Scintigraphic evaluation of intrathecal infusion systems: selection of patients for surgical or medical management.

PURPOSE: Continuous intrathecal medication through a surgically implanted infusion system is an established method for treating intractable spasticity or pain. To determine if imaging can guide surgical or medical management in patients with suspected infusion system malfunction, we reviewed our experience in evaluating the functional status of these systems with indium-111 DTPA scintigraphy. METHODS: We retrospectively reviewed 23 indium-111 DTPA studies in 19 patients (7 female, 12 male; ages 20-83 years, average age 47 years). Indications included intractable spasticity or increasing pain. Infusion systems were classified scintigraphically as either functioning or malfunctioning; malfunctions were further classified as either mechanical or catheter-related. Imaging findings were correlated with subsequent clinical management. RESULTS: Fifteen of 23 (65%) studies demonstrated functioning infusion systems; these patients were all treated medically. Eight of 23 (35%) studies demonstrated malfunctioning systems; 6 of 8 were subsequently treated surgically and 2 of 8 medically. CONCLUSION: Indium-111 DTPA scintigraphy can differentiate between functioning and malfunctioning infusion systems, guiding appropriate medical or surgical management.

Identification of a point mutation in the thyrotropin receptor of the hyt/hyt hypothyroid mouse.

The hyt/hyt hypothyroid mouse has an autosomal recessive, fetal-onset, severe hypothyroidism related to TSH hyporesponsiveness and associated with elevated TSH. Our previous work has suggested that the hypothyroidism and TSH hyporesponsiveness may result from a mutation in the hyt/hyt TSH receptor (TSHr) of the thyroid gland. Based on DNA sequencing of the entire coding region of the TSHr gene from the wild-type BALB/cBY +/+ mouse, the +/+ TSHr is 92% and 94% identical at the nucleotide and amino acid residue levels, respectively, compared to the rat TSHr gene. The coding region of the hyt/hyt TSHr, compared to that of the +/+ TSHr, has a single base change, CCG to CTG, at nucleotide position 1666, which leads to the replacement of a highly conserved proline at amino acid position 556 with a leucine in transmembrane domain IV. This mutation was introduced by site-directed mutagenesis into the wild-type human TSHr and transiently expressed in COS-7 cells. Although the size and abundance of the mutant TSHr mRNA suggested that there was no effect on the nature of the mRNA, TSH binding and the response to TSH in transfected cells were abolished. Further studies are necessary to clarify how the Pro to Leu replacement interferes with receptor expression on the cell surface or influences TSH binding. These functional consequences of the mutation appear to account for the observed TSH hyporesponsiveness and hypothyroidism in the hyt/hyt mouse.

Sequence and chromosomal assignment of a novel cDNA identified by immunoscreening of a thyroid expression library: similarity to a family of mitochondrial solute carrier proteins.

An immunoglobulin G (IgG) preparation of the serum from a patient with active Graves' disease was used to isolate cDNA clones from a lambda gt11 cDNA library of human thyroid follicular carcinoma tissue by immunoscreening. One of these clones, hML-7, is further characterized herein by sequencing, Northern analysis, and chromosomal mapping. The clone reacted with IgG preparations from the sera of 14 of 19 patients with active Graves' disease but not with IgG preparations from 11 normal individuals, three patients with toxic thyroid adenoma, and three with rheumatoid arthritis. The hML-7 cDNA hybridized to a 3.6 kilobase (kb) mRNA transcript in poly(A+) RNA preparations from human thyroid tissue and continuously cultured rat thyroid cells; expression of this transcript in rat FRTL-5 thyroid cells was positively regulated by TSH. The 3.6 kb transcript was less abundant in rat liver (BRL3A) cells or differentiated rat (L6) myoblasts than in cultured rat thyroid cells and was not detectable in mouse L-M fibroblasts, human IM-9 lymphocytes, Chinese hamster ovary cells, or human cervical carcinoma cells. The cDNA from hML-7 was sequenced and compared with the sequence of cross-hybridizing cDNA clones isolated from human Graves' thyroid and rat FRTL-5 thyroid cell lambda gt11 expression libraries. A 1.05 kb open reading frame, which is highly conserved between human and rat, was defined. The predicted amino acid sequence of 348 residues exhibited a strong homology with the mitochondrial ADP/ATP carrier protein (adenine nucleotide translocase; ADP/ATP translocator) and with two other members of the same mitochondrial protein family, the phosphate carrier and the hydrogen ion uncoupling protein. The gene represented by the hML-7 cDNA has been assigned to human chromosome 10.

