Modification of footed pajamas to confirm arthropod bites: The Modified Onesie Biting Bug Assessment suit

When children present with features of bed bug bites, many parents are reluctant to accept the diagnosis. Furthermore, standard methods to detect arthropods in or around one's home can be expensive, time-consuming, and frustrating. We developed a simple, inexpensive way to provide evidence that the lesions are in fact due to arthropod bites. The Modified Onesie Biting Bug Assessment (MOBBA) suit utilizes simple alterations to a full-body onesie-type footed pajama, exposing some body surfaces to insect predators while protecting other areas.

Misleading appearances of the bladder on pediatric genitourinary imaging

The authors reviewed images of the bladder on 100 consecutive Tc-99m DTPA pediatric renograms for any abnormal distribution of radionuclide or asymmetry suggestive of anatomic bladder abnormality. The results were correlated with radiographic contrast voiding cystourethrograms and ultrasound examination. Of 81 patients with adequate bladder imaging, 50 (62%) had symmetric and uniform distribution of radioactivity within the bladder. Thirty-one patients (38%) had a sufficiently abnormal bladder appearance to suggest anatomic abnormality. Of these 31 patients, 27 had contrast cystograms and ultrasound evaluation; only one (4%) had a proven bladder abnormality which correlated with the abnormal scintigraphic appearance. The appearance of the bladder on pediatric genitourinary imaging is a nonspecific and unreliable indicator of anatomic bladder abnormality.

Superselective embolization for renal hemorrhage with a new coaxial catheter and steerable guidewire

We utilized a new commercially available 2.2 French coaxial catheter and steerable guidewire to superselectively catheterize and embolize a small renal artery branch to abolish hemorrhage which was a complication of percutaneous nephrostomy. Because of the superselective technique and small caliber of the vessel occluded, there was no demonstrable loss of global renal function or evidence of significant cortical infarction by laboratory and radionuclide scintigraphic studies.

Lymphoma of the skeleton: scintigraphic evaluation

We retrospectively reviewed the 99mTc-diphosphonate scans of 980 patients with Hodgkin or non-Hodgkin lymphoma to define the typical appearance and distribution of skeletal lesions. The results were compared with the presence of skeletal symptoms and the findings on 67Ga-citrate scintigraphy, when available. Forty (4%) of the 980 patients had 77 scintigrams showing osseous involvement; there was an average of 3.5 lesions per study. Compared with patients with non-Hodgkin lymphoma, patients with Hodgkin disease had significantly fewer axial lesions (44% vs 82%, p less than .000001, two-tailed test) and more frequent involvement of the extremities. Subtle lesions were common. Of the lesions detected by scintigraphy, significantly more were detected by 99mTc-diphosphonate imaging (95%) than were detected by 67Ga-citrate (44%) (p less than .00001, two-tailed test), and most of these were far less apparent on the 67Ga-citrate study. Skeletal pain was an insensitive but specific indicator of skeletal disease. These results show that skeletal scintigraphy in patients with lymphoma typically reveals multiple subtle and asymptomatic lesions with frequent extremity involvement. Diffusely increased calvarial activity is commonly seen and often persists in proved remission. Increased juxtaarticular activity is specific for malignant skeletal involvement.

Prevention of motion artifacts on dual isotope subtraction parathyroid scintigraphy

A simple, effective technique is described to identify and eliminate motion artifacts which might potentially invalidate dual isotope subtraction parathyroid scintigraphy. Cobalt-57 markers, appropriately placed on the patient, allow detection of movement and permit realignment if movement occurs between imaging sequences. This technique should assure the accuracy of dual isotope parathyroid subtraction scintigraphy.

Gastroesophageal reflux demonstrated by hepatobiliary imaging in scleroderma

Radionuclide hepatobiliary imaging was performed on a patient with a longstanding history of scleroderma who presented with abdominal pain suggestive of biliary disease. Cystic duct patency was documented after 10 min with tracer accumulation in the second portion of the duodenum which failed to progress consistent with the duodenal hypomotility of scleroderma. The patient was given intravenous Kinevac resulting in gastroesophageal reflux of radionuclide.

