The 99mTc-DMSA renal scan and 99mTc-DTPA diuretic renogram in children and adolescents with incidental diagnosis of horseshoe kidney.

A prospective study was conducted to determine the possibility of obstructive hydronephrosis in horseshoe kidney found incidentally in school children and adolescents by using a radionuclide diuretic renogram. In a 2-year period, 22 school children and adolescents with horseshoe kidney were found in a mass renal sonography survey. They each underwent a 99mTc dimercaptosuccinic acid renal cortical scan to confirm the horseshoe kidney. Each diuretic renogram was performed with the patient in the supine position to rule out obstructive hydronephrosis. The patients were advised to empty their bladders before the intravenous injection of furosemide (1 mg x kg(-1)). The half-time for the clearance of radioactivity from the renal pelvis were calculated. Of the 22 patients, asymmetrical renal cortical function between the two kidneys was found in 14 (63.6%). Eleven kidneys (11/44, 25%) showed stasis of radioactive urine in the renal pelvic region prior to injection of furosemide. There was no incidence of bilateral hydronephrosis in these 22 patients. Only one kidney (1/44, 2.3%) showed obstructive hydronephrosis and five showed clearance of radioactive urine stasis from the renal pelvis immediately after standing up for voiding. There is a low percentage of obstructive hydronephrosis in these cases of horseshoe kidney found incidentally in children and adolescents. A follow-up cohort study on these patients would be valuable for monitoring the development of complications.

Investigation of pulmonary epithelial permeability in patients after hyperbaric oxygen therapy by 99mTc diethylenetriaminepentaacetic acid aerosol inhalation lung scintigraphy.

The aim of this study was to evaluate the possibility of pulmonary epithelial permeability damage in patients after hyperbaric oxygen therapy (HBOT) by 99mTc diethylenetriaminepentaacetic acid (99mTc-DTPA) aerosol inhalation lung scintigraphy. Twenty-five controls and 21 patients with normal chest X-rays and no cigarette smoking for at least 1 year were recruited for the study. 99mTc-DTPA aerosol inhalation lung scans were performed after 20 HBOT sessions in 21 patients with refractory osteomyelitis or diabetic foot. The HBOT with 100% oxygen at 2.5 atm absolute for 100 min was performed five times a week. Clearance rates (%/min) of 99mTc-DTPA aerosol in each lung field were calculated from the dynamic images for 30 min. Clearance rates of 99mTc-DTPA aerosol were compared between patients and controls by the unpaired t test. Thirteen patients who had 99mTc-DTPA aerosol lung scans before and after HBOT therapy studies were tested for statistical significance by using the paired t test. There was no statistically significant difference (P>0.05, unpaired t test) between patients and controls in every lung field. For the 13 patients who had 99mTc-DTPA aerosol studies both before and after 20 HBOT sessions, the results also showed no statistically significant difference (P>0.05, paired t test). It is concluded that there was no demonstrable pulmonary epithelial permeability change under current clinical HBOT protocol.

The effects of exercise training on walking function and perception of health status in elderly patients with peripheral arterial occlusive disease.

OBJECTIVE: To determine the effects of 12-week exercise programme on ambulatory function, free-living daily physical activity and health-related quality of life in disabled older patients with intermittent claudication. DESIGN: Prospective, randomized controlled trial. SETTING: University Medical Center and Veterans Affairs Medical Center, Taipei, Taiwan. SUBJECTS: Thirty-two of 64 patients with Fontaine stage II peripheral arterial occlusive disease (PAOD) were randomized to exercise training and 32 to usual care control. Five patients from the exercise group and six patients from the control group dropped out, leaving 27 and 26 patients, respectively, completing the study in each group. INTERVENTIONS: Twelve weeks of treadmill exercise training. MAIN OUTCOME MEASURES: Treadmill walking time to onset of claudication pain and to maximal claudication pain, 6-min walk distance, self-reported ambulatory ability and perceived health-related quality of life (QOL). RESULTS: Compliance of exercise programme was 83% of the possible sessions. Exercise training increased treadmill walking time to onset of claudication pain by 88% (P < 0.001), time to maximal pain by 70% (P < 0.001), and 6-min walk distance by 21% (P < 0.001). SUBJECTS: Perception of health-related QOL improved from 12% to 178% in the exercise group. These improvements were significantly better than the changes in the control group (P < 0.05). CONCLUSIONS: Significant improvements in claudication following 12-week exercise training in elderly PAOD patients were observed. Increase in treadmill walking time to maximal claudication pain in these patients translated into the improvement of perceived physical health, which enabled the patients to become more functionally independent.

