Intrahepatic cholestasis due to hypersensitivity reaction to procainamide.

Hypersensitivity reactions to procainamide involving liver dysfunction are rare. We describe a patient who developed liver dysfunction after procainamide administration, manifested by fever, jaundice, elevated bilirubin concentration, and alkaline phosphatase concentration. Hepatobiliary scintigraphy demonstrated good hepatic uptake of the radionuclide without movement from hepatic parenchyma. To our knowledge, this is the first reported case of procainamide-induced intrahepatic cholestasis as demonstrated by radionuclide hepatobiliary scintigraphy.

Clinical use of thrombolytic agents in venous thromboembolism.

The use of thrombolytic agents in venous thromboembolism has been shown to be highly effective. Patients treated with lytic agents show more rapid clot resolution and lung reperfusion and more rapid and greater reversal of the abnormal hemodynamic responses to pulmonary embolism than patients receiving heparin. Moreover, lytic therapy removes thromboemboli more completely from the pulmonary microcirculation, whereas residual thromboemboli tend to accumulate with heparin therapy. In addition, lytic therapy tends to preserve the venous valves, whereas distortion and destruction occur with heparin therapy. Hence, lytic therapy confers a number of short- and long-term benefits not observed with heparin therapy.

Effect of metabolic alterations on the accumulation of technetium-99m-labeled d,l-HMPAO in slices of rat cerebral cortex.

It is widely recognized that the distribution of technetium-99m-labeled d,l-hexamethylpropylene amine oxime (99mTc-HMPAO) in the brain is determined by the regional blood flow. However, other factors may affect this process including the metabolism of the brain tissue. To examine this possibility we studied the effects of metabolic alterations on 99mTc-HMPAO uptake in rat brain cortex slices, with concurrent measurement of oxygen consumption (QO2). 99mTc-HMPAO uptake was determined by incubating slices of rat cerebral cortex at 37 degrees C in Krebs-Ringer phosphate glucose medium containing 99mTc-HMPAO with and without test substances. Differential gradients for 99mTc activity between the tissue and the suspending medium (T/M ratio) were derived from the equation T/M[99mTc] = counts per gram of tissue/counts per milliliter of medium. The QO2 of the brain slices was measured using a biological oxygen monitor equipped with a polarographic oxygen probe. Inhibitors affecting oxidative phosphorylation caused parallel suppression of the T/M ratio and QO2. Agents that uncouple oxidation from phosphorylation increased the QO2 and decreased the T/M ratio. Incubation of slices at 22 degrees C depressed the T/M ratio and QO2. The presence of inhibitors of oxidative phosphorylation in the incubation medium increased the release of 99mTc activity from slices that had been prelabeled with 99mTc-HMPAO. These findings suggest that the altered metabolic status of the brain tissue modulates the kinetics and net accumulation of 99mTc-HMPAO at the cellular level by either depressing uptake, increasing back-diffusion, or both.

Bone scanning in Waldenstrom's macroglobulinemia.

We present a case report of a remarkably positive bone scan in a patient known to be suffering from Waldenstrom's macroglobulinemia. Although bone involvement in this disease was originally thought not to be present, reports of bone involvement are becoming more frequent. Documenting the presence and extent of bone involvement is important because local palliative radiotherapy and/or orthopedic measures, similar to those recommended for patients suffering from multiple myeloma, may be required to prevent pathologic fractures and patient discomfort.

Radionuclide imaging in a case of tertiary syphilis involving the liver and bones.

Tertiary syphilis is an unusual entity. We have encountered a case of tertiary syphilis of the liver and bone demonstrated by scintigraphy. With liver involvement, the liver scan showed focal defects due to gummas, and distortion due to scarring. Bone involvement was shown as increased cortical activity from periostitis, focal hot spots due to osteomyelitis, and cold defects due to gumma formation. Because syphilis is easily treated, but may not be as readily recognized, the diagnosis should be considered in cases of focal liver or bone disease of obscure etiology.

