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Nuclear Medicine Imaging of Abdominal Infections and Inflammations

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Radionuclide Imaging of Infection and Inflammation

Abstract

Abdominal inflammations include retroperitoneal fibrosis and inflammatory bowel diseases (IBD). Infections can present as liver or spleen abscesses, bowel infections in IBD patients, appendicitis, psoas muscle abscesses or kidney infections. Although most of these conditions are commonly investigated by radiological or endoscopic techniques, the role of nuclear medicine modalities can be relevant for specific clinical issues. Scintigraphy with autologous radiolabelled leukocytes has a major role in case of suspected infection, but the use of [18F]-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG-PET/CT) is increasingly emerging, particularly for inflammatory diseases and in patients with fever of unknown origin and abdominal pain.

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Author information

Authors and Affiliations

  1. Department of Medical-Surgical Sciences and of Translational Medicine, Sapienza University of Rome, Rome, Italy

    Alberto Signore & Chiara Lauri

  2. Nuclear Medicine Unit, AOU Sant’Andrea, Rome, Italy

    Alberto Signore, Tiziana Lanzolla & Chiara Lauri

Authors
  1. Alberto Signore
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  2. Tiziana Lanzolla
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  3. Chiara Lauri
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Corresponding author

Correspondence to Alberto Signore .

Editor information

Editors and Affiliations

  1. Regional Center of Nuclear Medicine, University Hospital of Pisa, Pisa, Italy

    Elena Lazzeri

  2. Department of Medical-Surgical Sciences and of Translational Medicine, Sapienza University of Rome, Roma, Italy

    Alberto Signore

  3. Department of Translational Research and Advanced Technologies in Medicine and Surgery, Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy

    Paola Anna Erba

  4. Nuclear Medicine Department, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy

    Napoleone Prandini

  5. Nuclear Medicine, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy

    Annibale Versari

  6. Nuclear Medicine Department, Private Hospital “PIO XI”, Roma, Italy

    Giovanni D´Errico

  7. Department of Translational Research and Advanced Technologies in Medicine and Surgery, Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy

    Giuliano Mariani

Clinical Cases

Clinical Cases

11.1.1 Case 11.1

  • Paola A. Erba 

Female, age 45 years. 25 November 2010: Bilateral hysteroannessiectomy because of endometrial adenocarcinoma (G1, PT1a, Stage IA). 29 November 2011: Spleno-pancreatectomy, partial gastrectomy, partial hepatic resection: nonmucinous adenocarcinoma (G2 pT3pN1 (1/5)).

Since February 2012: Asthenia, anorexia, septic fever.

CT, 16 February 2012: Hypodense fluid-colliquative lesions in the liver with hyperdense peripheral ring.

PET, 21 February 2012: Focal hepatic lesions in segments VI and VIII with peripheral ring uptake associated with multiple lesions outside the liver.

Whole-body radiolabelled autologous WBC scintigraphy with SPECT/CT: Heterogeneous uptake in the liver due to the presence of cold areas (liver metastases); no uptake outside the liver.

11.1.1.1 Suspected Site of Infection

Differential diagnosis between liver metastases and liver abscesses.

11.1.1.2 Radiopharmaceutical Activity

111In-oxine WBC, injected activity 19 MBq.

11.1.1.3 Imaging

Static planar spot images (4 min/image; 128 × 128 matrix). SPECT/CT images of the abdomen: dual head SPECT, matrix size 64 × 64, 35 s/step, 360° rotation, 5 mm/slice, low-dose CT slice thickness: 5 mm (Fig. 11.14). Planar imaging acquisition after 6 h and after 24 h. SPECT/CT images of the abdomen after 24 h.

Fig. 11.14
figure 14figure 14

(a) 111In-oxine-WBC scintigraphy: planar imaging show normal biodistribution of the labelled WBCs in the thorax and abdomen (1 and 5 anterior chest, 2 and 6 posterior chest, 3 and 7 anterior abdomen, 4 and 8 posterior abdomen); the uptake in the liver is heterogeneous with areas of focal uptake, suspicious for infection, identified in VI and VIII segments. (b) SPECT/CT images (CT, upper; fused images, lower): cold areas in correspondence of the focal lesions with a peripheral ring of increased activity identified by PET/CT. (c) [18F]FDG PET/CT was performed 1 h after 402 MBq of [18F]FDG administration. Transaxial images (CT, upper; fused images, lower) showed focal lesions with peripheral ring uptake were observed in the liver (SVI and SVIII)

Full size image

11.1.1.4 Conclusion/Teaching Point

In the presence of suspected residual disease, on anatomic imaging or PET/CT and clinical signs of sepsis, relapse of disease should be considered after a negative labelled-WBC scan. Before starting chemotherapy, it is important to exclude septic focal lesions.

11.1.2 Case 11.2

  • Alberto Biggi✠ 

Male, age 64 years. 13 October 2011: Nephrectomized for clear cell renal carcinoma. Residual mild renal failure. During the follow-up, because of persistent abdominal pain and asthenia, an MRI (9 February 2012) was performed that showed a solid mass (4 × 4 cm) T1-hypo, T2-hyper in the surrenalic left area. For differential diagnosis between an abscess and a tumour relapse, an [18F]FDG PET/CT was also performed (16 February 2012) that showed a clear focal uptake in the solid mass, suggesting tumour metastases.

