INTERESTING IMAGE
CT Opacity in the Lungs Was Preceded by Increased MDP Activity on Bone Scintigraphy Le Song, MD, Weifang Zhang, MD, and Yanyan Zhang, MD Abstract: Elevated 99mTc-methylene diphosphonate (MDP) uptake in the left lung was demonstrated in a 41-year-old man with chronic lymphocytic leukemia. Lung infection was considered because the patient also had fever and pancytopenia. However, the thoracic CT performed the next day did not reveal abnormality which could explain the cause of left lung MDP activity. The repeated thoracic CTs weeks later demonstrated multiple ground-glass opacity in the left lung. Key Words: bone scintigraphy, lung infection, CT (Clin Nucl Med 2014;39: 996Y999)
Received for publication March 3, 2014; and revision accepted April 2, 2014. From the Department of Nuclear Medicine, Peking University Third Hospital, Beijing, People’s Republic of China. Conflicts of interest and sources of funding: none declared. Reprints: Yanyan Zhang, MD, Department of Nuclear Medicine, Peking University Third Hospital, 49 North Huayuan Road, Haidian District, Beijing 100191, People’s Republic of China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3911Y0996
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REFERENCES 1. Liu B, Gwal K, Servaes S, et al. Acute lymphocytic leukemia presented as back pain and revealed by bone scintigraphy. Clin Nucl Med. 2013;38:649Y651. 2. Strain JP, Hill TC, Parker JA, et al. Diffuse, intense lung uptake on a bone scan: a case report. Clin Nucl Med. 2000;25:608Y610. 3. Kwak HS, Sohn MH, Lim ST, et al. Technetium-99m MDP bone scintigraphic findings of hypercalcemia in accelerated phase of chronic myelogenous leukemia. J Korean Med Sci. 2000;15:598Y600. 4. Othman S, El-Desouki M. Bone scan appearance in aggressive osteogenic sarcoma with pleural, lung, bone, and soft-tissue metastases. Clin Nucl Med. 2003;28:926. 5. Horvatic Herceg G, Bracic I, Korsic M, et al. ‘‘Sandstorm’’ image: bone scintigraphy in pulmonary alveolar microlithiasis. Eur J Nucl Med Mol Imaging. 2009;36:1353. 6. Mogharrabi M, Javadi H, Assadi M. Bilateral lung 99mTc-MDP uptake on the bone scintigraphy in the myelodysplastic syndromes (MDS). Clin Nucl Med. 2013;38:372Y374. 7. Kuyvenhoven JD, Ommeslag DJ, Ackerman CM, et al. Lung uptake on technetium-99m-MDP bone scan in Wegener’s vasculitis. J Nucl Med. 1996;37:857Y858. 8. Gezici A, van Duijnhoven EM, Bakker SJ, et al. Lung and gastric uptake in bone scintigraphy of sarcoidosis. J Nucl Med. 1996;37:1530Y1532. 9. Matsuo T, Tsukamoto Y, Tamura M, et al. Acute respiratory failure due to ‘‘pulmonary calciphylaxis’’ in a maintenance haemodialysis patient. Nephron. 2001;87:75Y79. 10. Vaquer RA, Dunn EK, Bhat S, et al. Reversible pulmonary uptake and hypertrophic pulmonary osteoarthropathic distribution of technetium-99m methylene diphosphonate in a case of Pneumocystis carinii pneumonia. J Nucl Med. 1989;30:1563Y1567. 11. Gholamrezanezhad A, Moinian D, Mirpour S, et al. Unilateral pulmonary metastases from Ewing’s sarcoma shown in a technetium-99m-methylenediphosphonate bone scan. Hell J Nucl Med. 2006;9:181Y183. 12. Ono K, Ochiai R, Yoshida T, et al. Comparison of diffusion-weighted MRI and 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) for detecting primary colorectal cancer and regional lymph node metastases. J Magn Reson Imaging. 2009;29:336Y340. 13. Dadparvar S, Anderson GS, Bhargava P, et al. Paraneoplastic encephalitis associated with cystic teratoma is detected by fluorodeoxyglucose positron emission tomography with negative magnetic resonance image findings. Clin Nucl Med. 2003;28:893Y896. 14. Chamroonrat W, Cheng G, Servaes S, et al. Cytomegalovirus pneumonitis detected by gallium-67 scintigraphy with a negative diagnostic chest computed tomography. Clin Nucl Med. 2010;35:542Y544. 15. Chamroonrat W, Zhuang H. Early acute hematogenous osteomyelitis detected by bone scintigraphy but not MRI. Clin Nucl Med. 2013;38:285Y288. 16. Makis W, Abikhzer G, Stern J. Incidental early stage endometrial adenocarcinoma diagnosed by F-18 FDG PET-CT, which was negative on ultrasound and nonspecific on MRI. Clin Nucl Med. 2010;35:265Y266. 17. Codreanu I, Zhuang H. Isolated cholangiolitis revealed by 18F-FDG-PET/CT in a patient with fever of unknown origin. Hell J Nucl Med. 2011;14:60Y61.