Parotid gland biopsy and 67Ga imaging correlation in systemic sarcoidosis

We correlated the results of parotid gland biopsy, chest roentgenograms, and gallium citrate scintigraphy in 24 patients evaluated for possible systemic sarcoidosis. Of 19 patients ultimately proven to have sarcoidosis, 11 (57.9 percent) had positive parotid gland biopsy. The yield of parotid gland biopsy in patients with abnormal gallium parotid activity was only marginally higher (64.7 percent). Abnormal parotid gland uptake of gallium citrate was seen in 17 of these 19 patients (89.5 percent) and was always associated with abnormal lung or perihilar activity. The parotid gland biopsy is a useful technique for obtaining the tissue diagnosis of sarcoidosis; however, gallium scintigraphy should not be performed to select patients as this will only marginally increase the biopsy yield.

Radioiodine therapy of hyperthyroidism precludes thallium-201 myocardial scintigraphy

The authors attempted to perform Tl-201 myocardial perfusion scintigraphy in a 42-year-old man 23 and 35 days after he received 9.8 mCi of oral I-131 for documented Graves' disease. Interference from primary and scattered photons from residual thyroid I-131 made Tl-201 myocardial scintigraphy technically impossible. A series of phantom and patient studies using I-131 and Tl-201 were performed, yielding guidelines for planning Tl-201 myocardial scintigraphy following radioiodine therapy.

Intraosseous rheumatoid nodule

The authors present a case of an intraosseous rheumatoid nodule in the rib of a 9-year-old boy.

Scintigraphic documentation of hemorrhage from coronary artery bypass graft

Tc-99m labeled RBC imaging was used to conclusively demonstrate continuing intrathoracic hemorrhage from the anastomotic site of a coronary artery bypass graft. Demonstration of continuing hemorrhage and localization of the most likely site of bleeding resulted in timely and appropriate surgical intervention, which resulted in hemostasis and eventual patient recovery. Tc-99m RBC imaging may be an ideal noninvasive technique to investigate the site and activity of intrathoracic hemorrhage after coronary bypass surgery and other thoracic procedures.

Evaluation of traumatic mesenteric hemorrhage in a hemophiliac with Tc-99m labeled red blood cell scintigraphy

A hemophiliac with a self-inflicted abdominal stab wound was evaluated with computerized tomography, ultrasound, and technetium-99m labeled red blood cell (Tc-99m RBC) imaging. A large intra-abdominal hematoma was best defined by CT and ultrasound; however, continued bleeding, indicating the need for emergency surgery, could only be demonstrated by radiolabeled red blood cell scintigraphy.

Superior vena cava syndrome and bilateral subclavian vein thrombosis. CT and radionuclide venography correlation

Radionuclide venography (RNV) and CT with contrast infusion were performed in a patient with superior vena cava (SVC) syndrome and upper extremity swelling due to SVC and bilateral subclavian vein thrombosis resulting from infection of a Le Veen peritoneovenous shunt. Although CT was suggestive of thrombosis and excluded extrinsic compression by a mass, obstruction of the SVC and deliniation of collateral venous channels were best demonstrated by RNV.

Severe systemic reaction to diphosphonate bone imaging agents: skin testing to predict allergic response and a safe alternative agent

We describe a severe systemic reaction which occurred in a patient on two occasions after i.v. injection of chemically related diphosphonate bone imaging agents. Skin testing showed reactivity to multiple commercially available diphosphonate compounds but no significant response to pyrophosphates. A subsequent pyrophosphate bone scan resulted in no adverse reaction. Severe systemic reactions to diphosphonates can occur, skin testing may prove useful in evaluating allergic reactions, and pyrophosphates appear to be a safe alternative agent in patients proven or suspected allergic to diphosphonates.

