Bone scintigraphy and secondary osteomalacia due to nephrotoxicity in a chronic hepatitis B patient treated with tenofovir.

Tenofovir is a nucleotide analogue used for the treatment of chronic hepatitis B and HIV infection. The safety of tenofovir is high but it has been described that tenofovir produces tubular toxicity and Fanconi's syndrome in some HIV-infected patients. To our knowledge this is the first documented case of bone involvement in Fanconi's syndrome in a patient treated with tenofovir for chronic hepatitis B without HIV coinfection. Bone scintigraphy has proven to be very useful for the diagnosis of secondary osteomalacia. Normalization of the bone scan after the withdrawal of the drug and the decline in alkaline phosphatase and phosphate serum levels reinforce the cause-effect relationship.

Valor pronóstico de la gammagrafía de perfusión miocárdica con 201Tl normal en el postinfarto agudo de miocardio / Prognostic value of normal myocardial perfusion scintigraphy with 201Tl in post-acute myocardial infarction

Objetivo. El objetivo de este trabajo ha sido determinar el valor pronóstico de los estudios de perfusión miocárdica con 201Tl normal en pacientes que habían sufrido un IAM en los tres meses anteriores. Material y métodos. Se realizó una prueba de esfuerzo seguida de 201Tl GATED-SPECT. Se hizo seguimiento a 63 pacientes con gammagrafía de perfusión normal: grupo I (57% varones, edad 65±12 años). Se comparó con otro grupo de 60 pacientes con gammagrafía de perfusión patológica: grupo II (81% varones, edad 64±10 años). Se analizó la aparición de nuevo infarto o muerte cardiaca ocurridos durante este periodo (63±3 meses) y se relacionó la aparición de eventos con los factores de riesgo cardiovascular, la perfusión y la función ventricular. Resultados. En el grupo I se produjeron 5 eventos en 4 pacientes: 3 nuevos infartos y 2 muertes cardiacas, mientras que en el grupo II ocurrieron 18 eventos en 14 pacientes: 8 nuevos infartos y 10 muertes cardiacas (p<0,0001). Los eventos se relacionaron con la edad, el tiempo transcurrido desde la exploración, la diabetes, el defecto de perfusión y la función ventricular postesfuerzo. El grupo I muestra una supervivencia media de 108 (103–112) meses y el grupo II de 97 (88–107) meses (p=0,01). Conclusiones. Los pacientes con perfusión miocárdica normal tienen menor número de eventos que los pacientes con gammagrafía patológica. El tamaño del defecto se ha relacionado con la aparición de eventos. Una FEVI postestrés deprimida tiene mal pronóstico(AU)

Objective. The purpose of this work has been to determine the prognostic value of normal thallium-201 myocardial perfusion scintigraphy (MPS) in patients who had suffered myocardial infarction in the three months prior to the examination. Material and methods. A stress test followed by 201Tl Gated SPECT was performed. A follow-up was made of 63 patients with normal perfusion scintigraphy. According to the MPS results, the patients were divided into 2 groups. Group I (n=63; 57% males, age 65±12), patients with normal MPS, and group II (n=60; 81% males, age 64±10), patients with abnormal MPS. The appearance of a new infarction or cardiac death occurring during this period (63±3 months) was analyzed. The appearance of events was related with the cardiovascular risk factors, perfusion study and ventricular function. Results. Five events occurred in group I in 4 patients: 3 new infarctions and 2 cardiac deaths. In group II, there were 18 events in 14 patients: 8 new infarctions and 10 cardiac deaths (p<0,0001). The events were related with age, time from MPS, diabetes, size of perfusion defect and post stress ventricular ejection fraction. Mean survival en group I was 108 months (103–112) and in group II 97 (88–107) (p=0,01). Conclusion. Patients with normal MPS had fewer major events than patients with abnormal MPS. The size of MPS has been related with the appearance of events. A depressed post-stress left ventricular ejection fraction has a poor prognosis(AU)

[Prognostic value of normal myocardial perfusion scintigraphy with 201Tl in post-acute myocardial infarction]. / Valor pronóstico de la gammagrafía de perfusión miocárdica con 201Tl normal en el postinfarto agudo de miocardio.