Demonstration of viable, stunned myocardium with technetium-99m-sestamibi.

Delayed improvement of left ventricular contractile function in the setting of acute ischemia followed by reperfusion ("stunned myocardium") has been observed in a number of clinical scenarios, and may have important clinical implications. At present, there are no widely accepted techniques available to demonstrate its presence. We report a case in which a rest 99mTc-sestamibi scan performed 12 hr after thrombolytic therapy in the setting of acute myocardial infarction demonstrated viable myocardium in a region that was akinetic by contrast ventriculography. After surgical revascularization, follow-up 99mTc-sestamibi images showed normal perfusion and radionuclide ventriculography demonstrated normal left ventricular function. Demonstration of preserved 99mTc-sestamibi myocardial uptake in the infarct zone despite an extensive region of akinesis by contrast ventriculography predicted the recovery of left ventricular function after revascularization in this case. This suggests that perfusion imaging with 99mTc-sestamibi early after myocardial reperfusion can detect stunned myocardium and thus facilitate the decision-making process regarding management of such patients.

Accumulation of 99mTc-polyphosphate in two squamous cell carcinomas of the lung: Case report.

Technetium-99m-polyphosphate was found to accumulate in two squamous cell carcinomas of the lung. In one case, microscopy and electron microscopy failed to demonstrate calcification in the tumor. Possible mechanism(s) of accumulation of polyphosphate in nonosseous tissues was reviewed.

Relative accretion of 99mTc-polyphosphate by forming and resorbing bone systems in rats: its significance in the pathologic basis of bone scanning.

The relative roles of osteogenesis andd osteolysis in the production of positive radionuclide images of skeletal lesions were investigated. The uptake of 99mTc-polyphosphate (Tc-PP) by each process was measured in an animal model that permitted bone formation and resorption to be studied independently. Ten rats received intramuscular implants of bone-forming demineralized matrix (DM) and resorbing devitalized bone (DV). Radiographs and Tc-PP scintiscans were made each week thereafter. At 6-10 weeks, the implants and normal bone samples were removed, counted for 99mTc, and examined histologically. The uptake of Tc-PP BY DM implants was first detected on images made 3 weeks after implanatation, and by DV implants, 1-2 weeks later. Serial radiography showed progressive calcification of DM an resorption of DV implants. Microscopic examinations of undecalcified sections, stained with a modified Goldner preparation, revealed vital-bone formation in the DM implants and osteoclastic resorption in the DV. Activity counts per gram of DM and DV implants were, respectively, 200% and 90% that of normal bone. Since only the bone-forming system (DM) accumulated Tc-PP at greater than normal concentrations, this study indicates that positive bone images of osteolytic lesions solely reflect compensatory osteogenic responses.

Resting early peak diastolic filling rate: a sensitive index of myocardial dysfunction in patients with coronary artery disease.

Resting first-pass radionuclide angiocardiography (RNA) was used to derive left-ventricular (LV) peak diastolic filling rates (PFR) in normals (Group 1:N = 12) and in patients with coronary artery disease (CAD), both without (Group 2:N = 27) and with previous myocardial infarction (Group 3:N = 23). Resting peak filling rates were significantly depressed in both Group 2 (1.61 +/- 0.36; p less than 0.01) and Group 3 (1:35 +/- 0.26; p less than 0.001) patients when compared with Group 1, normals (2.14 +/- 0.63). Even though LV systolic function of Group 2 patients was normal and comparable to that in Group 1 (EF = 0.55 +/- 0.06 against EF 0.55 +/- 0.06 NS), diastolic dysfunction [PFR less than 1.61 end diastolic volume/sec (EDV/sec)] was present at rest in 14 of 27 (52%). Depressed PFR values was also seen in 20 of 23 Group 3 patients (87%). It appears that (a) resting PFR is a sensitive and easily obtainable parameter of the diastolic dysfunction associated with CAD; (b) abnormal PFR values are seen in almost all patients with previous myocardial damage, and (c) a significant proportion of CAD patients without any evidence of abnormal systolic function have depressed resting PFR of the LV.

