Pamidronate sodium and calcitonin-resistant Paget's disease. Immediate response in a patient.

One three-day course of intravenous pamidronate sodium (3-amino-1-hydroxypropylidene-1,1-bisphosphonate), 30 mg/d, in a patient with calcitonin-resistant Paget's disease resulted in the following: marked clinical improvement within two weeks; normalization of urinary hydroxyproline value; fall of serum alkaline phosphatase value (900 to 250 U/L); a rise in serum osteocalcin value by the tenth week that returned to pretreatment levels in the 16th week; transient hypocalcemia with elevation of parathyroid hormone value; reduction in urinary calcium excretion; and improvement in bone scans. No adverse reactions occurred, with the exception of mild and transient hyperpyrexia for 48 hours during pamidronate administration. White blood cell counts did not change and serum interleukin 1 was undetectable before and after treatment with pamidronate. Pamidronate seems to be highly effective in the treatment of Paget's disease of the bone, but its profound effects on mineral and bone metabolism require close monitoring during the short-term period of intravenous treatment.

Pretreatment with propylthiouracil but not methimazole reduces the therapeutic efficacy of iodine-131 in hyperthyroidism.

Ninety-three hyperthyroid patients were treated with 1 dose of iodine-131 (131I) during the past 10 years. Thirty-three were pretreated with propylthiouracil (PTU), 22 with methimazole (MMI), and 38 received no antithyroid drugs (ATD). ATD were discontinued 5-55 days before 131I therapy in three fourths of the cases and more than 4 months before therapy in one fourth of the cases. The frequency of cures in the 3 groups, 6-8 months after radioiodine therapy, was retrospectively studied. The cure rate among those who discontinued PTU for 5-55 days before 131I was significantly reduced (24%), compared with those who discontinued MMI for the same duration (61%) or those who received no ATD (66%). When PTU was discontinued for more than 4 months, the cure rate was similar to those who received no ATD. It is concluded that if ATD are used as initial therapy for hyperthyroidism, then PTU (but not MMI) may reduce the therapeutic efficacy of subsequent 131I. The reduction in cure rate was observed even when PTU was discontinued for as long as 55 days before 131I therapy. To our knowledge, this is the first report to compare, in one study, the effects of pretreatment with PTU and MMI on 131I therapy.

Pelvic extramedullary hematopoiesis.

Extramedullary hematopoiesis is an infrequent cause of thoracic masses. Extrathoracic locations are even less common. We have studied two patients, one with suspected pelvic neoplasm, with technetium-99m sulfur colloid marrow image and transmission computerized tomography. This noninvasive evaluation established the diagnosis of pelvic extramedullary hematopoiesis in both. We recommend a similar diagnostic approach in patients with chronic anemia or other predisposing disease, presenting with a pelvic or abdominal mass.

The role of gallium-67 scintigraphy in diagnosing sources of fever in ventilated patients.

OBJECTIVE: To evaluate the diagnostic value of gallium-67 scintigraphy in febrile ventilated patients by correlating the findings of 67Ga scintigraphy to sources of fever and pulmonary density, as determined by a comprehensive protocolized diagnostic evaluation. DESIGN: Prospective observational study. PATIENTS: Thirty-two intubated patients on mechanical ventilation for > or = 3 days with fever (> or = 38.3 degrees C) and a new or progressive density on chest radiograph. Twenty patients (21 tests) had adult respiratory distress syndrome (ARDS). INTERVENTION: Diagnostic evaluation for fever included bronchoscopy with protected specimen brushing and (protected) bronchoalveolar lavage (BAL); computed tomography (CT) of sinuses; cultures of blood, urine, and central lines; and CT of the abdomen in high-risk patients. MEASUREMENTS AND RESULTS: Uptake of 67Ga was reported as either focal or diffuse pulmonary uptake and extrapulmonary uptake. The combined causes of fever were pneumonia (9), fibroproliferation of late ARDS (7), abdominal process (4), sinusitis (4), urinary tract infection (3), and others (6). Causes of the pulmonary densities were pneumonia (9), ARDS (13), atelectasis (7), congestive heart failure (3), and empyema (1). Marked and diffuse pulmonary uptake was found only in patients with ARDS; however, it was not useful in discriminating those patients with pulmonary fibroproliferation as the sole cause of fever (p = 0.167) from those with infection. 67Ga scintigraphy was inadequate for detecting pneumonia but valuable in identifying extrapulmonary sites of infection in patients with ARDS (p = 0.021). CONCLUSIONS: 67Ga scintigraphy should be considered only as an adjunct diagnostic test in the febrile, ventilated patient who has no obvious source of fever, despite a negative evaluation that includes testing for pneumonia, sinusitis, and urinary tract infection, conditions that are rarely detected by 67Ga scintigraphy.

