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Bone scan (lateral oblique views), 111 In-WBC scan (anterior view) and FDG scan (sagittal slices from right to left) of a 45-year-old male. While the 111 In-WBC scan shows no abnormalities , faint focal FDG uptake can be seen (arrow) in the distal tibia. Infection was not confirmed by subsequent MRI or follow-up. Low-grade infection could not be entirely ruled out in this patient because histology was not performed
Source publication
Indium-111-labelled white blood cells ((111)In-WBCs) are currently considered the tracer of choice in the diagnostic work-up of suspected active chronic osteomyelitis (COM). Previous studies in a limited number of patients, performed with dedicated PET systems, have shown that [(18)F]2'-deoxy-2-fluoro- D-glucose (FDG) imaging may offer at least sim...
Contexts in source publication
Context 1
... 24 h in our study. 2) with proven COM and true negative in 23/25 regions (central skeleton: n=5; appendicular skeleton: n=18; Fig. 3) without evidence of COM during further diagnos- tic work-up. False-positive results occurred in two re- gions (central skeleton: n=0; appendicular skeleton: n=2) and were characterised by their faint FDG uptake (Fig. 4). There were no false-negative ...
Context 2
... results of FDG scanning (Fig. 4), as established by negative MRI, were characterised by their faint uptake, which was clearly below the intense level of uptake noted in cases of histologically proven COM. Unfortunately, histology was not performed in these pa- tients and therefore the histopathological correlate of the findings remains unclear. When the data analysis ...
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Citations
... 22 La GOT presenta una alta sensibilidad (89-100%) pero una muy baja especificidad (0-10%) por lo que no se recomienda para el enfrentamiento de esta patología. [24][25][26] La GLM þ SPECT ha reportado una alta sensibilidad (79-100%) y especificidad (89-97%). 22,27,28 Tiene el beneficio de no ser influenciado por la cirugía reciente. ...
Resumen
La infección asociada a fracturas (IAF) es una de las complicaciones más frecuentes y desafiantes del trauma ortopédico, sin embargo, su importancia ha sido subestimada existiendo históricamente una falta de estandarización en su manejo. En los últimos años la evidencia científica disponible ha ido en aumento, y a consecuencia de ello múltiples guías clínicas y consensos de expertos han sido publicados.
El objetivo de este trabajo es proporcionar una actualización, dirigida principalmente a especialistas en Ortopedia y Traumatología, buscado estandarizar criterios diagnósticos y de tratamiento basado en evidencia científica reciente.
... Although 18 F-FDG is not an infection-specific tracer, it presents several advantages compared to cell-labelled imaging techniques [14]. The detection of infection by the labelledleukocyte method depends on the migration of labelled neutrophils to the sites of infection, whereas 18 F-FDG PET can demonstrate focal areas of increased metabolic activity without the need for leukocyte activation and migration. ...
Multivisceral transplant (MVTx) refers to a composite graft from a cadaveric donor, which often includes the liver, the pancreaticoduodenal complex, and small intestine transplanted en bloc. It remains rare and is performed in specialist centres. Post-transplant complications are reported at a higher rate in multivisceral transplants because of the high levels of immunosuppression used to prevent rejection of the highly immunogenic intestine. In this study, we analyzed the clinical utility of 28 18F-FDG PET/CT scans in 20 multivisceral transplant recipients in whom previous non-functional imaging was deemed clinically inconclusive. The results were compared with histopathological and clinical follow-up data. In our study, the accuracy of 18F-FDG PET/CT was determined as 66.7%, where a final diagnosis was confirmed clinically or via pathology. Of the 28 scans, 24 scans (85.7%) directly affected patient management, of which 9 were related to starting of new treatments and 6 resulted in an ongoing treatment or planned surgery being stopped. This study demonstrates that 18F-FDG PET/CT is a promising technique in identifying life-threatening pathologies in this complex group of patients. It would appear that 18F-FDG PET/CT has a good level of accuracy, including for those MVTx patients suffering from infection, post-transplant lymphoproliferative disease, and malignancy.