OBJECTIVE: The purpose of this work has been to determine the prognostic value of normal thallium-201 myocardial perfusion scintigraphy (MPS) in patients who had suffered myocardial infarction in the three months prior to the examination. MATERIAL AND METHODS: A stress test followed by (201)Tl Gated SPECT was performed. A follow-up was made of 63 patients with normal perfusion scintigraphy. According to the MPS results, the patients were divided into 2 groups. Group I (n=63; 57% males, age 65±12), patients with normal MPS, and group II (n=60; 81% males, age 64±10), patients with abnormal MPS. The appearance of a new infarction or cardiac death occurring during this period (63±3 months) was analyzed. The appearance of events was related with the cardiovascular risk factors, perfusion study and ventricular function. RESULTS: Five events occurred in group I in 4 patients: 3 new infarctions and 2 cardiac deaths. In group II, there were 18 events in 14 patients: 8 new infarctions and 10 cardiac deaths (p<0,0001). The events were related with age, time from MPS, diabetes, size of perfusion defect and post stress ventricular ejection fraction. Mean survival en group I was 108 months (103-112) and in group II 97 (88-107) (p=0,01). CONCLUSION: Patients with normal MPS had fewer major events than patients with abnormal MPS. The size of MPS has been related with the appearance of events. A depressed post-stress left ventricular ejection fraction has a poor prognosis.

[Quantification of myocardial scintigraphy in patients with low probability of coronary artery disease. Normal values of thallium-201 gated SPECT]. / Cuantificación del estudio de perfusión miocárdica en pacientes con baja probabilidad de cardiopatía isquémica. Valores normales de gated-SPECT con (201)Tl.

INTRODUCTION: This study has aimed to establish quantitative normality parameters in the thallium-201 GATED SPECT and to assess the changes related to age, gender, risk factors and stress testing. METHODS: A total of 427 patients with low pre-test likelihood of coronary artery disease were selected (45.5% men). The examinations were performed, by obtaining 32 25-second images on a 180% arc. The isotope used was thallium-201 and the SU SEGAMI software was using for the examination procedure. RESULTS: Myocardial tracer uptake in each one of the vascular territories was: left descending artery 77%+/-4; circumflex artery 76%+/-5 and right coronary artery 70%+/-4 (P=.000). Uptake in the right coronary artery territory was lower in men (68.7% vs 70.5% in women, P=.000) and in the left descending artery territory in the obese. There were no gender-related differences in the post-stress ejection fraction for both genders (65.7% in men vs 66.8% in women). However, ventricular volumes were higher in men (end-diastolic volume 80ml+/-27 vs 61ml+/-22; P=0.000 and end-systolic volume 27.2ml+/-25 vs 19ml+/-8; P=0.000). There is an inverse relationship between age and end-diastolic volume. Smokers have higher end-diastolic volumes than non-smokers. CONCLUSIONS: Quantification of T1201 uptake in patients having low pre-test probability of coronary artery disease and normal thallium GATED-SPECT in the RCA territory is lower in men. The ventricular function study shows that there are no differences in post-stress EF based on gender but that the end-diastolic and end-systolic volumes are higher in men.

[Myocardial perfusion study in patients who do not reach submaximal frequency on ergometry]. / Estudio de perfusión miocárdica en pacientes que no alcanzan la frecuencia submáxima en la ergometría.