Testes exhibit elevated expression of calcitonin gene-related peptide receptor component protein.

Calcitonin gene-related peptide (CGRP) receptor component protein (RCP) is a novel protein that modulates CGRP responsiveness in a variety of cell types. Using probes based on the isolation of CGRP-RCP complementary DNA (cDNA) from a guinea pig organ of Corti cDNA library, we cloned human (h) and mouse (m) CGRP-RCP cDNAs, both of which encode 148-residue proteins that at the amino acid levels are approximately 88% identical to each other and to the 146-residue guinea pig CGRP-RCP. Northern blot analysis confirmed the presence of CGRP-RCP messenger RNA in all of the human and mouse tissues tested. In these human tissues, hCGRP-RCP messenger RNA (major band at approximately 3.1 kb, minor band at approximately 7.5 kb) was most prevalent in the testis. In the mouse, the highest abundance of CGRP-RCP RNA was clearly in the testis (major band at approximately 1.6 kb, minor band at approximately 1.1 kb). Based on this tissue distribution of RNA, we sought to identify the cells in the murine testis that contained CGRP-RCP protein. Numerous antisera generated against hCGRP-RCP, including one to recombinant hCGRP-RCP, exhibited strong immunoreactivity localized to the head region of spermatozoa. No CGRP-RCP immunoreactivity was observed in other cells at less mature stages of sperm maturation, in Sertoli or interstitial (Leydig) cells, or in human spermatozoa. Murine epididymal (mature) spermatozoa exhibited CGRP-RCP immunoreactivity identical to that of testicular spermatozoa. Spermatozoa that underwent an experimentally induced acrosome reaction (acrosomal discharge) lost their CGRP-RCP immunoreactivity. Therefore, it appears that CGRP-RCP is associated with the acrosome, suggesting that it may play an important role in reproduction.

Semantic organization of hallucinated "voices" in schizophrenia.

The authors found that the different hallucinated "voices" of four schizophrenic subjects reported over 1-3 weeks expressed semantic content that was at least as persistent as clauses sampled from single 5-7-minute conversational discourses of four comparison speakers. The high degree of semantic recurrence of voices from one day to the next may contribute to the mistaken belief that these experiences derive from a particular nonself agent or speaker.

Condensing osteitis of the clavicle: case report and review of the literature.

Osteitis condensans of the clavicle is a benign, often painful disorder of unknown etiology manifested by bony sclerosis of the clavicular head with an uninvolved sternoclavicular joint. The case presented demonstrates the characteristic scintigraphic findings of osteitis condensans of the clavicle. A review of the published pathologically proven cases reveals this disorder to have distinctive clinical and radiological features that allow differentiation from infection, neoplasia, and arthritides in most instances. The frequent observation, as in this case, of devitalized bone and marrow fibrosis with remodeling of cancellous bone suggests that osteonecrosis may play an important role in the pathogenesis of this disorder.

Demonstration of unilateral sialadenitis on postradiotherapy gallium-67-citrate imaging.

Intense, asymetric uptake of 67Ga-citrate in the right parotid and submandibular glands was observed in an asymptomatic patient who had undergone locoregional radiotherapy for Stage IA Hodgkin's disease 8 mo earlier. In view of the modified minimantle radiation field and adjunctive 99mTc salivary imaging, a unilateral radiation-induced sialadenitis best explained this unusual scintigraphic appearance.

Technetium-99m-sulfur colloid SPECT imaging in infants with suspected heterotaxy syndrome.

UNLABELLED: For the evaluation of a variety of hepatosplenic disorders, SPECT complements planar 99mTc-sulfur colloid liver/spleen imaging. By isolating small, ectopic or poorly functioning spleen(s) from overlying or adjacent liver, SPECT imaging should facilitate identification of splenic tissue in infants with suspected heterotaxy syndrome. METHODS: During a 10-yr period, 10 planar-only and 9 planar-plus-SPECT liver/spleen scans were obtained from 15 infants, 13 of whom were less than 1 mo of age at first examination. Four of the planar-only group had follow-up planar-plus-SPECT imaging. Scintigraphic diagnosis regarding presence of splenic tissue was correlated with clinical diagnosis. RESULTS: Thirteen infants had splenic tissue; two were asplenic. Planar-only imaging provided correct diagnoses in six [four with, two without spleen(s)] but was negative or equivocal in four infants. Planar-plus-SPECT imaging was positive in all in whom it was performed; moreover, in 4/13 infants (31%), splenic tissue was documented only by SPECT imaging. CONCLUSION: Particularly when planar views are inconclusive, SPECT imaging is invaluable for identification and localization of functioning splenic tissue in infants with suspected heterotaxy syndrome.