Breast uptake of iodine-131 mimicking lung metastases in a thyroid cancer patient with a pituitary tumour.

We report a case of a 44-year-old female thyroid cancer patient with a pituitary tumour. 131I whole body scanning showed a change of chest uptake from a unilateral crescent uptake to a bilateral full breast uptake pattern. Hyperprolactinaemia and a pituitary tumour were diagnosed as a result of observing the 131I breast uptake.

Prolonged interference of patent blue on pulse oximetry readings.

BACKGROUND: We evaluated the effect of intra-arterial injection of Patent Blue (PB) on pulse oximetry. METHODS: Ten consecutive female patients who underwent intra-arterial insertion of catheter for chemotherapy were enrolled in this study. All patients received general anesthesia and ECG, pulse oximetry, and direct arterial blood pressure were monitored throughout the perioperative period. Baseline arterial blood saturation (SpO2), haemoglobin concentration (Hgb), estimated arterial saturation (SaO2), arterial oxygen partial pressure (PaO2) were obtained through arterial blood gas analysis, and true arterial saturation (ScoO2) through CO-Oximetry analysis. The subsequent values obtained at various points of time following the intra-arterial administration of PB were compared with the baseline data. RESULTS: The SpO2 readings taken after intra-arterial injection of PB were significantly lower than the baseline reading. The extent of the reduction of SpO2 readings two hours after the administration of PB was relevant to the total accumulative dosage of PB (rs = -0.846, P < 0.05). However, the reduction of SpO2 bore no significant relation with Hgb concentration or with the ratio of PB dosage to Hgb concentration. CONCLUSIONS: Intra-arterial administration of PB interferes with pulse oximetry readings and the effect lasts for a variable duration. The extent of desaturation may be related to the total accumulative dosage of intra-arterial PB injected.

99mTc-sulphur-colloid and heat-denatured 99mTc-labelled red cell scans demonstrating a giant intrapelvic spleen in a girl after splenectomy.

A 17 x 12 x 5-cm giant intrapelvic mass in a 14-year-old girl is reported. This mass developed 6 years after a splenectomy for splenic torsion. The heat-denatured 99mTc-labelled red cell scan and 99mTc-sulphur-colloid scan confirmed the specific red cell sequestration function and reticuloendothelial activity in the giant intrapelvic spleen. The size and development of the giant intrapelvic spleen are unusual. The usefulness of functional images to diagnosis the nature of the intrapelvic mass is well demonstrated.

The optimal imaging time for [99Tcm]TRODAT-1/SPET in normal subjects and patients with Parkinson's disease.

Imaging of dopamine transporters (DATs) in the brain using [99Tcm]TRODAT-1 showed excellent pharmacokinetics for estimation of transporter concentrations. It has been reported that there may be differences in the binding kinetics of DAT radiotracers to DATs between normal subjects and patients with Parkinson's disease (PD). The aim of this study was to determine an optimal time point for (99Tcm]TRODAT-1 brain single photon emission tomography (SPET) acquisition that provides stable target to non-target ratios reflecting the DAT concentration in the brain. Serial [99Tcm]TRODAT-1 brain SPET images 2, 3 and 4 h after intravenous injection of [99Tcm]TRODAT-1 (925 MBq) were performed in five healthy subjects and nine PD patients. Regions of interests were drawn, and caudate/occipital (C/O) and putamen/occipital (P/O) specific to non-specific [99Tcm]TRODAT-1 binding ratios were calculated. The C/O and P/O ratios in healthy subjects showed consistent increases with time, but in PD patients, the C/O and P/O ratios of [99Tcm]TRODAT-1 reached a stable level at 3 h post-injection. There was a statistically significant difference (P < 0.001) between PD and normal subjects at 4 h post-injection for both the C/O and the P/O ratios. In conclusion, we recommend the acquisition of [99Tcm]TRODAT-1 SPET images at 4 h post-injection, as at this time point the C/O and P/O ratios can be used to discriminate between PD patients and healthy subjects.

