Scientific Letter
Role of nuclear medicine in the differential diagnosis of bone infarction and osteomyelitis in drepanocytosis
Papel de la medicina nuclear en el diagnóstico diferencial entre infarto óseo y osteomielitis en el contexto de drepanocitosis
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En fase metabólica y en el estudio con coloides: hipercaptación focal en tuberosidad tibial izquierda, con captación fisiológica en el estudio con coloides. Hipercaptación difusa leve en los dos tercios proximales de la diáfisis tibial izquierda, hipocaptante en el estudio con coloides.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Cristina Sandoval-Moreno, Lourdes Castillejos-Rodríguez, M. Pilar García-Alonso, Bárbara Rubio-Gribble, Francisco Javier Penín-González" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Cristina" "apellidos" => "Sandoval-Moreno" ] 1 => array:2 [ "nombre" => "Lourdes" "apellidos" => "Castillejos-Rodríguez" ] 2 => array:2 [ "nombre" => "M. 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"en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific Letter</span>" "titulo" => "Role of nuclear medicine in the differential diagnosis of bone infarction and osteomyelitis in drepanocytosis" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "353" "paginaFinal" => "355" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Cristina Sandoval-Moreno, Lourdes Castillejos-Rodríguez, M. Pilar García-Alonso, Bárbara Rubio-Gribble, Francisco Javier Penín-González" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Cristina" "apellidos" => "Sandoval-Moreno" "email" => array:2 [ 0 => "cristycsm@gmail.com" 1 => "cristina.sandoval@salud.madrid.org" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Lourdes" "apellidos" => "Castillejos-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "M. Pilar" "apellidos" => "García-Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Bárbara" "apellidos" => "Rubio-Gribble" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Francisco Javier" "apellidos" => "Penín-González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Universitario de Getafe, Getafe, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel de la medicina nuclear en el diagnóstico diferencial entre infarto óseo y osteomielitis en el contexto de drepanocitosis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 2345 "Tamanyo" => 90480 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During the blood pool phase, the bone scan showed an increased diffusion of the radiotracer in the vascular-interstitial compartment in the left tibial tuberosity. In the metabolic phase and the colloid study: focal increased uptake in the left tibial tuberosity, with normal uptake in the colloid study. Slightly increased diffuse uptake in the two proximal thirds of the left tibial diaphysis, with decreased uptake in the colloid study.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sickle cell disease is an autosomal recessive disease in which red blood cells with abnormal haemoglobin S take on a sickle shape, causing obstruction of capillary blood blow and haemolysis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Vaso-occlusive crises with bone involvement (bone infarction) are the most common clinical manifestation, mainly in the humerus, tibia and femur.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Tissue devitalization after vaso-occlusive crises, the saturation of macrophages with products derived from chronic haemolysis and splenic dysfunction predispose to bone infection,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> and <span class="elsevierStyleItalic">Salmonella</span> is the most frequent causative agent.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinical manifestations are similar in both cases (tenderness, warmth, erythema and swelling)<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and the findings of conventional imaging techniques (radiography and ultrasonography) are frequently inconclusive. In the field of nuclear medicine, dual-tracer bone scintigraphy (with diphosphonate and colloid tracers) is available for the purpose of differential diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a boy aged 12 years with sickle cell disease that visited the emergency department with pain in the proximal region of the left tibia lasting 48<span class="elsevierStyleHsp" style=""></span>h in the absence of trauma. The patient initially improved with analgesic treatment (morphine hydrochloride) but worsened on the third day, with exacerbation of pain, local oedema and elevation of acute phase reactants and procalcitonin. The patient did not have leukocytosis or fever (although the absence of fever is infrequent, it has been described to reach proportions of up to 22% of cases in some series<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>).