Clinical Nuclear Medicine
& Volume 39, Number 11, November 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 11, November 2014
CT Opacity in the Lungs
FIGURE 1. A 41-year-old immunosuppressive man presented with persistent fever and new onset of the left shoulder pain. His clinical history was significant with chronic lymphocytic leukemia for which he just finished sixth circle of chemotherapy (cyclophosphamide and vincristine). Laboratory examination revealed severe pancytopenia, which was related to leukemia and associated chemotherapy. An x-ray was performed, which demonstrated discontinuation in the left clavicle (arrow). A pathological fracture was considered and bone scintigraphy was performed to assess potential other sites of osseous involvement.1
* 2014 Lippincott Williams & Wilkins
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
997
Clinical Nuclear Medicine
Song et al
& Volume 39, Number 11, November 2014
FIGURE 2. The whole-body bone scintigraphy (A) did not reveal any osseous lesion. However, there was diffuse, intense MDP in the left thorax. In addition, there was mildly increased activity in both kidneys, which was expected after chemotherapy. To determine the exact location of the abnormal activity (pleura vs. the lungs), SPECT images of the chest were acquired. Image (B) showed clearly that the activity was in the left lung. Although the patient did not have prominent respiratory symptoms at the presentation, considering the patient’s fever, pancytopenia, and bone scan finding, a left lung infection was considered.
998
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* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 11, November 2014
CT Opacity in the Lungs
FIGURE 3. A thoracic CT (A) was performed 1 day after the bone scan for further evaluation of the unexplained bone tracer activity in the left lung. Surprisingly, except for mild bilateral pleural effusion, no abnormality in the lung parenchyma was identified. Despite of the CT findings, intensive antibiotic therapy was administrated empirically. However, the patient’s fever and general condition was not improved. Repeat thoracic CT at 2 (B) and 3 (C) weeks demonstrated resolution of pleural effusion. However, the images showed ground-glass opacity in the left lung, which largely matched the region of the bone SPECT findings (comparing to Fig. 2). Forty-six days after the bone scintigraphy, the patient succumbed to sepsis. Many different etiologies,2Y10 including hypercalcemia, hyperparathyroidism, metastatic calcification, vasculitis, amyloidosis, sarcoidosis, pulmonary alveolar microlithiasis, and drug-induced vitamin D intoxication, can lead to diffuse increased bone tracer activity in the lungs. However, such diffuse lung activity is more likely involving both lungs. The mechanism of increased MDP activity in the left lung in our case is unclear and is probably related to increased regional vascularity and permeability caused by infection. Our case is unique in 2 aspects. First, the abnormal MDP activity was shown only in hemithorax, which is more often caused by malignant disease.11 Secondly, the CT abnormality in the left lung was preceded by bone scan findings, which is not common. It was reported previously that abnormal radioactive tracers could be visualized without observable anatomical changes.12Y17 However, it is not well known that elevated MDP activity in the lung might occur before observable abnormality on CT scan.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
999
CT Opacity in the Lungs Was Preceded by Increased MDP Activity on Bone Scintigraphy Le Song, MD, Weifang Zhang, MD, and Yanyan Zhang, MD Abstract: Elevated 99mTc-methylene diphosphonate (MDP) uptake in the left lung was demonstrated in a 41-year-old man with chronic lymphocytic leukemia. Lung infection was considered because the patient also had fever and pancytopenia. However, the thoracic CT performed the next day did not reveal abnormality which could explain the cause of left lung MDP activity. The repeated thoracic CTs weeks later demonstrated multiple ground-glass opacity in the left lung. Key Words: bone scintigraphy, lung infection, CT (Clin Nucl Med 2014;39: 996Y999)