Diagnosis and treatment of pyogenic psoas abscess in diabetic patients: usefulness of computed tomography and gallium-67 scanning.

OBJECTIVES: To examine retrospectively the clinical presentations, microbiologic characteristics, and treatment outcomes of psoas abscess in patients with diabetes mellitus (DM) and to assess the usefulness of computed tomography and gallium-67 scanning in its early diagnosis. METHODS: During a 9-year period, psoas abscesses in patients with DM were collected at a medical center. The clinical history and associated etiologic factors, microbiologic results, clinical outcomes, and hospitalization days were recorded. The use of imaging in the diagnosis of psoas abscess and other concomitant infectious lesions was also studied. RESULTS: Fifteen patients with DM and psoas abscess (13 women and 2 men; mean age 58.7 +/- 9.0 years) were found. The most frequent symptom was fever (12 of 15). Of the six different microorganisms that grew in the blood and/or abscess cultures, Staphylococcus aureus was the most frequent (7 of 15). The most commonly associated pathologic finding was vertebral osteomyelitis (5 of 15). Computed tomography and/or magnetic resonance imaging confirmed the diagnosis of psoas abscesses in all 15 patients. The gallium-67 scan especially aided in the diagnosis of the patients who had initially been diagnosed as having fever of unknown origin (4 of 5) and in the diagnosis of concomitant lesions (9 of 12). Debridement or surgical drainage of the abscess was done in 12 patients. All the patients received adequate antibiotic treatment. However, the mortality rate was 20%. The average hospitalization stay was 42.7 +/- 20.7 days. CONCLUSIONS: Psoas abscess in patients with DM is a disease with both diagnostic and therapeutic challenges. We found the infecting microorganisms to be variable and the mortality rate high.

Recurrence of pneumococcal meningitis due to primary spontaneous cerebrospinal fluid fistulas.

The authors report a case of pneumococcal meningitis which recurred 3 times in a Taiwanese boy due to spontaneous cerebrospinal fluid (CSF) fistulas. The first time occurred at the age of 2 years, and the second episode presented as meningoencephalomyelitis at the age of 6 years 10 months. Studies including serum levels of immunoglobulin and complements, brain magnetic resonance imaging, and coronal cranial computed tomography (CT) were negative for a specific etiology. The third episode of meningitis developed 2 months after the second episode. Repeated immunological studies and high-resolution CT of paranasal sinuses and temporal bones were negative. Technetium-99m diethylenetriamine pentaacetic acid (Tc-99m-DTPA) radionuclide cisternography revealed abnormal retention of radioactivity over the right mastoid area. Neurosurgery was undertaken to seal the dural tear and pack the petrosal fissure. Two years after surgery, he has had no further CSF leak age or meningitis. Tracing back the history, there was no head injury, cranial surgery, brain tumor, or hydrocephalus, which might have created CSF fistulas. Primary spontaneous CSF fistulas constitute the most reasonable diagnosis. In cases of recurrent bacterial meningitis, underlying anatomic defects should be carefully evaluated if there is no immune defect.

Dopamine deficiency in rubral tremor caused by midbrain hemangioma: case report.