... Studies have found PET to be of clinical use when investigating chronic osteomyelitis using 18F-FDG PET and suspected spondylodiscitis [70][71][72] . 18F-FDG PET has also demonstrated 100% diagnostic precision in axial bone compared to radiolabeled leukocyte scintigraphy [73] . ...
Neurosurgery as a specialty has developed at a rapid pace as a result of the continual advancements in neuroimaging modalities. With more sophisticated imaging options available to the modern neurosurgeon, diagnoses become more accurate and at a faster rate, allowing for greater surgical planning and precision. Herein, the authors review the current heavily used imaging modalities within neurosurgery, weighing their strengths and weaknesses, and provide a look into new advances and imaging options within the field. Of the many imaging modalities currently available to the practicing neurosurgeon, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), and ultrasonography (US) are used most heavily within the field for appropriate diagnosis of neuropathologies in question. For each, their strengths are weighed regarding appropriate capabilities in accurate diagnosis of cranial or spinal lesions. Reasoning for choosing one over the other for various pathologies is also reviewed. Current limitations of each is also assessed, providing insight for possible improvement for each. New advancements in imaging options are subsequently reviewed for best uses within neurosurgery, including the new utilization of FIESTA sequencing, glymphatic mapping, black-blood MRI, and functional MRI. The specialty of neurosurgery will continue to heavily rely on improvements within imaging options available for improved diagnosis and greater surgical outcomes for the patients treated. The synthesis of techniques provided herein may provide meaningful guidance for neurosurgeons in effectively diagnosing neurological pathologies while also helping guide future efforts in neuroimaging developments.
... Compared with bone scintigraphy, [18F]FDG-PET has been proposed as a superior method for the diagnosis of osteomyelitis due to its improved spatial resolution and higher specificity, allowing more accurate localization of focal inflammatory lesions characterized by increased glucose uptake [12,13]. In infected bone, [18F]FDG is more readily taken up via glucose transporters, which is related to migrating inflammatory cells, microorganisms, and granulation tissue [14]. ...
To investigate imaging features of osteomyelitis of the jaw (OMJ) using [18F]fluoride positron emission tomography (PET) and [18F]fluorodeoxyglucose (FDG)-PET compared with computed tomography (CT) and magnetic resonance imaging (MRI) to assess extent and disease activity. Six female patients (55.3 ± 10.0 years) were enrolled for assessment of symptomatic OMJ. 4/6 patients underwent [18F]FDG-PET/MRI and [18F]fluoride-PET/CT, one patient MRI and [18F]fluoride-PET/CT and another patient only [18F]FDG-PET/MRI. Image analysis was performed by two radiologists, an oral and maxillofacial surgeon, and a nuclear medicine specialist. The extent of affected jawbone was analyzed both qualitatively and quantitatively, including the PET tracer uptake, CT-Hounsfield-Units (HU) and MRI parameters in affected and healthy jawbone. All patients had trabecular sclerosis in the affected jawbone compared to healthy jawbone (560 ± 328 HU vs. 282 ± 211 HU; p > 0.05), while 3/6 patients had cortical erosions. Bone marrow edema and gadolinium enhancement were documented in 5/6 patients. In affected jawbone, [18F]fluoride-uptake was increased in all patients compared to healthy jawbone (SUVmean 15.4 ± 4.2 vs. 2.1 ± 0.6; p < 0.05), and [18F]FDG-uptake was moderately higher (SUVmean 1.9 ± 0.7 vs. 0.7 ± 0.2; p > 0.05). The extent of regions with increased metabolic activity was less than the extent of morphologic changes in all patients. Information on jawbone metabolism and inflammation is different from morphologic changes and therefore has the potential to provide a more accurate and objective assessment of the extent and activity of OMJ.
... These results suggest that a 99m Tc-HMPAO-labeled leukocyte scan will accurately predict remission near the end of antibiotic treatment. Moreover, based on reports using 111 In-labeled WBCs, WBC scans appear well suited for monitoring the response of DFO patients to antibiotic therapy over time because the abnormal scan findings revert to normal within two-eight weeks after the start of successful antibiotic therapy [114]. WBC scans have also been used to assess the efficacy of antibiotic treatment in patients with DFO. ...