Received for publication March 3, 2014; and revision accepted April 2, 2014. From the Department of Nuclear Medicine, Peking University Third Hospital, Beijing, People’s Republic of China. Conflicts of interest and sources of funding: none declared. Reprints: Yanyan Zhang, MD, Department of Nuclear Medicine, Peking University Third Hospital, 49 North Huayuan Road, Haidian District, Beijing 100191, People’s Republic of China. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0363-9762/14/3911Y0996
996
www.nuclearmed.com
REFERENCES 1. Liu B, Gwal K, Servaes S, et al. Acute lymphocytic leukemia presented as back pain and revealed by bone scintigraphy. Clin Nucl Med. 2013;38:649Y651. 2. Strain JP, Hill TC, Parker JA, et al. Diffuse, intense lung uptake on a bone scan: a case report. Clin Nucl Med. 2000;25:608Y610. 3. Kwak HS, Sohn MH, Lim ST, et al. Technetium-99m MDP bone scintigraphic findings of hypercalcemia in accelerated phase of chronic myelogenous leukemia. J Korean Med Sci. 2000;15:598Y600. 4. Othman S, El-Desouki M. Bone scan appearance in aggressive osteogenic sarcoma with pleural, lung, bone, and soft-tissue metastases. Clin Nucl Med. 2003;28:926. 5. Horvatic Herceg G, Bracic I, Korsic M, et al. ‘‘Sandstorm’’ image: bone scintigraphy in pulmonary alveolar microlithiasis. Eur J Nucl Med Mol Imaging. 2009;36:1353. 6. Mogharrabi M, Javadi H, Assadi M. Bilateral lung 99mTc-MDP uptake on the bone scintigraphy in the myelodysplastic syndromes (MDS). Clin Nucl Med. 2013;38:372Y374. 7. Kuyvenhoven JD, Ommeslag DJ, Ackerman CM, et al. Lung uptake on technetium-99m-MDP bone scan in Wegener’s vasculitis. J Nucl Med. 1996;37:857Y858. 8. Gezici A, van Duijnhoven EM, Bakker SJ, et al. Lung and gastric uptake in bone scintigraphy of sarcoidosis. J Nucl Med. 1996;37:1530Y1532. 9. Matsuo T, Tsukamoto Y, Tamura M, et al. Acute respiratory failure due to ‘‘pulmonary calciphylaxis’’ in a maintenance haemodialysis patient. Nephron. 2001;87:75Y79. 10. Vaquer RA, Dunn EK, Bhat S, et al. Reversible pulmonary uptake and hypertrophic pulmonary osteoarthropathic distribution of technetium-99m methylene diphosphonate in a case of Pneumocystis carinii pneumonia. J Nucl Med. 1989;30:1563Y1567. 11. Gholamrezanezhad A, Moinian D, Mirpour S, et al. Unilateral pulmonary metastases from Ewing’s sarcoma shown in a technetium-99m-methylenediphosphonate bone scan. Hell J Nucl Med. 2006;9:181Y183. 12. Ono K, Ochiai R, Yoshida T, et al. Comparison of diffusion-weighted MRI and 2-[fluorine-18]-fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) for detecting primary colorectal cancer and regional lymph node metastases. J Magn Reson Imaging. 2009;29:336Y340. 13. Dadparvar S, Anderson GS, Bhargava P, et al. Paraneoplastic encephalitis associated with cystic teratoma is detected by fluorodeoxyglucose positron emission tomography with negative magnetic resonance image findings. Clin Nucl Med. 2003;28:893Y896. 14. Chamroonrat W, Cheng G, Servaes S, et al. Cytomegalovirus pneumonitis detected by gallium-67 scintigraphy with a negative diagnostic chest computed tomography. Clin Nucl Med. 2010;35:542Y544. 15. Chamroonrat W, Zhuang H. Early acute hematogenous osteomyelitis detected by bone scintigraphy but not MRI. Clin Nucl Med. 2013;38:285Y288. 16. Makis W, Abikhzer G, Stern J. Incidental early stage endometrial adenocarcinoma diagnosed by F-18 FDG PET-CT, which was negative on ultrasound and nonspecific on MRI. Clin Nucl Med. 2010;35:265Y266. 17. Codreanu I, Zhuang H. Isolated cholangiolitis revealed by 18F-FDG-PET/CT in a patient with fever of unknown origin. Hell J Nucl Med. 2011;14:60Y61.