Technetium-99m(Sn2+)pyrophosphate in ischemic and infarcted dog myocardium in early stages of acute coronary occlusion: histochemical and tissue-counting comparisons.

We have investigated the pattern of accumulation of Tc-99m(Sn2+)pyrophosphate (Tc-99m PPi) in myocardial tissue of dogs during the early stages of acute occlusion of the left anterior descending coronary artery. Three groups were studied after: (a) 40 min occlusion followed by 6 hr reperfusion (n = 6); (b) 6 hr occlusion followed by one hour reperfusion (n = 5); and (c) 7 hr occlusion with no reperfusion (n = 4). Areas of myocardial infarction were defined with triphenyl-tetrazolium chloride (TTC) staining, and blood flow was determined with 9-mu radioactive microspheres. In Group C uptake in infarcted and peri-infarct areas was not enhanced, most likely owing to low flow. In Group B, with late reperfusion, Tc-99m PPi sequestration was increased in both infarcted and peri-infarcted tissues. In Group A, areas ischemic during occlusion but with normal flow and viability by TTC after 6 hr of reperfusion showed significant uptake of Tc-99m PPi (twice the uptake of nonischemic regions).

Autologous radioiodinated fibrinogen, simplified.

A method for the rapid preparation of radioiodinated autologous fibrinogen has been improved. Plasma is separated from cells by a single centrifugation. Fibrinogen is isolated in two salting-out steps at a 1:4 dilution of plasma and 22.5% saturated ammonium sulfate. Iodination is accomplished with chloramine T at a chloramine T-to-fibrinogen molar ratio of 12:1. Free iodide is removed by a single dilution and salting-out step at 29% saturated ammonium sulfate. Preparation time is about 1 hr; clottable radioactivity is 90-95%. Denaturation due to storage is undetectable at 6 weeks. Advantages of this procedure are (A) a short preparation time and (B) a purified autologous radioiodinated fibrinogen preparation.

Bone scan in dental diseases.

Bone images of the jaws and related dental structures were obtained in 25 patients undergoing skeletal surveys. The upper and lower jaws were divided into eight quadrants to facilitate comparisons between scintigraphic image findings and the results of dental examination. Fourteen of these 25 patients had at least one jaw quadrant with a positive image. The areas of positive uptake correlated well with dental examination findings, which included healing extraction sites and common dental diseases, such as pulpal and periodontal infections and irritations from ill-fitting dentures. The potential usefulness of bone imaging as an adjunct in dental diagnosis is discussed.

Diagnosis of acute myocardial infarction in patients undergoing open heart surgery: a comparison of serial myocardial imaging with cardiac enzymes, electrocardiography, and vectorcardiography.

In 44 consecutive patients undergoing elective open heart surgery (OHS), serial electrocardiograms (ECG), vectorcardiograms (VCG), serum CPK, cardiac isoenzymes (CPKMB), and myocardial images using Tc-99m pyrophosphate were obtained, before and after the operation, for the detection of acute myocardial infarction (AMI). Twenty-nine patients developed one or more positive tests postoperatively. Two patients had positive myocardial scintiscans; both had other evidence of infarction. Conversely, the appearance of CPKMB, or new ECG and VCG changes, occurred frequently without evidence of infarction, and were not associated with the development of a positive scintiscan. The results show that false-negative results are infrequent in patients imaged early after OHS, and that cardiac surgical procedures do not cause a high incidence of false-positive scintigrams. Consequently, radionuclide imaging for AMI offers an important adjunct for excluding acute infarction following open heart surgery.

Clinical appraisal of current nuclear and other noninvasive cardiac diagnostic techniques.