... These results suggest that a 99m Tc-HMPAO-labeled leukocyte scan will accurately predict remission near the end of antibiotic treatment. Moreover, based on reports using 111 In-labeled WBCs, WBC scans appear well suited for monitoring the response of DFO patients to antibiotic therapy over time because the abnormal scan findings revert to normal within two-eight weeks after the start of successful antibiotic therapy [114]. ...
... This approach is particularly powerful in the evaluation of suspected infection superimposed on confounding pathology such as Charcot neuropathic changes. Sixteen to thirty hours after the initial scan, delayed scans of the bone marrow are often performed using a longer-lived tracer if OM is suspected; however, bone deformities such as fracture or abnormal marrow distribution from atypical hematopoietic activity may lead to false positives [114]. To overcome this, visualization of the bone marrow using a second radiotracer (dual-tracer approach) may be adopted. ...
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host’s immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
... There were 1319 fracture sites, of which 610 sites were infected according to reference tests. Five [43,[45][46][47]52] studies used a prospective study design, whereas the others [31-42, 44, 48-51] were retrospective ones. 13 [31,33,35,36,38,39,42,43,45,46,49,50,52] studies claimed that the nuclear medicine specialists were masked to the final diagnosis of the reference tests, while 9 [32,34,37,40,41,44,47,48,51] studies did not clarify this fact. ...
... Five [43,[45][46][47]52] studies used a prospective study design, whereas the others [31-42, 44, 48-51] were retrospective ones. 13 [31,33,35,36,38,39,42,43,45,46,49,50,52] studies claimed that the nuclear medicine specialists were masked to the final diagnosis of the reference tests, while 9 [32,34,37,40,41,44,47,48,51] studies did not clarify this fact. Among the included studies, 5 [33,37,39,44,48] ...
... Regarding the tracers of the included studies, 3 [46,51,52] used indium-111 and 99m Tc-hexamethylpropyleneamine oxime ( 99m Tc-HMPAO), which have gained popularity in recent years [46,51,52]. The pooled sensitivity and specificity of leukocyte scintigraphy to diagnose FRI were 0.86 (95% CI 0. 53 Content courtesy of Springer Nature, terms of use apply. ...
Background
The aim of this study was to compare the accuracy of available nuclear imaging modalities in the diagnosis of suspected fracture-related infection (FRI).Methods
We conducted a comprehensive literature search of PubMed, EMBASE and the Cochrane Library to retrieve diagnostic accuracy studies in which FRI was investigated using different nuclear imaging modalities. The pooled sensitivity, specificity, likelihood ratios and diagnostic odds ratios were constructed using the bivariate meta-analysis framework, while the superior index was pooled using Bayesian network meta-analysis.Results22 eligible studies (1,565 patients) were included in the quantitative analysis. A broad overlapping confidence interval (CI) of pooled sensitivity was observed among bone scintigraphy (0.94; 95% CI 0.85–0.98), 18F-FDG PET and PET/CT (0.91; 95% CI 0.85–0.94) and leukocyte scintigraphy (0.86; 95% CI 0.53–0.97). Bone scintigraphy (0.34; 95% CI 0.08–0.75) seemed to be less specific than all the other modalities, while leukocyte scintigraphy (0.96, 95% CI 0.92–0.98) was notably more specific than 18F-FDG PET and PET/CT (0.78; 95% CI 0.69–0.85). Based on the superiority index, 18F-FDG PET/CT (3.78; 95% CI 0.14–11.00), 18F-FDG PET (2.98; 95% CI 0.14–9.00) and leukocyte scintigraphy (1.51; 95% CI 0.11–7.00) all achieved high accuracy in detecting FRI.Conclusion
Bone scintigraphy is a highly sensitive nuclear imaging technique but lacks the specificity needed to unequivocally differentiate among various conditions suspected to be FRI. Leukocyte scintigraphy, 18F-FDG PET/CT and PET all present good satisfactory accuracy for the diagnosis of FRI, but their costs should be further reduced to promote their wide application.