Clinical Nuclear Medicine
& Volume 39, Number 11, November 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 11, November 2014
CT Opacity in the Lungs
FIGURE 1. A 41-year-old immunosuppressive man presented with persistent fever and new onset of the left shoulder pain. His clinical history was significant with chronic lymphocytic leukemia for which he just finished sixth circle of chemotherapy (cyclophosphamide and vincristine). Laboratory examination revealed severe pancytopenia, which was related to leukemia and associated chemotherapy. An x-ray was performed, which demonstrated discontinuation in the left clavicle (arrow). A pathological fracture was considered and bone scintigraphy was performed to assess potential other sites of osseous involvement.1
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
997
Clinical Nuclear Medicine
Song et al
& Volume 39, Number 11, November 2014
FIGURE 2. The whole-body bone scintigraphy (A) did not reveal any osseous lesion. However, there was diffuse, intense MDP in the left thorax. In addition, there was mildly increased activity in both kidneys, which was expected after chemotherapy. To determine the exact location of the abnormal activity (pleura vs. the lungs), SPECT images of the chest were acquired. Image (B) showed clearly that the activity was in the left lung. Although the patient did not have prominent respiratory symptoms at the presentation, considering the patient’s fever, pancytopenia, and bone scan finding, a left lung infection was considered.
998
www.nuclearmed.com
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Nuclear Medicine
& Volume 39, Number 11, November 2014
CT Opacity in the Lungs
FIGURE 3. A thoracic CT (A) was performed 1 day after the bone scan for further evaluation of the unexplained bone tracer activity in the left lung. Surprisingly, except for mild bilateral pleural effusion, no abnormality in the lung parenchyma was identified. Despite of the CT findings, intensive antibiotic therapy was administrated empirically. However, the patient’s fever and general condition was not improved. Repeat thoracic CT at 2 (B) and 3 (C) weeks demonstrated resolution of pleural effusion. However, the images showed ground-glass opacity in the left lung, which largely matched the region of the bone SPECT findings (comparing to Fig. 2). Forty-six days after the bone scintigraphy, the patient succumbed to sepsis. Many different etiologies,2Y10 including hypercalcemia, hyperparathyroidism, metastatic calcification, vasculitis, amyloidosis, sarcoidosis, pulmonary alveolar microlithiasis, and drug-induced vitamin D intoxication, can lead to diffuse increased bone tracer activity in the lungs. However, such diffuse lung activity is more likely involving both lungs. The mechanism of increased MDP activity in the left lung in our case is unclear and is probably related to increased regional vascularity and permeability caused by infection. Our case is unique in 2 aspects. First, the abnormal MDP activity was shown only in hemithorax, which is more often caused by malignant disease.11 Secondly, the CT abnormality in the left lung was preceded by bone scan findings, which is not common. It was reported previously that abnormal radioactive tracers could be visualized without observable anatomical changes.12Y17 However, it is not well known that elevated MDP activity in the lung might occur before observable abnormality on CT scan.
* 2014 Lippincott Williams & Wilkins
www.nuclearmed.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
999