Cholestatic jaundice after hepatic transplantation. A nonimmunologically mediated event.

Serial liver biopsy and close clinical monitoring in 55 consecutive hepatic allografts have disclosed a syndrome of cholestatic jaundice that simulates rejection. This syndrome is associated with distinct histologic findings and resolves spontaneously without modification of immunosuppressive management. The cause of the cholestasis is probably related to subcellular organelle damage produced by cold ischemia, and its importance stems from the confusion it creates with regard to rejection diagnosis. Recognition of this syndrome can result in decreased immunosuppression in hepatic allograft recipients, a secondary decrease in infectious complications, and improvement in the survival rate.

Bone scintigraphy and costochondritis.

Four patients with infectious costochondritis were studied with computed tomography (CT) and bone scintigraphy. In all four patients the bone scan detected and accurately localized the sites of involvement. CT did not image bilateral involvement in one patient. Three of the four patients were intravenous drug abusers; in two of these patients, a species of Aspergillus was the offending organism. Therefore, in patients with signs and symptoms of chest wall inflammation, scintigraphy is the most direct route to the diagnosis of costochondritis. This entity is apparently occurring more frequently because of the prevalence of intravenous drug abuse. Bone scintigraphy delineates both the extent of individual costochondral lesions and their multiplicity.

Indium-111 labeled leukocyte images demonstrating a lung abscess with prominent fluid level.

In-111 labeled leukocyte images show an abscess cavity with a fluid level on 24-hour upright images. Fluid levels, frequently seen on radiographs, are uncommon on nuclear images. This finding demonstrates rapid migration of labeled leukocytes into purulent abscess fluid.

Intraosseous fat necrosis and infarction associated with pancreatitis.

A case of trauma-induced pancreatitis with subsequent intraosseous fat necrosis and infarction is presented. The young patient demonstrated multiple cortical lytic lesions of the lower extremities and bilateral sterile joint effusions. Several radiographic modalities were employed in the workup of his disease. Related findings and pathophysiologic considerations are reviewed.

Radionuclide blood pool imaging of calvarial hemangioma.

A patient with new onset seizures was found to have radiographic findings of a calvarial hemangioma. Because of the history, additional diagnostic tests were employed, which excluded cerebral lesions. Findings characteristic of hemangioma on blood pool imaging were felt to confirm the diagnosis.

Unilateral absence of ventilation and perfusion due to thoracic aortic aneurysm.

An elderly man presented with progressive atelectasis of the left lung, a mediastinal mass, and dilatation of the thoracic aorta. Ventilation and perfusion radionuclide lung scans revealed the complete absence of ventilation in the left lung and near-complete absence of perfusion. Evaluation by MRI and angiography showed an obstructing mediastinal "mass" to be a saccular aortic aneurysm. A thoracic aortic aneurysm should be a consideration in the differential diagnosis for unilateral decrease or absence of ventilation and perfusion with a history or findings of mediastinal mass or aneurysm.

The headless bone scan: an uncommon manifestation of metastatic superscan in carcinoma of the prostate.

Five cases of metastatic prostatic carcinoma are presented. In each case, skeletal metastases were extensive, but the calvaria was not involved, resulting in a headless appearance. The mechanism for this scintigraphic manifestation is presented, and its value is emphasized.

Angiography of cerebellar hemorrhage secondary to hypertension.

In a patient with cerebellar hemorrhage due to hypertension, deterioration may be so rapid there is not sufficient time for radiographic studies prior to craniectomy. In the less critically ill patient, posterior fossa angiography is the procedure of choice and is highly accurate in localizing the mass lesion. Angiography is particularly helpful in the patient with an atypical presentation because an etiology of the hemorrhage other than hypertension may be demonstrated.

Acute calculous cholecystitis with patent cystic duct.

In the diagnosis of acute cholecystitis, the interpretation of cholescintigraphy is usually not difficult. It is conceivable, however, that with unusual location of obstructing calculi atypical images could result. Three cases were studied with cholescintigraphy and one with cholecystography in which more distal locations of obstructing calculi resulted in partial visualization of the gallbladder and erroneous interpretations were possible. Nuclear medicine radiologists should, therefore, be aware that atypical gallbladder images may be the result of unexpected location of obstructing calculi. Clues for assisting in interpretation are offered.

Hepatic rupture in preeclampsia: the role of diagnostic imaging.

The diagnosis of hepatic rupture in patients with pregnancy-induced hypertension (preeclampsia and eclampsia) is rarely made preoperatively. Diagnostic imaging can be utilized in some patients to confirm the preoperative diagnosis. Since hematoma formation precedes hepatic rupture, then, when diagnostic modalities such as sonography and computed tomography identify patients with hematomas, these patients are at risk of rupture, and should be hospitalized until the hematomas resolve.