At a time of rapid increases in the cost of medical care and the application of complex invasive procedures to cardiovascular diagnosis, the use of noninvasive methods has aroused interest. This report discusses the usefulness and limitations of various noninvasive diagnostic methods including nuclear medicine techniques, echocardiography, exercise electrocardiography and determination of systolic time intervals. Emphasis is placed on the applicability of these methods to specific disease processes (such as ischemic heart disease, cardiac valve disease, pulmonary embolic disease), their relative merits, future potential and present shortcomings.

Effects of the Mueller maneuver on global and regional left ventricular function in angina pectoris with or without previous myocardial infarction.

In patients with coronary artery disease, left ventricular (LV) regional wall akinesia can develop during the Mueller maneuver. The present study determines if the presence of myocardial ischemic disease with no infarction is a sufficient condition for this to occur, or if the presence of prior acute myocardial infarction (MI) is necessary. In men, first-pass radionuclide ventriculography was performed in the 30 degree left anterior oblique supine position to measure LV ejection fraction, end-diastolic and end-systolic volumes and heart rate, and to obtain an image of the LV cavitary perimeter. This procedure was performed in 4 subject groups: 13 normal volunteers, 25 patients with coronary artery disease but no prior MI, 13 patients with coronary artery disease and prior nontransmural MI, and 36 patients with coronary artery disease and prior transmural MI. All patients had angina and underwent routine contrast coronary angiography; 60 also underwent contrast coronary angiography; 60 also underwent contrast LV angiography. Ejection fraction decreased during the Mueller maneuver in each of all the coronary artery disease groups (p less than 0.01), but not in the normal subjects. Heart rate increased in groups 1, 2 and 4 (p less than 0.01), and end-diastolic volume decreased in all 4 groups (p less than 0.01), whereas end-systolic volume did not change. Only in group 4 did regional wall akinesia develop (17 patients) during the Mueller maneuver. Among patients who had akinesia during the Mueller maneuver and also underwent routine contrast ventriculography, half of the akinetic segments were not seen on routine contrast study, but were seen only on radionuclide ventriculography during the Mueller maneuver.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of changes in resting left ventricular ejection fraction after coronary artery bypass grafting.

The prognostic significance of changes in resting left ventricular ejection fraction was examined in 102 patients who underwent successful coronary artery bypass grafting. Between preoperative and early postoperative radionuclide ventriculography, mean resting left ventricular ejection fraction improved from 47.2% to 53.9% (p less than 0.01). Left ventricular ejection fraction increased by 5% or greater in 64 patients (63%), remained unchanged (within 4%) in 31 (30%), and decreased by at least 5% in 7 (7%). During 14 to 39 months (mean 27 months) of clinical follow-up, patients with normal preoperative left ventricular ejection fraction had a lower prevalence of recurrent angina, congestive heart failure, and mortality resulting from cardiovascular disease. Cardiovascular morbidity and mortality occurred with equal frequency for patients who did and did not show early postoperative improvement in left ventricular ejection fraction (36% versus 39%). Among 69 patients who had a third radionuclide ventriculography at late follow-up, left ventricular ejection fraction was less than the early postoperative value in 69% and less than the preoperative result in 36%. Patients with early postoperative improvement in left ventricular ejection fraction were more likely to retain resting left ventricular contractile function, at least at the preoperative level (71% versus 46%).

The appearances of common dental diseases on radionuclide bone images of the jaws.

Radionuclide images of hospital patients were examined for abnormal areas within the jaws. Fourteen of 25 subjects studied showed one or more abnormal image areas, most of which were attributable to common dental lesions revealed by oral examinations. The lesions detectable on images included healing bone sites, periodontal and pulpal disease, residual osteitis and irritations caused by ill-fitting dentures.

Changes in septal regional ejection fraction early and late following coronary artery bypass grafting in patients without postoperative myocardial infarction.