UNLABELLED: The aim of the study was to evaluate the sensitivity and specificity of TI-201 myocardial perfusion SPECT for the diagnosis of ischaemic cardiopathy in a group of patients with chronotropic insufficiency. MATERIALS AND METHODS: The examinations of 750 patients who had attended for the diagnosis of ischaemic cardiopathy during 2005-2006 were selected. 28 % (n = 209) did not reach submaximal frequency. Data on the diagnosis was collected in 112 by telephone interview. Ergometry and SPECT were carried out following the usual techniques. RESULTS: Patients who reached submaximal frequency and patients with chronotropic insufficiency did not show differences in age and exercise time. The proportion of patients on beta-blocker treatment, with clinically positive ergometries and pathological SPECT was higher in the patient group which had not reached 85 % of their maximum frequency. The data obtained in the patient group which did not reach submaximal frequency and followed-up by telephone interview showed a SPECT sensitivity of 84 % and specificity of 96 %. The sensitivity of the ergometry was 25 % and its specificity was 96 %. CONCLUSIONS: Ergometry with myocardial perfusion SPECT has adequate sensitivity and specificity for the diagnosis of ischaemic cardiopathy, even in patients with chronotropic incompetence. The proportion of pathological examinations is higher in those patients in whom tachycardia could not be sufficiently induced, which seems to indicate that the inability to reach submaximal frequency is related with a higher probability of having ischaemic cardiopathy.

Estudio de perfusión miocárdica en pacientes que no alcanzan la frecuencia submáxima en la ergometría / Myocardial perfusion study in patients who do not reach submaximal frequency on ergometry

El propósito del trabajo fue evaluar la sensibilidad y especificidad de la tomografía computarizada por emisión de fotón único (SPECT) de perfusión miocárdica Tl201 para el diagnóstico de cardiopatía isquémica en el grupo de pacientes con insuficiencia cronotrópica. Material y método. Se seleccionaron exploraciones de 750 pacientes que habían acudido para el diagnóstico de cardiopatía isquémica durante los años 2005-2006. El 28 % (n = 209) no alcanzó la frecuencia submáxima. Mediante encuesta telefónica se recogieron datos acerca del diagnóstico en 112. La ergometría y la SPECT se realizaron según técnica habitual. Resultados. Los pacientes que alcanzaron la frecuencia submáxima y los pacientes con insuficiencia cronotrópica no presentaron diferencias en la edad y el tiempo de ejercicio. La proporción de pacientes en tratamiento con bloqueadores beta, con ergometrías clínicamente positivas y con SPECT patológicos fue mayor en el grupo de los pacientes que no habían alcanzado el 85 % de su frecuencia máxima. Los datos obtenidos en el grupo de pacientes que no alcanzaron la frecuencia submáxima y seguidos mediante encuesta telefónica muestran una sensibilidad de la SPECT del 84 % y una especificidad del 96 %. La sensibilidad de la ergometría fue del 25 % y su especificidad del 96 %. Conclusiones. La ergometría con SPECT de perfusión miocárdica tiene una adecuada sensibilidad y especificidad para el diagnóstico de cardiopatía isquémica aun en pacientes con incompetencia cronotrópica. La proporción de exploraciones patológicas es superior en aquellos pacientes que no se taquicardizaron lo suficiente, lo cual parece indicar que la incapacidad para alcanzar la frecuencia submáxima se relaciona con una mayor probabilidad de presentar cardiopatía isquémica

He aim of the study was to evaluate the sensitivity and specificity of TI-201 myocardial perfusion SPECT for the diagnosis of ischaemic cardiopathy in a group of patients with chronotropic insufficiency. Materials and methods. The examinations of 750 patients who had attended for the diagnosis of ischaemic cardiopathy during 2005-2006 were selected. 28 % (n = 209) did not reach submaximal frequency. Data on the diagnosis was collected in 112 by telephone interview. Ergometry and SPECT were carried out following the usual techniques. Results. Patients who reached submaximal frequency and patients with chronotropic insufficiency did not show differences in age and exercise time. The proportion of patients on beta-blocker treatment, with clinically positive ergometries and pathological SPECT was higher in the patient group which had not reached 85 % of their maximum frequency. The data obtained in the patient group which did not reach submaximal frequency and followed-up by telephone interview showed a SPECT sensitivity of 84 % and specificity of 96 %. The sensitivity of the ergometry was 25 % and its specificity was 96 %. Conclusions. Ergometry with myocardial perfusion SPECT has adequate sensitivity and specificity for the diagnosis of ischaemic cardiopathy, even in patients with chronotropic incompetence. The proportion of pathological examinations is higher in those patients in whom tachycardia could not be sufficiently induced, which seems to indicate that the inability to reach submaximal frequency is related with a higher probability of having ischaemic cardiopathy