... In total, 77 studies 37-113 (from 79 reports) were included in the diagnostic review, of which 69 were also included in a meta-analysis. [38][39][40][41][42][44][45][46][47][48][49][50][51][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][73][74][75][76][77][79][80][81][82][83][84][85][86][87][88][89][90][91][92][93][94][95]97,[99][100][101][102][103][104][105][106][107][108][109][110][111][112][113] Eleven studies were included in the review of inter-rater agreement, 37,58,59,65,68,86,92,[114][115][116][117] and one was included in the review of implementation. 118 Seven studies were included in both the diagnostic and inter-rater reliability reviews. ...
... 37 45,63,66,72,75,80 and one study attributed osteomyelitis to each of the following conditions specifically: soft tissue infection, 96 septic arthritis 98 and neuropathic osteoarthropathy. 100 Eighteen studies included patients with multiple aetiologies, 44,46,48,50,52,54,58,60,65,78,81,83,85,91,101,106,109,110 and three studies did not report any specific causes. 39,87,104 Only one study included patients with haematogenous osteomyelitis. ...
Background
Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis.
Objectives
To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis.
Data sources
We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018.
Review methods
Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively.
Results
Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis.
Limitations
Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy.
Conclusions
Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed.
Study registration
This study is registered as PROSPERO CRD42017068511.
Funding
This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 23, No. 61. See the NIHR Journals Library website for further project information.
... Results of prior studies have suggested that FDG PET may be superior to 111 In-labeled leukocyte scans for evaluation of FUO [11] and chronic bacterial osteomyelitis [12]. Because it PET/CT of Infection yields integrated anatomic and functional information, PET/CT is even more sensitive than PET alone for evaluating FUO [13] and is likely more sensitive than PET alone in the workup of suspected infection. ...
... Our study shows that PET/CT is more sensitive than tagged leukocyte scintigraphy for identifying a source of infection in inpatients. Results of prior studies have suggested that FDG PET may be superior to 111 In-labeled leukocyte scans for FUO [11] and chronic bacterial osteomyelitis [12]. Results of one prospective study [14] suggested that PET was less sensitive than 111 In-labeled leukocyte scans for identifying a source of infection, but potential patient selection bias [15] and possible erroneous false-positive classifications [16] limit broad application of the results. ...
OBJECTIVE. The purpose of this study is to assess the effectiveness of the volumetric parameters of dual-time-point imaging (DTPI) with 18F-FDG PET (DTPI FDG PET) in predicting the prognosis of patients with non-small cell lung cancer (NSCLC) treated with definitive radiation therapy (RT). MATERIALS AND METHODS. The records of consecutive patients who received definitive RT for NSCLC from April 2010 to April 2017 were retrospectively reviewed. Pretreatment DTPI FDG PET images were routinely obtained as part of the PET/CT examination. The maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the primary tumor (SUVmax-T, MTV-T, and TLG-T, respectively) and those of the primary tumor and lymph nodes (N) combined (SUVmax-TN, MTV-TN, and TLG-TN, respectively) were used as variables, and the percentage change in these parameters (change in SUVmax [ΔSUVmax], change in MTV [ΔMTV], and change in TLG [ΔTLG]) on DTPI FDG PET were analyzed. RESULTS. Of the 118 patients identified and reviewed, 59 met the study eligibility criteria. After a median follow-up of 23.3 months, the 3-year local control rate (LCR) and disease-specific survival rates were 53.5% and 45.0%, respectively. On multivariate analysis, significant predictors of LCR were TLG-T and change in TLG-TN (ΔTLG-TN), and significant predictors of disease-specific survival were adjuvant chemotherapy, treatment response, TLG-T, and change in TLG-T (ΔTLG-T). Low percentage changes in ΔTLG (< 41.0% for ΔTLG-T and < 32.0% for ΔTLG-TN) correlated with poor LCR and disease-specific survival. SUVmax and MTV were not significant predictors of both LCR and disease-specific survival. CONCLUSION. TLG and ΔTLG were significant prognostic factors in patients with NSCLC treated with definitive RT. In particular, a relatively low ΔTLG resulted in poor outcomes in terms of LCR and disease-specific survival.
