Radionuclide Imaging of Osteomyelitis

https://doi.org/10.1053/j.semnuclmed.2014.07.005Get rights and content

Radionuclide procedures frequently are performed as part of the diagnostic workup of osteomyelitis. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. Degenerative joint disease, fracture, and orthopedic hardware decrease the specificity of the bone scan, making it less useful in these situations. Gallium-67 scintigraphy was often used as an adjunct to bone scintigraphy for diagnosing osteomyelitis. However, now it is used primarily for spinal infections when 18F-FDG imaging cannot be performed. Except for the spine, in vitro–labeled leukocyte imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Leukocytes accumulate in bone marrow as well as in infection. Performing complementary bone marrow imaging with 99mTc-sulfur colloid facilitates the differentiation between osteomyelitis and normal marrow and improves test overall accuracy. Antigranulocyte antibodies and antibody fragments, such as 99mTc-besilesomab and 99mTc-sulesomab, were developed to eliminate the disadvantages associated with in vitro–labeled leukocytes. These agents, however, have their own shortcomings and are not widely available. As biotin is used as a growth factor by certain bacteria, 111In-biotin is useful to diagnose spinal infections. Radiolabeled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, can differentiate infection from sterile inflammation and may be useful to monitor response to treatment. 18F-FDG is extremely useful in the diagnostic workup of osteomyelitis. Sensitivity in excess of 95% and specificity ranging from 75%-99% have been reported. 18F-FDG is the radionuclide test of choice for spinal infection. The test is sensitive, with a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of 18F-FDG for diagnosing diabetic pedal osteomyelitis are contradictory, and its role for this indication remains to be determined. Initial investigations suggested that 18F-FDG accurately diagnoses prosthetic joint infection; more recent data indicate that it cannot differentiate infection from other causes of prosthetic failure. Preliminary data on the PET agents gallium-68 and iodine-124 fialuridine indicate that these agents may have a role in diagnosing osteomyelitis.

Section snippets

99mTc-Diphosphonates

Bone scintigraphy usually is performed with technetium-99m-methylene diphosphonate (99mTc-MDP). Uptake of this radiopharmaceutical, which binds to the hydroxyapatite crystal, depends on blood flow and rate of new bone formation. When osteomyelitis is the indication, a 3-phase bone scan usually is performed. Three-phase bone scintigraphy consists of a dynamic imaging sequence, the flow or perfusion phase, followed immediately by static images of the region of interest, the blood pool or soft

Indications

It is important to recognize that no single agent is equally efficacious in all regions of the skeleton. The selection of an appropriate study is governed by the clinical question posed. In adults, it is useful to divide musculoskeletal infections into 3 broad locations: spine, orthopedic hardware, and diabetic foot.

References (88)

  • E. García-Barrecheguren et al.

    FDG-PET: A new diagnostic approach in hip prosthetic replacement

    Rev Esp Med Nucl

    (2007)
  • C.J. Palestro et al.

    Nuclear medicine and diabetic foot infections

    Semin Nucl Med

    (2009)
  • S.I. Heiba et al.

    The optimized evaluation of diabetic foot infection by dual isotope SPECT/CT imaging protocol. J

    Foot Ankle Surg

    (2010)
  • D.R. Osman

    Diagnosis and management of musculoskeletal infection

  • C.J. Palestro et al.

    Radionuclide imaging of musculoskeletal infection: Conventional agents

    Semin Musculoskelet Radiol

    (2007)
  • C.J. Palestro et al.

    Labeled leukocyte imaging: Current status and future directions

    Q J Nucl Med Mol Imaging

    (2009)
  • C.J. Palestro et al.

    Combined labeled leukocyte and technetium-99m sulfur colloid marrow imaging for diagnosing musculoskeletal infection: Principles, technique, interpretation, indications and limitations

    Radiographics

    (2006)
  • C.J. Palestro et al.

    Multiagent imaging of inflammation and infection

    Clin Transl Imaging

    (2013)
  • L.A. Forstrom et al.

    Biodistribution and dosimetry of [F-18] fluorodeoxyglucose labeled leukocytes in normal human subjects

    Nucl Med Commun

    (2002)
  • N. Dumarey et al.

    Imaging infection with 18F-FDG labeled leukocyte PET/CT: Initial experience in 21 patients

    J Nucl Med

    (2006)
  • J.N. Rini et al.