Nevertheless, the patient was hospitalized due to septic fever associated with abnormal laboratory findings and a radiolabelled WBC whole body scan was performed (29 February 2012) that showed no uptake in the mass, which confirmed its neoplastic nature.

11.1.2.1 Suspected Site of Infection

Surrenalic left area.

11.1.2.2 Radiopharmaceutical Activity

111In-oxine-WBC, injected activity 13 MBq, planar imaging acquisition after 6 h and after 24 h.

11.1.2.3 Imaging

Static planar spot images (4 min/image; 128 × 128 matrix). SPECT/CT images of the abdomen: dual head SPECT, matrix size 64 × 64, 35 s/step, 360° rotation, 5 mm/slice, low-dose CT slice thickness: 5 mm (Fig. 11.15).

Fig. 11.15
figure 15figure 15

(a, b) 111In-oxine-WBC planar imaging showing normal biodistribution of the labelled WBCs; 4 h: 1 anterior chest, 2 posterior chest, 3 anterior abdomen, 4 posterior abdomen, 5 anterior pelvis, 6 posterior pelvis; 24 h: 7 anterior chest, 8 posterior chest, 9 anterior abdomen, 10 posterior abdomen, 11 anterior pelvis, 12 posterior pelvis; no area of focal uptake suspected for infection was identified, in particular in the left kidney area. No significant WBC uptake in the suspected lesion identified by the MRI and PET/CT. (c) [18F]FDG PET/CT was performed 1 h after 402 MBq of [18F]FDG administration and shows a focal uptake in the suspected neoplastic lesion identified by MRI. The suspected lesion identified by MRI in the left kidney area is characterized by absence of uptake of WBC and by focal [18F]FDG uptake, confirming tumor relapse

Full size image

11.1.2.4 Conclusion/Teaching Point

After surgery, in the presence of suspected residual disease, on anatomic imaging and clinical signs of sepsis, relapse of disease should be considered after a negative labelled WBC scan. The patient was finally operated on for relapse of clear cell renal carcinoma.

11.1.3 Case 11.3

  • Jose Martin-Comin 

Male, age 48 years, presenting with bloody diarrhoea, abdominal pain, showed general laboratory data for inflammatory disease, and was referred to colonoscopy that showed a normal colonic mucosa and multiple biopsies compatible with Crohn’s disease. He was then referred to nuclear medicine for a radiolabelled WBC scan in order to confirm disease and evaluate its activity and extent.

Scintigraphy confirmed the colonic location of the disease with severe activity and no complications, and steroid treatment was started. After 1 year, the colonoscopy was repeated and was normal again, but due to an increase of pain and subobstruction, stronger immunosuppression was added to the therapy. After 3 months, symptoms and subobstruction disappeared, but the Crohn’s disease activity index (CDAI) was still 300. Therefore, a new radiolabelled WBC scan was requested.

Scintigraphy showed very mild colonic uptake, in contrast with elevated CDAI. Therapy was discontinued and CDAI decreased with time to normal values.

The patient had no clinical relapse for 7 years, and no other colonoscopies were performed. After 7 years, abdominal pain started again. CDAI increased to 250 and a new colonoscopy was again normal with normal biopsies. For the correct evaluation of the disease activity and the extent, a third radiolabelled WBC scan was requested. Scintigraphy identified a diffused ileal accumulation of WBC without colonic involvement. In these 7 years, the disease evolved from colon to ileum. The radiolabelled scan always correctly identified disease activity, differently from colonoscopy and CDAI measurement.

11.1.3.1 Suspected Site of Disease

Colonic Crohn’s disease.

11.1.3.2 Radiopharmaceutical Activity

99mTc-HMPAO-WBC (550–625 MBq) was administered on each occasion.

11.1.3.3 Imaging

Planar anteroposterior images were acquired for 300–500 s, 2 h after cell administration (Fig. 11.16).

Fig. 11.16
figure 16

99mTc-HMPAO-leukocyte scintigraphy in Crohn’s disease. (a) At the time of diagnosis, a severe colonic disease is detected. (b) One year later, patient was in remission with very mild and diffused colonic activity. (c) After 7 years, the patient had a clinical disease relapse and images showed moderate to severe pan-ileitis. Note physiologic accumulation of labeled cells by the spleen, which is always higher than liver accumulation; this is a sign of undamaged labeled cells

Full size image

11.1.3.4 Conclusion/Teaching Point

Radiolabelled WBC scintigraphy can help in the evaluation of Crohn’s disease extent and evaluate its activity. It is a useful method in addition to colonoscopy and allows the examination of all bowel segments.

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Signore, A., Lanzolla, T., Lauri, C. (2021). Nuclear Medicine Imaging of Abdominal Infections and Inflammations. In: Lazzeri, E., et al. Radionuclide Imaging of Infection and Inflammation. Springer, Cham. https://doi.org/10.1007/978-3-030-62175-9_11

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