Inadvertent ligation of the left pulmonary artery instead of patent ductus arteriosus. Noninvasive diagnosis by pulmonary perfusion imaging

Pulmonary perfusion scintigraphy was used to noninvasively evaluate a neonate four days after attempted surgical closure of a large patent ductus arteriosus (PDA). No perfusion to the left lung was seen, suggesting inadvertent ligation of the left pulmonary artery (PA). This was confirmed by cardiac catheterization and reoperation. Radionuclide pulmonary perfusion imaging is an ideal noninvasive technique for evaluating pulmonary perfusion in neonates after complicated thoracic surgery.

Abnormal lung and liver uptake of gallium-67 and technetium-99m MDP in hypercalcemia of lymphoma with metastatic pulmonary calcification

Abnormal pulmonary uptake of Ga-67 citrate and Tc-99m MDP and reversible liver uptake of Tc-99m MDP was seen in a patient with hypercalcemia of lymphoma and biopsy-proven metastatic pulmonary calcification. Abnormal lung uptake of Tc-99m MDP may confirm the diagnosis of pulmonary calcification, lessening the need for invasive procedures to evaluate pathologic lung uptake of Ga-67 citrate.

Technetium-99m red blood cell blood-pool imaging in functional asplenia due to leukemic infiltration

Tc-99m labeled RBC blood-pool and Tc-99m sulfur colloid imaging were performed in a patient with chronic myelogenous leukemia (CML) in blast crisis. Functional asplenia was demonstrated on the sulfur colloid study despite intact organ perfusion as demonstrated by blood-pool imaging. Tc-99m RBC blood-pool imaging appears to be an ideal noninvasive technique to document intact spleen perfusion in functional asplenia.

Menstruation. A hazard in radionuclide renal transplant evaluation

Serial Tc-99m DTPA studies were performed to evaluate renal transplant blood flow and function in a 34-year-old woman. A hypervascular pelvic mass with increased blood pool activity was intermittently identified. This hypervascular lesion suggested a pathologic condition of the pelvis, and its blood pool simulated bladder activity, confusing interpretation of renal function. This perplexing vascular lesion was the uterus, with varying degrees of blood flow and blood pool activity depending on the timing of the renal study in relation to the menstrual cycle.

Serendipitous detection of an errant central venous catheter

The inappropriate placement of a patient's central venous catheter in the pleural space by the serendipitous injection of Tc-99m labeled red blood cells through the catheter during a GI bleeding study was discovered. Position and patency of central venous lines can be incidentally evaluated by using existing central venous catheters for administration of radiopharmaceuticals during radionuclide imaging studies.

Heterotopic bone formation: clinical, laboratory, and imaging correlation

The clinical findings, laboratory data, radiographs, and radionuclide studies of 50 patients referred for evaluation of possible heterotopic bone formation (HBF) were reviewed. HBF begins approximately 17 days following injury or neurologic insult, heralded by an acute rise in serum alkaline phosphatase (SAP), and increased vascularity on three-phase radionuclide bone imaging (RNBI). RNBI soft-tissue uptake is evident at 24 days and radiographic calcification is visible 1 wk later. Clinical signs and symptoms occur relatively late in the course of disease. HBF mimics thrombophlebitis and should be considered in all patients referred for venography if the clinical situation is appropriate. Serial SAP measurements and three-phase RNBI should allow early diagnosis in virtually all cases.

Heterotopic bone formation (myositis ossificans) and lower-extremity swelling mimicking deep-venous disease

A quadriplegic patient with a swollen leg was suspected of having deep-venous thrombosis, and was studied with radionuclide venography (RNV) and contrast venography. Focal narrowing of the femoral vein, seen on RNV, was due to extrinsic compression. Although soft-tissue radiographs were normal, Tc-99m diphosphonate imaging established the diagnosis of early heterotopic bone formation (myositis ossificans), which was responsible for the venous compression. Clinically this inflammatory process can mimic deep-venous thrombosis, and should be considered in evaluating patients at risk for both heterotopic bone formation and deep-venous thrombosis.