[Hyperemic reactivity scintigraphy in endothelial function]. / La gammagrafía de reactividad hiperémica en el estudio de la función endotelial.

OBJECTIVE: The aim of this study was to compare a recently described method to evaluate endothelial function; the hyperemic reactivity scintigraphy (HRS) with the ultrasonographic flow-mediated dilatation (FMD) in brachial artery and its relationship with myocardial SPECT. METHODS: 42 consecutive patients that underwent myocardial scintigraphy were included. Thirty-six patients had simultaneous measurement of FMD. Both studies were obtained after 5 minutes occlusion of the upper arm with a blood pressure cuff inflated at 250 mmHg. HRS was performed dynamically at rate 1 frame/sec during 3 minutes after intravenous injection of 740 MBq of Tc-99 sestamibi. Time-activity curves allowed obtaining the following indexes: medium hyperemic activity/medium contrallateral activity (MHA/MCA) and maximum hyperemic activity/maximum contrallateral activity (MxHA/CxHA). RESULTS: In 13 patients SPECT was normal. Twenty-nine patients had perfusion defects in scintigraphy. There was relationship between the FMD and the MHA/MCA (r = 0.23; p = 0.018) and the FMD and the MxHA/CxHA (r = 0.18; p = 0.05). Patients with alterations in the SPECT had an index MxHA/CxHA lower than patients with normal SPECT (1.8 +/- 0.2 vs 1.5 +/- 0.4; p = 0.04). We did not find relationship between FMD and alterations in SPECT. CONCLUSIONS: There is relationship between FMD and HRS. HRS is lower in patients with perfusion defects in the SPECT. HRS could provide additional value to myocardial scintigraphy.

[Silent ischemia versus angina in Tl-201 tomoscintigraphy]. / Isquemia silente versus angina en la tomogammagrafía con Tl-201.

INTRODUCTION: The aim of this work was to describe the variables associated to silent ischemia in patients with reversible perfusion defects in poststress myocardial perfusion scintigraphy. METHODS: Tl-201 myocardial perfusion SPECT of 522 patients showing total or partially reversible perfusion defects after exercise testing were quantitatively analyzed retrospectively. Relationship between silent ischemia, size of perfusion defect and presence of risk factors was performed. RESULTS: Ischemia was silent in 412 (73 %) patients. In 176 (33 %) patients exercise test was electrically positive. There were no differences in perfusion defect size between patients with and without angina in exercise test (27 +/- 12 vs 27 +/- 14), but patients with angina had a greater degree of reversibility, in left descending artery (LDA) territory (56 +/- 40 vs 45 +/- 40 p < 0.01). Silent ischemia was more frequently observed in patients with previous acute myocardial infarction (46 % vs 35 %). There was no relationship between the production of exertional angina and the presence of risk factors. CONCLUSIONS: A high number of patients with reversible perfusion defects on SPECT had silent ischemia. Patients with angina during exercise test had more defect reversibility in LDA territory. Silent ischemia is more frequent in patients with previous acute myocardial infarction.

[Osteitis in secondary syphilis]. / Osteítis en sífilis secundaria.