False-negative morphine-augmented cholescintigraphy: a case of subacute gallbladder perforation.

The gallbladder and an infected pericholecystic biloma secondary to subacute perforation were visualized during morphine-augmented cholescintigraphy. Perforation of the gallbladder may relieve cystic duct obstruction and contribute to false-negative visualization in the setting of acute cholecystitis.

Indium-111-labeled leukocyte scintigraphy: diagnosis of subperiosteal abscesses complicating osteomyelitis in a child.

Preoperative 111In-labeled leukocyte scintigraphy demonstrated extensive subperiosteal abscesses complicating acute bilateral tibial osteomyelitis in a child. Plain radiographs showed only marked soft-tissue swelling; three-phase bone scintigraphy depicted both "hot" and "cold" areas consistent with acute osteomyelitis.

Gallbladder nonvisualization with pericholecystic rim sign: morphine-augmentation optimizes diagnosis of acute cholecystitis.

UNLABELLED: This study investigated the value of morphine-augmentation in patients who demonstrated gallbladder nonvisualization with a pericholecystic rim sign at 1 hr, a cholescintigraphic pattern considered highly predictive of acute cholecystitis. METHODS: Retrospectively, 170 consecutive morphine-augmented cholescintigrams were analyzed for the presence of a pericholecystic rim sign, marked or mild, associated with gallbladder nonvisualization at 1 hr (before morphine); those with a pericholecystic rim sign were further evaluated for persistent gallbladder nonvisualization versus gallbladder visualization after morphine. Scintigraphic interpretations were correlated with surgical pathology or clinical diagnosis. RESULTS: Before morphine, 43/170 (25%) patients demonstrated gallbladder nonvisualization with a pericholecystic rim sign. Since only 31 had acute cholecystitis, a diagnosis based solely on that scintigraphic pattern would have resulted in 12 false-positives. After morphine, gallbladder visualization correctly excluded acute cholecystitis in seven; a single false-negative was encountered; five false-positives remained. Morphine-augmentation improved the positive predictive value from 72% (gallbladder nonvisualization with pericholecystic rim sign before morphine) to 86% (gallbladder nonvisualization after morphine). Of 24 patients with marked pericholecystic rim signs, 21 had acute cholecystitis. Of 31 with acute cholecystitis, however, 10 (32%) had a mild pericholecystic rim sign. CONCLUSION: Morphine-augmented cholescintigraphy optimizes the diagnosis of acute cholecystitis in patients with the suggestive, but not pathognomonic, cholescintigraphic pattern at 1 hr of gallbladder nonvisualization with a pericholecystic rim sign, regardless of its intensity.

Post-therapy iodine-131 localization in unsuspected large renal cyst: possible mechanisms.

Sensitive and specific, whole-body 131I scintigraphy remains an important technique for diagnosing metastases from differentiated papillary or follicular thyroid carcinoma. False-positive 131I localization is well recognized and can occur in a variety of conditions. We present a case of intense 131I localization in a previously unsuspected large renal cyst; the lesion was not visualized on routine preablation diagnostic 131I scintigraphy but was obvious on post-therapeutic whole-body imaging, underscoring the value of post-therapy imaging in detecting abnormalities not apparent on diagnostic studies. Radioiodine within the urinary bladder or, at times, the renal collecting system is expected, because 131I excretion is primarily by glomerular filtration. In the case presented here, 131I activity within the renal cyst supports the concept that iodide is subject to an active secretory process by the renal tubule.

Gallbladder visualization during post-therapy iodine-131 imaging of thyroid carcinoma.

A persistent, extra-thyroidal focus of 131I on whole-body imaging of thyroid carcinoma usually represents a functioning metastasis. We report a case of 131I localization within a septated gallbladder, initially mimicking an isolated hepatic metastasis. Adjunctive liver/spleen and hepatobiliary scintigraphy helped to elucidate the true nature of this 131I activity.

Gallium-67 breast uptake in a patient with hypothalamic granuloma (sarcoid).