... 6,26 An important addition in recent times is the possibility of hybrid imaging (single photon emission CT [SPECT]/CT, PET/CT, PET/MRI), which allows for better anatomic details. 27 The sensitivity of BS is high (89%-100%), but its specificity is so low (0%-10%) that BS is not recommended in the workup of FRI. 23,25,28,29 The sensitivity and specificity of WBC scintigraphy + SPECT for diagnosing FRI is reported to be 79%-100% and 89%-97%, respectively. 23,30-32 A major advantage of WBC scintigraphy is that its accuracy is not influenced by recent surgery. ...
Summary: Fracture-related infection (FRI) is a severe complication
after bone injury and can pose a serious diagnostic challenge. Overall,
there is a limited amount of scientific evidence regarding diagnostic
criteria for FRI. For this reason, the AO Foundation and the European
Bone and Joint Infection Society proposed a consensus definition for
FRI to standardize the diagnostic criteria and improve the quality of
patient care and applicability of future studies regarding this condition.
The aim of this article was to summarize the available evidence and
provide recommendations for the diagnosis of FRI. For this purpose,
the FRI consensus definition will be discussed together with a proposal
for an update based on the available evidence relating to the diagnostic
value of clinical parameters, serum inflammatory markers, imaging
modalities, tissue and sonication fluid sampling, molecular biology
techniques, and histopathological examination. Second, recommendations
on microbiology specimen sampling and laboratory operating
procedures relevant to FRI will be provided.
Key Words: fracture-related infection, diagnosis, diagnostic criteria,
definition, clinical criteria, medical imaging, histopathology, microbiology,
serum inflammatory markers, fracture, infection
Level of Evidence: Diagnostic Level V. See Instructions for
Authors for a complete description of levels of evidence.
... ese studies used 99m Tc-HMPAO-WBCs with Leukokit ® . Hence, Leukokit ® has been used for WBC labelling also using other chelating agents for 99m Tc [19] or other isotopes such as 111 In [20,21], 18 F-FDG [22,23], and 64 CuCl [24]. us, the use of Leukokit ® plays a pivotal role for WBCs isolation and radiolabelling procedure in clinical practice. ...
The scintigraphy with radiolabelled autologous leukocytes (WBCs) is considered the gold-standard technique for imaging infections. Leukokit® is a commercially available, disposable, sterile kit for labelling WBCs ex vivo. In this kit, WBCs isolation from red blood cells (RBCs) was performed using poly(O-2-hydroxyethyl)starch (HES) as the RBCs sedimentation agent. Due to its poor availability, HES has been recently replaced by Gelofusine as the RBC sedimentation agent. The aim of this study was to compare the labelling efficiency and the diagnostic accuracy of WBCs labelled with Leukokit® with HES vs Leukokit® with Gelofusine. WBCs were isolated using HES or Gelofusine for 45 minutes and then purified from platelets (PLTs) and labelled with 1.1 ± 0.3 GBq of freshly prepared 99mTc-HMPAO. The following parameters were evaluated: the number and type of recovered WBCs, RBCs contamination, PLTs contamination, vitality of neutrophils, and chemotactic properties of neutrophils. Clinical comparison was performed between 80 patients (33 males; age 67.5 ± 14.2) injected with 99mTc-HMPAO-WBCs, using HES as the sedimentation agent, and 92 patients (38 males; age 68.2 ± 12.8) injected with 99mTc-HMPAO-WBCs using Gelofusine as the sedimentation agent. Patients were affected by prosthetic joint infections, peripheral bone osteomyelitis, or vascular graft infection. We compared radiolabelling efficiency (LE), final recovery yield (RY), and diagnostic outcome based on microbiology or 2-year follow-up. Results showed that HES provides the lowest RBCs and PLTs contamination, but Gelofusine provides the highest WBC recovery. Both agents did not influence the chemotactic properties of WBCs, and no differences were found in terms of LE and RY. Sensitivity, specificity, and accuracy were also not significantly different for WBCs labelled with both agents (diagnostic accuracy 90.9%, CI = 74.9-96.1 vs 98.3%, CI = 90.8-100, for HES and Gelofusine, respectively). In conclusion, Gelofusine can be considered a suitable alternative of HES for WBCs separation and labelling.