</p><p id="par0015" class="elsevierStylePara elsevierViewall">A radiograph and an ultrasound examination were ordered due to the need to make a differential diagnosis between bone infarction and osteomyelitis. Both showed nonspecific inflammatory soft tissue changes in the anterior region of the left tibia and neither allowed differentiation of the disease. Empirical intravenous antibiotherapy was initiated, and a bone scintigraphy was ordered.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient underwent a bone scintigraphy scan, with capture of static images in the blood pool phase (at 5<span class="elsevierStyleHsp" style=""></span>min) and the metabolic phase (2<span class="elsevierStyleHsp" style=""></span>h) following intravenous injection of 335<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">99m</span>Tc-HDP. The images revealed increased distribution in the vascular and interstitial compartment and increased osteogenic activity in the left tibial tuberosity, with very faint and diffuse tracer uptake in the two proximal thirds of the ipsilateral tibial diaphysis, and no other abnormalities in the rest of the examined structures. This scintigraphic pattern may appear in bone infarcts as well as osteomyelitis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A bone marrow scintigraphy was performed at 24<span class="elsevierStyleHsp" style=""></span>h to differentiate between the two diseases. Images were captured in a similar position 20<span class="elsevierStyleHsp" style=""></span>min after the intravenous injection of 201<span class="elsevierStyleHsp" style=""></span>MBq of <span class="elsevierStyleSup">99m</span>Tc-sulfur colloid. Imaging showed normal uptake in the tuberosity of the left tibia, with decreased uptake in the two proximal thirds of the ipsilateral tibial shaft (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The scintigraphic pattern was compatible with osteomyelitis in the tuberosity of the left tibia and with bone infarction in the two proximal thirds of the ipsilateral tibial diaphysis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Early in the course of disease, it is difficult to differentiate between osteomyelitis and bone infarction based on clinical or radiological features. Nevertheless, plain radiography is used as the initial imaging technique to rule out other diseases (tumours and fractures). The characteristic radiologic findings cannot be detected until at least 10 days have elapsed since the onset of symptoms.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">An ultrasound examination may be useful in sites that can be accessed with this technique, mainly for the detection of collections and abscesses in soft tissue.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Dual-tracer bone scintigraphy can differentiate between bone infarction and osteomyelitis. On scintigraphy, osteomyelitis presents with increased tracer uptake (there may be decreased uptake in the early stages). Increased uptake is also observed in cases of bone infarction during the revascularization phase, starting from the third day from onset (uptake may be normal or decreased before the third day).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is during the revascularization phase that bone marrow scintigraphy can differentiate between the two diseases, as bone infarction continues to exhibit decreased uptake, whereas osteomyelitis exhibits normal tracer uptake.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Bone marrow scanning targets the reticuloendothelial system of bone marrow, while bone scanning reflects the reparative osteoblastic response.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Bone scintigraphy is abnormal in both osteomyelitis and bone infarction, whereas bone marrow scintigraphy is normal in osteomyelitis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the context of sickle-cell disease, it is important to take into account the medical history, as previous bone infarctions may continue to exhibit decreased uptake<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and it is not possible to determine whether they are new or old lesions by means of scintigraphy, which requires consideration of current manifestations and the previous history in their assessment.