– organ specific – show damage of appropriate organ (defect of functioning tissue)
• Tc-99m diphosphonates – bone scan
• Tc-99m DMSA - kidneys
– organ non-specific – accumulates directly in inflammed tissue (little bit tumors, wounds, hematomas)
• Ga-67 citrate – infective, non-infective, tumors
• labeled leukocytes – pyogenic infection
• Tc-99m IgG – non-infective
• F-18 FDG
![Page 5: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/5.jpg)
Ga-67 - properties• Used in a form of citrate• Binds to plasmatic proteins, excretion by
kidneys (24 h) and then intestinal mucosa• Degree of accumulation correlates with
process activity• Basic principles of accumulation:
– Complexes with plasma transferrin– Binds to intracellular lactoferrin inside leukocytes– Can binds directly to some parts of bacteria
• Patient preparation:– Laxatives - fast elimination from the bowel
![Page 6: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/6.jpg)
Ga-67 - procedure
• Injection of 150-180 MBq – high energy, long half-life, high absorbed
dose, worse spatial resolution (image qual)
• Acquisition 4-6 h p.i., then from 24 h to 3-4 days
• Collimator for medium energy
• Whole-body study, spot view (larger frame matrix), SPECT
![Page 7: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/7.jpg)
Ga-67 – clinical significance
• High sensitivity (90%) but low specificity –
used as a locating agent – it locates site of damage so other more specific methods can be used
• More suitable for chronic inflammation
• Not very good for abdominal inflammation evaluation due to physiological excretion via intestinal mucosa
![Page 8: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/8.jpg)
Ga-67 – clinical indications
• Specific inflammation (sarcoidosis, tuberculosis)
• Imunocompromised patients (lung inf)
• Thoracic inflammation (fibrosis, vasculitis)
• Non-infective inflam – process activity (kollagenosis)
• Fever of unknown origin– wide spectrum of possible causes
• Osteomyelitis
• Abdominal and retroperitoneal inflamation (pyelonefritis, absces)
![Page 9: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/9.jpg)
Labeled leucocytesproperties
• Basic pinciples of accumulation– positive chemotaxis (no injury during
labeling process)– also healing wounds and tumors
• Labeling process– in vitro - separation, laboured– in vivo - monoclonal antibodies
• Patient preparation– fasted (blood processing)
![Page 10: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/10.jpg)
Labeled leucocytes procedure
• Labeling – 60 ml venous blood (kids min. 12 ml) – separation, washing up, labeling – cca 1.5 h– Labeling with Tc-99m HMPAO (300 – 500 MBq)
or In-111 oxin (20-40 MBq)
• Data acquisition – 30 min, 4-6, 24 (48 In) h post injection– Whole-body study, spot view (larger frame
matrix), SPECT
![Page 11: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/11.jpg)
Labeled leucocytes clinical indication
• Unspecific bowel disease (Crohn, UC)
• Diabetic foot syndroma
• Musculosceletal infection
• Fever of unknown origin (within 2-3 w)
• Imunocompromised patients
• Joint prosthesis infection
• Acute arthritis
• Vascular prosthesis infection
![Page 12: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/12.jpg)
Tc-99m IgG
• Non-specific polyclonal
• Labeled with In-111 or Tc-99m.
• Accumulates predominantly within interstitial space
• Physiological accumulation – blood-pool, liver, spleen, kindeys, bone marrow and nasal mucosa
• Main indication
– Revmatic (non-infective) inflamation
![Page 13: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/13.jpg)
F-18 FDG• Metabolic analog of glucose
– enter cells but no metabolism – accumulates according to degree of metabolic turnover
• Imaging by PET
• Metabolically active processes (inflam, tumors) - more glucose than other tissue
• Mainly used as a locating agent (like Ga-67) and mark of activity
• PET – much better spatial resolution (better image quality)
![Page 14: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/14.jpg)
New ways
• Imaging of bacteria– labeled chemotherapeuticals (chinolony)
• dependent on antibiotics therapy
• Chemotactic peptides– interleukin 2 – non-infective inflammation
(autoimmune)
• Combined methods– Streptavidin (tissue senzibilization) and then
labeled biotin
![Page 15: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/15.jpg)
Ga-67 citrate
physiological distribution
male and female
![Page 16: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/16.jpg)
Ga-67 - sarkoidosis
![Page 17: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/17.jpg)
Ga-67 – sarkoidosispanda-sign
![Page 18: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/18.jpg)
Ga-67 – sarkoidosispanda and delta sign
![Page 19: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/19.jpg)
Ga-67 – lung fibrosis
![Page 20: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/20.jpg)
Ga-67 - tuberculosis
![Page 21: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/21.jpg)
Ga-67 - urosepticaemia
![Page 22: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/22.jpg)
Ga-67 – thyroiditiscomparison with Tc-99m pertechnetate
![Page 23: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/23.jpg)
Labeled leucocytes
physiological distribution
![Page 24: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/24.jpg)
Labeled leucocytes ulcerative colitis
![Page 25: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/25.jpg)
Labeled leucocytes ulcerative colitis or Crohn´s disease?
![Page 26: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/26.jpg)
Labeled leucocytes ulcerative colitis
![Page 27: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/27.jpg)
Labeled leucocytes infection of hip prosthesis
![Page 28: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/28.jpg)
Diabetic foot syndroma
![Page 29: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/29.jpg)
Patient JU 1961, X-ray chron. OM
![Page 30: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/30.jpg)
Patient JU 1961, bone scan posit.
![Page 31: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/31.jpg)
Patient JU 1961, leu scan negative
![Page 32: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/32.jpg)
F-18 FDGphysiological distribution
![Page 33: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/33.jpg)
FUO
Fever of unknown origin(all methods failed)PET revealed:- aortitis/vasculitisAs a bonus:- Breast cancer(vasculitis as a paraneoplastic sign)
![Page 34: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/34.jpg)
Vascular prosthesis infection PET FDG
![Page 35: Radionuclide imaging in patients with fever Otto Lang MD Dept Nucl Med 3rd School of Medicine Charles University Prague materials for medical students](https://reader036.vdocuments.us/reader036/viewer/2022062515/56649ce45503460f949b14dc/html5/thumbnails/35.jpg)
Joint prosthesis infectionPET FDG