BACKGROUND: The aim of this study is to report two patients with osteitis in secondary syphilis. The increase in the number of cases of syphilis, linked to the changes in sexual behavior and to the increase of immigrants from areas of high prevalence of STD, as well as its relationship with HIV infection, makes important to clinicians become aware of unusual presentation of secondary syphilis. PATIENTS: We report two patients diagnosed of secondary syphilis, one of them with HIV infection. Both showed dermatological lesions in palms and soles, malaise and fever. Bone scintigraphy showed significant uptake in parietal and frontal bones in both patients. Clinical response was quickly achieved after penicillin treatment. CONCLUSIONS: In patients with secondary syphilis and osteoarticular symptoms luetic osteitis must be included in differential diagnosis. Bone scintigraphy should be the first diagnostic tool because it possibilities to perform a total body scan which allows localizing asymptomatic lesions. Moreover bone scan shows a high sensitivity.

Osteítis en sífilis secundaria / Osteitis in secondary syphilis

Introducción: El objetivo del presente trabajo es presentar dos casos de osteítis en sífilis secundaria. El aumento de la incidencia de sífilis, debido a los cambios en los comportamientos sexuales y al aumento de los inmigrantes procedentes de áreas con elevada prevalencia de enfermedades de transmisión sexual (ETS), y su relación con el virus de la inmunodeficiencia humana (VIH), hace que sea importante familiarizarse con formas menos frecuentes de presentación de esta infección sistémica. Pacientes: Se presentan dos pacientes diagnosticados de sífilis secundaria, uno de ellos con infección por el VIH y el otro no. En el momento del diagnóstico ambos tenían lesiones cutáneas que afectaban palmas y plantas, síntomas generales y fiebre. La gammagrafía ósea demostró en ambos casos lesiones osteoblásticas múltiples en los huesos parietales y frontal. Los dos enfermos respondieron con mejoría clínica al tratamiento con penicilina. Conclusiones: En los pacientes con sífilis secundaria y sintomatología osteoarticular se debe hacer el diagnóstico diferencial de afectación ósea sifilítica. Recomendamos como técnica de elección la gammagrafía ósea debido a su gran sensibilidad y a la posibilidad de realizar rastreos corporales que permiten el diagnóstico de lesiones sintomáticas. (AU)

[Brain SPECT with 201-thallium in AIDS patients]. / SPECT cerebral con 201Tl en pacientes con SIDA.

UNLABELLED: Brain lymphoma is a late complication in AIDS. Lymphoma incidence is increasing in AIDS patients due to the introduction of HAART and prolongation of these patients' life expectancy. This work aims to evaluate the usefulness of brain SPECT with 201Tl in patients with AIDS who present focal brain lesions in computed tomography (CT). METHODS: Seventeen patients with neurologic symptoms and focal neurologic lesions in the CNS (central nervous system) were studied. The images were interpreted as positive when the intensity of the focal deposit of the tracer was greater than that of the adjacent tissue. The SPECT results were compared with serologic data, clinical evolution and/or radiologic follow-up and cerebral biopsy. RESULTS: SPECT images showed focal uptake of radiotracer in 3 patients. All three died shortly after the SPECT was performed. All of them had negative serology for toxoplasmosis. Four patients were diagnosed of progressive multifocal leukoencephalopathy and the ten remaining cases had a good clinical and/or radiologic response. CONCLUSIONS: Brain SPECT with 201Tl is a very useful non-invasive technique for the differential diagnosis of cerebral focal lesions in AIDS patients.

SPECT cerebral con 201Tl en pacientes con SIDA / Brain spect with 20 tallium in aids patients