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, currently available nuclear medicine techniques can be very useful, as dual-tracer bone scintigraphy makes possible the early differential diagnosis of bone infarction versus osteomyelitis through non-invasive means, which is important in children with sickle cell disease in who both diseases overlap.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sandoval-Moreno C, Castillejos-Rodríguez L, García-Alonso MP, Rubio-Gribble B, Penín-González FJ. Papel de la medicina nuclear en el diagnóstico diferencial entre infarto óseo y osteomielitis en el contexto de drepanocitosis. An Pediatr (Barc). 2017;87:353–355.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 2345 "Tamanyo" => 90480 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During the blood pool phase, the bone scan showed an increased diffusion of the radiotracer in the vascular-interstitial compartment in the left tibial tuberosity. In the metabolic phase and the colloid study: focal increased uptake in the left tibial tuberosity, with normal uptake in the colloid study. Slightly increased diffuse uptake in the two proximal thirds of the left tibial diaphysis, with decreased uptake in the colloid study.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "PMID: <span class="elsevierStyleInterRef" id="intr0010" href="pmid:21454142">21454142</span>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteomielitis y drepanocitosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.E. Pérez Gutiérrez" 1 => "N. Diez Monge" 2 => "D. Estripeaut" 3 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 10 | 21 |
| 2024 October | 90 | 32 | 122 |
| 2024 September | 87 | 35 | 122 |
| 2024 August | 118 | 57 | 175 |
| 2024 July | 104 | 32 | 136 |
| 2024 June | 112 | 25 | 137 |
| 2024 May | 76 | 49 | 125 |
| 2024 April | 76 | 33 | 109 |
| 2024 March | 67 | 41 | 108 |
| 2024 February | 71 | 27 | 98 |
| 2024 January | 94 | 24 | 118 |
| 2023 December | 81 | 19 | 100 |
| 2023 November | 87 | 28 | 115 |
| 2023 October | 65 | 25 | 90 |
| 2023 September | 49 | 24 | 73 |
| 2023 August | 84 | 18 | 102 |
| 2023 July | 88 | 26 | 114 |
| 2023 June | 101 | 28 | 129 |
| 2023 May | 116 | 21 | 137 |
| 2023 April | 70 | 19 | 89 |
| 2023 March | 107 | 27 | 134 |
| 2023 February | 83 | 22 | 105 |
| 2023 January | 75 | 10 | 85 |
| 2022 December | 88 | 47 | 135 |
| 2022 November | 103 | 39 | 142 |
| 2022 October | 94 | 44 | 138 |
| 2022 September | 73 | 28 | 101 |
| 2022 August | 95 | 49 | 144 |
| 2022 July | 69 | 43 | 112 |
| 2022 June | 69 | 29 | 98 |
| 2022 May | 76 | 44 | 120 |
| 2022 April | 85 | 35 | 120 |
| 2022 March | 103 | 52 | 155 |
| 2022 February | 140 | 34 | 174 |
| 2022 January | 134 | 36 | 170 |
| 2021 December | 114 | 37 | 151 |
| 2021 November | 91 | 39 | 130 |
| 2021 October | 151 | 77 | 228 |
| 2021 September | 101 | 46 | 147 |
| 2021 August | 83 | 32 | 115 |
| 2021 July | 57 | 27 | 84 |
| 2021 June | 127 | 52 | 179 |
| 2021 May | 147 | 52 | 199 |
| 2021 April | 226 | 267 | 493 |
| 2021 March | 161 | 30 | 191 |
| 2021 February | 98 | 17 | 115 |
| 2021 January | 103 | 32 | 135 |
| 2020 December | 88 | 28 | 116 |
| 2020 November | 85 | 22 | 107 |
| 2020 October | 153 | 31 | 184 |
| 2020 September | 171 | 23 | 194 |
| 2020 August | 129 | 17 | 146 |
| 2020 July | 107 | 21 | 128 |
| 2020 June | 93 | 12 | 105 |
| 2020 May | 48 | 22 | 70 |
| 2020 April | 45 | 20 | 65 |
| 2020 March | 41 | 12 | 53 |
| 2020 February | 55 | 26 | 81 |
| 2020 January | 59 | 19 | 78 |
| 2019 December | 54 | 14 | 68 |
| 2019 November | 34 | 7 | 41 |
| 2019 October | 40 | 14 | 54 |
| 2019 September | 40 | 10 | 50 |
| 2019 August | 51 | 22 | 73 |
| 2019 July | 41 | 14 | 55 |
| 2019 June | 52 | 12 | 64 |
| 2019 May | 51 | 20 | 71 |
| 2019 April | 78 | 25 | 103 |
| 2019 March | 41 | 23 | 64 |
| 2019 February | 45 | 28 | 73 |
| 2019 January | 28 | 35 | 63 |
| 2018 December | 44 | 26 | 70 |
| 2018 November | 62 | 28 | 90 |
| 2018 October | 78 | 23 | 101 |
| 2018 September | 36 | 10 | 46 |
| 2018 August | 3 | 0 | 3 |
| 2018 July | 3 | 0 | 3 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 5 | 0 | 5 |
| 2018 April | 18 | 0 | 18 |
| 2018 March | 38 | 0 | 38 |
| 2018 February | 13 | 0 | 13 |
| 2018 January | 19 | 0 | 19 |
| 2017 November | 0 | 14 | 14 |
| 2017 October | 0 | 10 | 10 |
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