To elucidate the nigrostriatal involvement in rubral tremor, we studied single photon emission computed tomography (SPECT) imaging with [2-[[2-[[[3-(4-chlorophenyl)-8-methyl-8-azabicyclo[3.2.1]oct-2- yl]methyl](2-mercaptoethyl)amino]ethyl]amino]ethanethiolato(3-)- N2,N2',S2,S2']oxo-[1R-(exo-exo)]-[99mTc]technetium ([99mTc]TRODAT-1) in a 70-year-old woman with a midbrain hemangioma. She had developed a slow tremor in her right arm and leg after an episode of hemorrhage at the age of 28. The tremor was 3 to 5 Hz in frequency at rest, which was enhanced by outstretching the limb and action. There was no rigidity or bradykinesia. Neurological examination also revealed mild palsy of the left oculomotor nerve. The magnetic resonance imaging (MRI) of the brain showed a small hemangioma in the left midbrain localized mainly in the substantia nigra. The [99mTc]TRODAT-1 SPECT imaging revealed significantly reduced [99mTc]TRODAT-1 uptake in the left caudate and putamen, but it was only mildly reduced in the right striatum. This reduction in uptake was even more severe than that of patients with Parkinson's disease, and indicated that the dopamine function was markedly impaired in the left nigrostriatal system. The tremor had not progressed over the years, and she responded moderately to treatment with levodopa. We concluded that the rubral tremor in the right extremities was probably caused by a dopamine deficiency in the left nigrostriatal system. This suggests that a dopamine deficiency secondary to the midbrain hemangioma might have contributed to the development of the rubral tremor in this patient.

Spinal anesthesia in MELAS syndrome: a case with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes.

MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes) is one of the classic mitochondrial encephalomyopathies with variable clinical presentation and multisystem involvement. Enhanced sensitivity to neuromuscular blockade or anesthetic agents and susceptibility to malignant hyperthermia in these patients have ever been reported, all of which complicate the management of general anesthesia. To avoid these appalling troubles in general anesthesia, we chose spinal anesthesia for a patient with MELAS syndrome receiving appendectomy. The patient obtained adequate anesthesia and good recovery without neurologic sequelae. Although there is little information about the application of regional anesthesia in MELAS patients, we demonstrate that it may be a satisfactory choice. However, it is suggested that regional anesthesia is performed only when neurological abnormalities of spinal cord or peripheral nerves are definitely ruled out.

Gallium-67 scanning in endogenous Klebsiella endophthalmitis with unknown primary focus.

A whole-body gallium-67 (Ga-67) scan of a 61-y-old male with diabetes mellitus who suffered from endogenous Klebsiella endophthalmitis is reported. The scan revealed right orbital and lower abdominal lesions. Urinary analysis revealed pyuria. The causes of endogenous Klebsiella endophthalmitis and the usefulness of Ga-67 are discussed.

Pyometra as a lower abdominal doughnut sign on a Ga-67 scan.

A 77-year-old woman was referred for Ga-67 scan to evaluate intermittent fever and chills that had lasted more than 20 days. The Ga-67 whole-body scan revealed a doughnut-shaped Ga-67 accumulation in the lower abdominal region. Combined Ga-67 and Tc-99m MDP bone scan confirmed that this activity was in the uterus, because the shape of the urinary bladder on bone scan was different from that of the Ga-67-avid lesion. Pyometra was proved during operation, and pus culture was performed.

Decreased dopamine transporter binding in Machado-Joseph disease.

UNLABELLED: The aim of this study was to use 99mTc-TRODAT-1 brain SPECT for investigation of the binding of dopamine transporter (DAT) in the nigrostriatal dopaminergic pathway of symptomatic Machado-Joseph disease (MJD) and to compare the results with the abnormal cytidylate, adenylate, and guanylate (CAG) expansion in the MJD1 gene and other clinical factors. METHODS: Ten symptomatic MJD patients (8 women, 2 men; age range, 20-71 y; mean age +/- SD, 36.4 +/- 10.6 y; mean duration of illness, 9.8 +/- 5.4 y) and 21 healthy volunteers (age range, 24-71 y; mean age, 47.6 +/- 20.1 y) were examined. Brain SPECT images were acquired 4 h after injection. The ratio of specific to nonspecific nigrostriatal 99mTc-TRODAT-1 binding was measured and compared with the clinical symptoms, duration of illness, and size of abnormal expanded CAG repeats. RESULTS: All nigrostriatal 99mTc-TRODAT-1 ratios were significantly lower in MJD patients than in healthy volunteers (P < 0.05). Discriminant function analysis of all MJD patients showed that the decreased binding of 99mTc-TRODAT-1 in the putamen was not significantly different from that in the caudate nucleus. Eight of 10 MJD patients had significantly decreased 99mTc-TRODAT-1 uptake. Of these 8, 2 had extrapyramidal signs and 6 had no obvious extrapyramidal signs. The other 2 patients, who had normal 99mTc-TRODAT-1 uptake, had no obvious extrapyramidal signs. CONCLUSION: Our findings indicate that 99mTc-TRODAT-1 brain SPECT is an appropriate method for evaluating damage to the nigrostriatal DAT in symptomatic MJD patients with and without extrapyramidal signs. The decreased binding of 99mTc-TRODAT-1 in the nigrostriatal dopaminergic pathway in symptomatic MJD patients correlates with the phenotype of extrapyramidal signs but not with the abnormal CAG repeat length, age at disease onset, or disease duration.