Changes in regional ejection fraction (rEF) of the interventricular septum following coronary artery bypass graft (CABG) surgery were examined using first-pass radionuclide ventriculography (RNVG) in patients without objective evidence of postoperative myocardial infarction (MI). One hundred and one patients had pre- (mean 6.3 days) and early postoperative (mean 8.7 days) RNVGs, and 60 of these patients had follow-up studies at 14-39 months (mean 27 months) postsurgery. Early post-CABG, mean rEF in the proximal septum was unchanged from the preoperative value (35.3%), with almost equal numbers of patients showing increased (n = 36), unchanged (n = 33) or decreased (n = 32) rEFs. In the distal septum, mean rEF increased from 47.1 to 50.7%, with more than twice as many patients having increased (n = 44) as decreased (n = 20) rEF. At late follow-up, proximal septum rEF in individual patients tended to revert to the presurgery baseline, with 72% (13/18) of regions with early decrease improved and 61% (14/23) of those with early improvement decreased. In the distal septum, rEF was less than early post-CABG in 76% (19/25) of patients with early improvement, while being improved in 27% (3/11) of those with early decrease in rEF. In the absence of MI, changes in rEF in the proximal septum early post-CABG tend to resolve over time. While global changes in cardiac systolic motion are the probable cause of many new post-CABG septal abnormalities, persistent septal dysfunction probably reflects effects of permanent damage as a result of the operative procedure.

Radiolabelling leukocytes with 99Tcm-stannous chloride colloid for the detection of inflammatory lesions.

Freshly prepared 99Tcm-stannous chloride colloid (99Tcm-SCC) was used to label human leukocytes. The radiolabelled leukocytes were then injected intravenously into rats bearing carrageenan-induced inflammation in their hindlimbs. Scintigraphic imaging (n = 3) and biodistribution studies (n = 4) 4 h post-injection were performed. The ratio of radioactivity (cpm/pixel) accumulated in the inflammation site to that in the corresponding area of the contralateral limb was 2.9 +/- 0.8, as calculated by region-of-interest analyses of the planar images. The distribution of radioactivity in the dissected tissue showed that the ratio of radioactivity (cpm/g) of infected tissue to that of a normal sample obtained from the contralateral limb was 2.6 +/- 0.5. The biodistribution study of dissected organs showed high uptake in liver (58.9 +/- 8.2%), spleen (4.3 +/- 1.8%) and lungs (6.3 +/- 2.4%). The results of this preliminary study indicate that 99Tcm-SCC can be used as an alternative agent for radiolabelling leukocytes for the detection of inflammatory lesions.

The radionuclide evaluation of septal wall motion following coronary bypass surgery.

We investigated the diagnostic accuracy of radionuclide global and regional left ventricular (LV) function after coronary revascularization. A consecutive series of 43 patients was studied. First-pass radionuclide angiograms were performed preoperatively (4 days +/- s.d. 3 days, range 1-18 days) and postoperatively (7 days +/- s.d. 3 days, range 3-19 days). Regional radionuclide LV function was assessed using the two-dimensional display of systole and the three-dimensional ejection fraction image. Electrocardiograms were obtained the day prior to surgery and every 8 h for the first three postoperative days. Creatine kinase (CK) and lactate dehydrogenase (LDH) isoenzymes were obtained the day prior to surgery and every 8 h for the first three postoperative days. In 39 patients who did not develop perioperative myocardial infarction by isoenzyme or ECG criteria, we found that 38 patients showed unchanged or improved global and regional LV function, while one patient without isoenzyme or ECG evidence of perioperative myocardial infarction developed a new septal wall motion abnormality. Thus, the specificity of the radionuclide radioventriculogram for new septal wall motion abnormalities was very high. In four patients who developed isoenzyme and ECG evidence of myocardial infarction, septal wall motion worsened in all four patients while global left ventricular ejection function fell significantly in three patients. Thus, the radionuclide radioventriculogram also had high diagnostic sensitivity. In summary, contrary to past and recent reports, this investigation demonstrated that the radionuclide radioventriculogram can be used to assess global and regional LV function after coronary artery bypass surgery and furthermore, that it reliably indicates the presence of a new postoperative myocardial infarction.