An unusual case is presented of bilateral breast uptake of [67Ga]citrate in a patient with a hypothalamic granuloma in the absence of galactorrhea is presented. A possible mechanism for this incidental finding is elevated prolactin levels, as other causes of gallium breast uptake such as drug therapy, and intrinsic breast disease, were not present.

Effect of multiple coil closure of patent ductus arteriosus on blood flow to the left lung as determined by lung perfusion scans.

Lung perfusion scans reveal that multiple-coil closure of the ductus does not interfere with pulmonary blood flow. However, caution is necessary when placing multiple coils in small infants.

Enhanced hepatic uptake of thallium-201 in patients with severe narrowing of the right coronary artery.

To assess the hepatic uptake of thallium-201 after exercise treadmill testing and to investigate whether hepatic uptake of thallium-201 may be a useful marker of right coronary artery (RCA) disease, 43 patients were studied: 17 with RCA disease (9 with 1-vessel disease, 8 with multivessel disease including the RCA), 8 with left coronary system disease alone, and 18 with a low probability (< 5%) of coronary disease. All subjects were studied with symptom-limited exercise and redistribution thallium-201 single-photon emission computed tomographic (SPECT) scintigraphy. Two indexes of hepatic uptake were derived: a liver-to-heart ratio after stress, and a stress-to-rest hepatic ratio. The low-probability group had a liver/heart ratio of 0.48 +/- 0.02. In the group with RCA disease alone, liver/heart ratio was 1.29 +/- 0.20 (p < 0.005 vs low-probability group). Patients with multivessel coronary artery disease involving the RCA had a ratio of 1.19 +/- 0.16 (p < 0.005 vs low-probability group), and patients with only left coronary system disease had a liver/heart ratio of 0.87 +/- 0.15 (p < 0.05 vs low-probability group). The stress/rest ratio of the low-probability group was 0.83 +/- 0.04. Patients with RCA disease alone had a stress/rest ratio of 1.49 +/- 0.25 (p < 0.05 vs low-probability group), and patients with multivessel disease involving the RCA had a stress/rest ratio of 1.16 +/- 0.08 (p < 0.005 vs low-probability group).(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of a prosthetic aortic valvular abscess with indium-111-labeled leukocytes.

An unsuspected annular abscess at the base of a prosthetic aortic valve in a patient with endocarditis was identified by indium-111-labeled leukocyte scintigraphy alone. This highly sensitive and specific technique expediently demonstrated the surgically proven inflammatory focus.

Postoperative cardiothoracic infection: diagnostic value of indium-111 white blood cell imaging.

During a 6.5-year period, 50 indium 111-labeled white blood cell scans were obtained in 49 selected patients who had undergone sternotomy. Retrospectively, six sternal wounds and eight cardiovascular prostheses were found to be infected in 13 patients. For cardiothoracic surgical sites, the sensitivity, specificity, and accuracy of indium-111-labeled white blood cell scintigraphy were 86%, 97%, and 95%, respectively. Whole-body imaging identified the presence of major extramediastinal sites of infection in 10 patients. In patients with complicated cardiothoracic conditions, indium-111-labeled white blood cell imaging provides valuable diagnostic information regarding a variety of postoperative infections.

Early cardioverter defibrillator infection: value of indium-111 leukocyte imaging.

In the early postoperative period, it may be difficult to diagnose an infected implantable cardioverter-defibrillator system using anatomic imaging modalities such as computed tomography alone. We describe a case that illustrates the complementary physiologic role of indium-111-labeled leukocyte scintigraphy in identifying and defining the extent of early postoperative implantable cardioverter-defibrillator infection.

Does local irradiation affect gastric emptying in humans?

The authors measured gastric emptying in 13 patients undergoing radiation therapy to the chest, abdomen, or pelvis for nongastrointestinal cancer to investigate whether gastric emptying (GE) was altered by this therapy. Symptoms and weight were monitored at regular intervals. Patients served as their own controls and were compared to a group of healthy subjects. When studied prior to radiation therapy (baseline), cancer patients had a gastric emptying rate that was similar to a healthy control group (t1/2 mean+/-SEM 92.0+/-15.3 vs. 80.4+/-8.2 min). Irradiation did not change the emptying rate, either after the first dose (early) of 180 cGy (t1/2 99.5+/-17.9) or after 2 weeks of therapy (late) with 3000 cGy (t1/2 75.5+/-7.3). There was no correlation of radiation field or tumor type with gastric emptying rate. Two of the 13 patients experienced nausea and vomiting during their course of radiation, but their gastric emptying was unchanged from baseline.