Cerebral perfusion SPECT in transient ischemic attack.

PURPOSE: The purpose of our study is to evaluate the efficacy of cerebral perfusion single photon emission computerized tomography (SPECT) in patients with transient ischemic attack (TIA). METHODS: Thirty-seven patients with TIA were collected for study. All patients had transient focal neurological symptoms or signs with complete recovery within 24 h after onset. The patients underwent cerebral perfusion SPECT between 6 h and 11 days after onset, with 10 cases performed within 24 h (group A), nine cases performed between 1 and 3 days (group B), 11 cases performed between 3 and 5 days (group C), and seven cases performed after more than 5 days (group D). A semi-quantitative method was used for analyzing the SPECT data, and the difference ratios between lesion side and contralateral normal side were calculated on each pair of regions of interest. RESULTS: In total, 78.4% (29/37) of patients had reduced perfusion in the cerebral cortical regions or deep nuclei, and the regions with reduced perfusion corresponded with clinical presentations of the patients. The abnormal rate with reduced perfusion was 90.0% in group A, 77.8% in group B, 72.7% in group C and 71.4% in group D. Cross cerebellar diaschisis (CCD) was present in seven patients, and all of the primary cerebral perfusion defects of these patients were located at the territory of left or right middle cerebral artery. CONCLUSION: Cerebral perfusion SPECT is a potential tool to detect cerebral perfusion defects and CCD in patients with TIA. Although the perfusion defect may persist more than 5 days after onset, we suggest cerebral perfusion SPECT should be performed as soon as possible.

The role of 67Ga in the early detection of spinal epidural abscesses.

In this study, we evaluated the role of 67Ga whole-body and single photon emission tomographic (SPET) imaging in the early diagnosis and lesion localization of spinal epidural abscess before confirmation by gadolinium-enhanced magnetic resonance imaging (MRI). Six patients with fever of unknown origin had a 67Ga whole-body scan, four of whom also underwent SPET imaging. For further confirmation of a spinal epidural abscess, gadolinium-enhanced MRI was performed in all patients. All patients had increased 67Ga uptake in a spinal or paraspinal area on the whole-body scan. They were later confirmed to have a spinal epidural abscess after gadolinium-enhanced MRI. Of these six patients, five underwent surgical drainage plus parenterally administered antibiotics, and had complete or partial recovery. One died before operation due to sepsis. In conclusion, we suggest performing a 67Ga whole-body survey as early as possible in patients with fever of unknown origin, fever and back pain and/or the spinal syndrome, before MRI is performed. If a spinal epidural abscess is strongly suspected, SPET is needed for further confirmation of spinal versus non-spinal and contiguous versus non-contiguous lesion(s). If MRI is unavailable, then 67Ga scintigraphy is a satisfactory method for investigating spinal epidural abscesses.

Development of a device for immobilization of head and correlation of functional-anatomical brain images.