    PET with FDG-labeled leukocytes versus scintigraphy with 111In-oxine-labeled leukocytes for detection of infection

    Radiology

    (2006)
  • S.Y. Aksoy et al.

    FDG and FDG-labelled leucocyte PET/CT in the imaging of prosthetic joint infection

    Eur J Nucl Med Mol Imaging

    (2014)
  • L.A. Diaz et al.

    Imaging of musculoskeletal bacterial infections by [124I]FIAU-PET/CT

    PLoS One

    (2007)
  • C. Love et al.

    Diagnosing spinal osteomyelitis: A comparison of bone and gallium scintigraphy and magnetic resonance imaging

    Clin Nucl Med

    (2002)
  • F. Gemmel et al.

    Radionuclide imaging of spinal infections

    Eur J Nucl Med Mol Imaging

    (2006)
  • D. Fuster et al.

    A prospective study comparing whole-body FDG PET/CT to combined planar bone scan with 67Ga SPECT/CT in the diagnosis of spondylodiskitis

    Clin Nucl Med

    (2012)
  • E. Lazzeri et al.

    Clinical feasibility of two-step streptavidin/111In-biotin scintigraphy in patients with suspected vertebral osteomyelitis

    Eur J Nucl Med Mol Imaging

    (2004)
  • E. Lazzeri et al.

    Clinical impact of SPECT/CT with In-111 biotin on the management of patients with suspected spine infection

    Clin Nucl Med

    (2010)
  • A. Guhlmann et al.

    Chronic osteomyelitis: Detection with FDG PET and correlation with histopathologic findings

    Radiology

    (1998)
  • A. Guhlmann et al.

    Fluorine-18-FDG PET and technetium-99m antigranulocyte antibody scintigraphy in chronic osteomyelitis

    J Nucl Med

    (1998)
  • M. Schiesser et al.

    Detection of metallic implant-associated infections with FDG PET in patients with trauma: Correlation with microbiologic results

    Radiology

    (2003)
  • T. Kalicke et al.

    Fluorine-18 fluorodeoxyglucose PET in infectious bone diseases: Results of histologically confirmed cases

    Eur J Nucl Med Mol Imaging

    (2000)
  • A. Schmitz et al.

    Fluorine-18 fluorodeoxyglucose positron emission tomography findings in spondylodiscitis: Preliminary results

    Eur Spine J

    (2001)
  • J. Meller et al.

    Chronic bacterial osteomyelitis: Prospective comparison of F-18-FDG imaging with a dual-head coincidence camera and In-111-labelled autologous leucocyte scintigraphy

    Eur J Nucl Med Mol Imaging

    (2002)
  • A. Hartmann et al.

    Diagnostic value of 18F-FDG PET/CT in trauma patients with suspected chronic osteomyelitis

    Eur J Nucl Med Mol Imaging

    (2007)
  • S. Gratz et al.

    F-18-FDG hybrid PET in patients with suspected spondylitis

    Eur J Nucl Med Mol Imaging

    (2002)
  • S. Ohtori et al.

    18F-fluorodeoxyglucose-PET for patients with suspected spondylitis showing Modic change

    Spine

    (2010)
  • K.D. Stumpe et al.

    FDG positron emission tomography for differentiation of degenerative and infectious endplate abnormalities in the lumbar spine detected on MR imaging

    Am J Roentgenol

    (2002)
  • T. Seifen et al.

    Prolonged back pain attributed to suspected spondylodiscitis. The value of 18F-FDG PET/CT imaging in the diagnostic work-up of patients

    Nuklearmedizin

    (2012)
  • R.S. Rosen et al.

    Increased 18F-FDG uptake in degenerative disease of the spine: Characterization with 18FFDG PET/CT

    J Nucl Med

    (2006)
  • F. de Winter et al.

    18-Fluorine fluorodeoxyglucose positron emission tomography for the diagnosis of infection in the postoperative spine

    Spine

    (2003)
  • C. Nanni et al.

    68Ga-Citrate PET/CT for evaluating patients with infections of the bone: Preliminary results

    J Nucl Med

    (2010)
  • F. De Winter et al.

    Fluorine-18 fluorodeoxyglucose positron emission tomography: A highly accurate imaging modality for the diagnosis of chronic musculoskeletal infections

    J Bone Joint Surg Am

    (2001)
  • X. Tomas et al.

    Accuracy of CT-guided joint aspiration in patients with suspected infection status post-total hip arthroplasty

    Skeletal Radiol

    (2011)
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