The clover and heart signs in vertebral scintigraphic images are highly specific of Paget's disease of bone

Newly Diagnosed Monostotic Paget's Disease of Bone during Living Kidney Donor Candidate Evaluation

The popularity of living-donor organ donation has increased recently as an alternative to deceased-organ donation due to the growing need for organs and a shortage of deceased-donor organs. This procedure requires an in-depth health assessment of candidates, who must be in excellent physical and mental health. We present a potential living-kidney donor withdrawn from donation due to a newly diagnosed Paget's disease of bone (PDB). The patient underwent computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, and bone densitometry with trabecular bone score (TBS) assessment. The sole lumbar vertebra affected by PDB was investigated comprehensively, non-invasively, quantitatively, and qualitatively.

Is a Patient with Paget's Disease of Bone Suitable for Living Kidney Donation?-Decision-Making in Lack of Clinical Evidence

Living donor kidney transplantation is a widely performed medical procedure. Living kidney donation requires an in-depth health assessment of candidates. The potential living kidney donor must remain healthy after kidney removal. A consequence of donation can be a decrease in glomerular filtration rate (GFR), and donors can become at risk of developing chronic kidney disease (CKD). We present a rationale for potential living kidney donor withdrawal due to Paget's disease of bone (PDB) based on a literature review. The treatment for PDB includes the use of, for example, non-steroidal anti-inflammatory drugs (NSAIDs), which can lead to acute kidney injury (AKI) as well as CKD, or bisphosphonates, which are not recommended for patients with decreased GFR.

Mickey Mouse Sign on Bone Scan in the Monostotic Form of Paget's Disease Mimicking Osseous Metastasis

Paget’s disease is a chronic benign bone disease characterized by excessive and abnormal bone remodeling. Monostotic Paget’s disease accounts for only 20% of the cases, and the monostotic form involving the vertebra with the Mickey Mouse sign is very rare. Herein, we report a case of suspected bony metastasis in the second lumbar vertebra that was diagnosed as Paget’s disease because of the Mickey Mouse sign on bone scintigraphy, and the diagnosis was confirmed by biopsy. Therefore, bone scintigraphy may provide a positive contribution to the diagnosis, and may help to avoid unnecessary biopsy in cases with specific signs and patterns.

Diagnosis and Management of Paget's Disease of Bone in Adults: A Clinical Guideline

An evidence-based clinical guideline for the diagnosis and management of Paget's disease of bone (PDB) was developed using GRADE methodology, by a Guideline Development Group (GDG) led by the Paget's Association (UK). A systematic review of diagnostic tests and pharmacological and nonpharmacological treatment options was conducted that sought to address several key questions of clinical relevance. Twelve recommendations and five conditional recommendations were made, but there was insufficient evidence to address eight of the questions posed. The following recommendations were identified as the most important: 1) Radionuclide bone scans, in addition to targeted radiographs, are recommended as a means of fully and accurately defining the extent of metabolically active disease in patients with PDB. 2) Serum total alkaline phosphatase (ALP) is recommended as a first-line biochemical screening test in combination with liver function tests in screening for the presence of metabolically active PDB. 3) Bisphosphonates are recommended for the treatment of bone pain associated with PDB. Zoledronic acid is recommended as the bisphosphonate most likely to give a favorable pain response. 4) Treatment aimed at improving symptoms is recommended over a treat-to-target strategy aimed at normalizing total ALP in PDB. 5) Total hip or knee replacements are recommended for patients with PDB who develop osteoarthritis in whom medical treatment is inadequate. There is insufficient information to recommend one type of surgical approach over another. The guideline was endorsed by the European Calcified Tissues Society, the International Osteoporosis Foundation, the American Society of Bone and Mineral Research, the Bone Research Society (UK), and the British Geriatric Society. The GDG noted that there had been a lack of research on patient-focused clinical outcomes in PDB and identified several areas where further research was needed. © 2019 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.

Interesting Signs in Nuclear Medicine

Classic radiological and nuclear medicine signs have been reported extensively because of a myriad of pathophysiological processes. When encountered, they aid in diagnosis of conditions and add confidence for the reader, at times even hinting at a specific diagnosis. The naming of signs is commonly associated with objects from everyday life to establish familiarity with visual findings. Association of signs and disease comes with regular practice and improves understanding of the image and its underlying cause. In this article, we have collated nuclear medicine signs reported in the literature since 1970.

Vertebral "clover" scintigraphic image in a vertebral metastasis misdiagnosed with Paget's disease

The diagnosis of Paget's bone disease (PD) is often reached fortuitously with X-ray or scintigraphy. The peculiar distribution of the bone tracer in some skeletal locations, such as vertebra, may be highly suggestive of this disorder. Indeed, there are two distinct vertebral images on the bone scan highly specific of PD: the "clover" and the "heart" images. It has been previously reported that the specificity of these images for PD diagnosis is very high, nearly 100%, then suggesting that these findings could be patognomonic of this process. We have recently observed a 55-year-old male patient with back pain secondary to a vertebral metastasis due to a hepatocellular carcinoma. Initially, the bone scan showed the characteristic "clover" image at T-12 level and he was misdiagnosed with PD. Afterwards, the MRI suggested the diagnosis of a vertebral metastasis, and a computed tomography-guided needle biopsy further confirmed the diagnosis. In view of the present data, this image cannot be considered as patognomonic of PD.

The spine in Paget's disease

Paget's disease (PD) is a chronic metabolically active bone disease, characterized by a disturbance in bone modelling and remodelling due to an increase in osteoblastic and osteoclastic activity. The vertebra is the second most commonly affected site. This article reviews the various spinal pathomechanisms and osseous dynamics involved in producing the varied imaging appearances and their clinical relevance. Advanced imaging of osseous, articular and bone marrow manifestations of PD in all the vertebral components are presented. Pagetic changes often result in clinical symptoms including back pain, spinal stenosis and neural dysfunction. Various pathological complications due to PD involvement result in these clinical symptoms. Recognition of the imaging manifestations of spinal PD and the potential complications that cause the clinical symptoms enables accurate assessment of patients prior to appropriate management.