Combined radionuclide phlebography and V/Q scan in the assessment of iliac vein thrombosis and pulmonary embolism - a case report establishing a cause and effect relationship

Deep vein thrombosis [DVT] is an important life threatening condition that is difficult to diagnose, particularly in the early stages. Looking for DVT in lower limb can be considered ancillary in suspected cases of pulmonary embolism [PE] indirectly highlighting a cause and effect relationship of a single disease [i.e cause being DVT and effect is the assault on the lung vasculature]. Prompt and early identification of one or both of these pathologies calls for urgent intervention in the form of instituting anticoagulation therapy. Synthetic Tc-99m labeled peptides like apcitide, a glycoprotein [GP IIb/IIIa] receptor antagonist is increasingly used as a specific tracer in the detection of acute DVT. But due to its non availability in certain countries, one needs to resort to indirect evidence in the form of Tc-99m MAA to help in the identification of DVT. Radionuclide phlebography [RPh] combined with lung perfusion scintigraphy [LP] is a one stop shop for the rapid and noninvasive diagnostic assessment of PE due to DVT. The aim of this case report is to highlight the underutilization of nuclear techniques in the evaluation of DVT in routine clinical practice. We report a case of a young Indian male who presented with sudden onset dyspnoea. On scintigraphic evaluation by a simultaneous RPh and LP, the cause and effect of DVT could be easily established

[99m]Tc-MDP abdominal scintigraphy in a paediatric case of GI protein loss - a viable and simple alternate to HSA imaging

A nine-month old male child presented with low-grade fever, loose stools and facial puffiness. Clinically patient was otherwise normal except for a firm liver on palpation. The laboratory tests revealed hypoproteinemia [both albumin and globulin] and iron deficiency anemia. Differential diagnosis considered were: 1. Nephrotic syndrome, 2. Cystic fibrosis [in view of recurrent diarrhea and respiratory complaints] 3. Chronic liver disease, in view of firm palpable liver 4. Lastly protein losing enteropathy [PLE]. As biochemically patient revealed no positive results, PLE was suspected. For confirmation 99mTc-Methylene diphosponate [MDP] scintigraphy was found to be useful in the setting of non availability of 99mTc-HSA. MDP scan revealed abnormal minimal extravasation of tracer from bowel loops in right lower abdominal quadrant suggesting a diagnosis of PLE. According to the American Gastroenterological Association [AGA] in patients with iron-deficiency anemia who do have GI symptoms, the prevalence of celiac disease is higher and ranges from 10% to 15% which may be a plausible explanation in our patient. The diagnosis of PLE is most commonly based on the determination of fecal alpha-1 antitrypsin clearance. However the localization of gastrointestinal protein [GI] protein loss is possible by scintgraphic techniques alone, as was done in our case using [99m]Tc-MDP instead of conventionally used [99m]Tc-HSA

Bochdalek hernia with intrathoracic kidney as one of its contents Incidentally identified by[99m] Tc-DTPA renogram

Congenital diaphragmatic hernia [CDH] is a rare anomaly with a reported incidence of 1 in 16,000 populations. It may be associated with herniation of stomach, intestinal loops, spleen, and kidney through a chest wall defect. We report a case of a 1 year old male child who presented with recurrent fever, occasional chills and rigor of 4 months duration. Left kidney was non visualised on ultrasound examination. Patient was referred for a [99m]Tc DTPA [Diethylenetriamine penta-acetic acid] renogram to look for the presence of an ectopic left kidney. An intrathoracic left kidney was identified that was normally functioning and PUJ [pelviureteric junction] non obstructed. A routine chest X-ray was performed to look for respiratory tract infection that showed bowel loops in left posterior thorax, raising a suspicion for CDH. The patient underwent thoracoscopic repair of CDH and the hernial contents were found to be left kidney, intestinal loops and spleen. Intrathoracic kidney is relatively rare and constitutes 5% of all ectopic kidneys and is invariably PUJ non obstructed