El linfoma cerebral es una complicación tardía en la evolución del SIDA. La incidencia de linfoma cerebral en estos pacientes está aumentando debido a que el uso de la terapia antiretroviral de alta actividad prolonga la vida de los pacientes con SIDA. El propósito del presente trabajo es valorar la utilidad del SPECT cerebral con 201 Tl en los pacientes con SIDA que presentan lesiones neurológicas focales en la tomografía axial computarizada (TAC). Métodos: Se ha estudiado a 17 pacientes que presentaban sintomatología neurológica y lesiones focales en el SNC (sistema nervioso central). Se ha interpretado que las exploraciones eran positivas cuando existían depósitos focales del trazador de intensidad superior a la del tejido adyacente. Los resultados del SPECT cerebral se han comparado con datos serológicos, evolutivos clínicos y radiológicos, y biopsia cerebral. Resultados: Los 3 pacientes en los que el SPECT cerebral fue positivo fallecieron al poco tiempo de la exploración. Todos ellos tenían serología negativa para toxoplasma. Cuatro pacientes fueron diagnosticados de leucoencefalopatía multifocal progresiva y los otros 10 experimentaron mejoría clínica y/o radiológica. Conclusiones: El SPECT cerebral con 201Talio es una técnica no invasiva de gran utilidad en el diagnóstico diferencial de las lesiones focales del SNC en los pacientes con SIDA (AU)

[Gallium-67 (Ga-67) scintigraphy in tuberculosis and Mycobacterium avium-M. intracellulare infections in patients with HIV infections]. / Rastreo con galio-67 (67Ga) en la tuberculosis y las infecciones por Mycobacterium avium-M. intracellulare en pacientes con infección por el VIH.

BACKGROUND: Diagnosis of mycobacterioses in HIV infected patients is sometimes difficult because of atypical findings. The aim of this study was to assess the utility of gallium scintigraphy in diagnosis of AIDS related mycobacterioses in patients with fever of unknown origin. PATIENTS AND METHODS: We retrospectively reviewed the scans of 220 HIV(+) patients with fever (176 males [80%] and 44 females) who were evaluated with conventional diagnostic procedures at least of a week before. RESULTS: Gallium scintigraphy was positive in 114 patients (51%) and negative in 106 (49%). Mycobacteria were isolated in 83 patients (38%), 75 of these patients (90%) had a positive scintigraphy (sensitivity 90%; specificity 71%). Positive predictive value was 66% and negative predictive value was 92%. Mycobacterium avium-M. intracellulare (MAI) and M. tuberculosis were diagnosed in 22 (29%) and 53 (71%) HIV(+) patients, respectively. Seventy one (94%) of 75 patients with mycobacterioses had gallium uptake in at least two localizations. CONCLUSIONS: 67Ga scintigraphy is very useful in HIV(+) patients with fever of unknown origin. A negative gallium scintigraphy makes unlikely the diagnosis of mycobacterioses.

Identification of AIDS-related tuberculosis with concordant gallium-67 and three-hour delayed thallium-201 scintigraphy.

Concordant gallium-67 and thallium-201 uptake has been described in malignant lesions. More recently, 201Tl accumulation has been described in some benign conditions. The authors report three HIV-positive patients who underwent 67Ga and 201Tl scintigraphy. These studies revealed concordant 67Ga and 201Tl uptake and tumour was erroneously diagnosed. All three patients were finally diagnosed as having tuberculosis.

Abnormal gallium-67 skull uptake: a sign of peripheral marrow activation in HIV-positive patients with disseminated mycobacterioses.

UNLABELLED: The purpose of this study was to investigate the significance of abnormal 67Ga-citrate skull uptake in AIDS patients with mycobacterioses. METHODS: Gallium-67 scans of 39 HIV-positive patients who have been diagnosed with mycobacterioses were analyzed; the scans of 15 consecutive HIV-positive patients without mycobacterioses were also reviewed as a control group. The skull was chosen to assess bone marrow uptake because of the absence of overlapping structures. RESULTS: Twenty-nine of 39 (74%) patients with mycobacterial infections had disseminated disease. Gallium-67 uptake in the skull was visualized in 24 of these 29 patients (82%). One of the patients without disseminated disease and one patient in the control group (n = 15) showed skull uptake. CONCLUSION: Abnormal 67Ga skull uptake appears to be a sensitive (82%) and specific (82%) indicator of disseminated mycobacterial infection in HIV-positive patients.