BACKGROUND: The excellent resolution of brain imaging modalities has important contributions in the diagnosis of brain diseases. However, involuntary movement by the patient may cause poor image quality. In this study, we developed a device to help keep a patient's head immobilized during brain image acquisition, for comparison between each follow-up study, and for functional-anatomical image correlation. METHODS: This device includes an acrylic material head supporter and a thermoplastic material facemask. The head supporter and the facemask can be firmly attached as a whole to support the head in a fixed position. Two capillary tubes filled with technetium-99m solution were placed perpendicularly on one side of the facemask as fiducial for imaging correlation between different studies. Ten patients, who each had two technetium-99m hexamethyl propyleneamine oxime (99mTc-HMPAO) brain single photon emission computer tomography (SPECT), were tested with this device for imaging. RESULTS: Three-dimensional cine motion and sectional imaging were displayed and confirmed head immobilization in all of these studies. In addition, the 99mTc fiducial were useful in the comparison of head positions among the different studies. In five subjects, the device also proved to be useful in functional-anatomical correlation among SPECT, magnetic resonance imaging (MRI), and computed tomography (CT) images. CONCLUSION: In conclusion, this device has been developed and found to be useful in (1) keeping patient's head immobilization, (2) keeping consistent head position for follow-up studies, and (3) SPECT, MRI and CT functional-anatomical imaging correlation.

Ectopic ACTH syndrome due to thymic carcinoid tumor in a girl.

An 8 year-old girl had a cushingoid appearance for six months. Hormone study showed extremely high serum levels of cortisol (> 60 micrograms/dl) and adrenocorticotropic hormone (930 pg/ml). Initial chest X-ray showed nothing unusual, but a technetium-99mm MIBI scan showed an accumulation lesion in the left upper chest cavity. Chest magnetic resonance imaging demonstrated that the mass was in the superior anterior mediastinum. She had complete removal of the tumor with partial thymectomy. The pathology revealed a thymic carcinoid tumor. Carcinoid tumors of the thymus are extremely rare in children and they usually present with Cushing's syndrome. To our knowledge, this is the youngest patient who has ever been reported with this disease.

Enhanced uptake of [11C]TPMP in canine brain tumor: a PET study.

UNLABELLED: In vitro studies have demonstrated the membrane potential-dependent enhanced uptake of phosphonium salts, including [3H]triphenylmethylphosphonium (TPMP), into mitochondria of carcinoma and glioma-derived tumor cells, suggesting the potential use of phosphonium salts as tracers for tumor imaging. This study characterizes the in vivo uptake of [11C]TPMP in canine brain glioma using PET. METHODS: Dynamic paired PET studies of [11C]TPMP followed by [68Ga]ethylenediaminetetraacetic acid (EDTA) were performed 4 d before and 9 d after tumor cell inoculation. Graphical analysis was used to evaluate [11C]TPMP retention in tumor tissue. Distribution of tracer uptake was compared with tumor histological sections. RESULTS: [11C]TPMP exhibited enhanced uptake and prolonged retention in tumor cells. Patlak plot was linear over the 20- to 95-min postinjection period (r = 0.97 +/- 0.1). [68Ga]EDTA exhibited a gradual washout from the tumor tissue. The tumor-to-normal brain uptake ratio at 55 to 95 min postinjection was 47.5 for [11C]TPMP and 8.1 for [68Ga]EDTA. Qualitative comparison with histological sections indicated that [11C]TPMP enhanced uptake was restricted to the tumor area. CONCLUSION: The enhanced uptake and prolonged retention in tumor suggest [11C]TPMP as a promising means for imaging of gliomas in dogs. The need for studies in humans is indicated.

Characterization of the calcaneal fat pad in diabetic and non-diabetic patients using magnetic resonance imaging.

It is well known that diabetic patients have a high incidence of foot ulceration. The purpose of this study was to determine whether magnetic resonance (MR) imaging can detect changes in the composition of the calcaneal fat pad in diabetic feet. MR data were collected in vitro from amputated specimens (eight from diabetic patients and eight from non-diabetic patients) as well as in vivo from age-matched diabetic and control subjects (four subjects each group.) Three types of images were acquired: spin lattice (T1), spin-spin (T2), and magnetization transfer (MT). The in vitro results showed statistically significant differences in the T1, T2, and MT parameters between the two disease groups. The same trends were shown in the study of live subjects but the differences were not statistically significant. The differences are believed to arise from changes in the composition of the tissues as a result of the progression of diabetes.