title: The optimized evaluation of diabetic foot infection by dual isotope SPECT/CT imaging protocol.
abstract: Sequential Tc-99m hydroxymethylene-diphosphonate (HDP) 3-phase bone (BS) and In-111 leukocyte scanning (WBCS) have been frequently used to evaluate the diabetic foot, as nonosteomyelitis BS uptake is repeatedly observed and osteomyelitis (OM) in WBCS is often uncertain without BS correlation. Additionally, both modalities are limited in lesion localization because of low resolution and lack of anatomic details. We investigated a method that combined BS/WBCS, and if needed, WBCS/bone marrow scanning (BMS) using SPECT/CT to accurately diagnose/localize infection in a practical protocol. Blood flow/pool images were obtained followed by WBC reinjection and next day dual isotope (DI) BS/WBCS planar and SPECT/CT. BMS/WBCS SPECT/CT (step 2 DI) was obtained on the following day when images were suspicious for mid/hindfoot OM. Diagnosis accuracy and confidence were judged for the various imaging combinations. Diagnosis was classified as OM, soft tissue infection (STI), both OM/STI, and other/no bony pathology by microbiology/pathology or follow-up. Distinction between various diagnostic categories and overall OM diagnostic accuracy in 213 patients were higher for DI than WBCS or BS alone, and for DI SPECT/CT than DI planar or SPECT only. Diagnostic confidence/lesion site was significantly higher for DI SPECT/CT than other comparative imaging methods. In a group of 97 patients with confirmed microbiologic/pathologic diagnosis, similar results were attained. Step 2 DI SPECT/CT performed in 67 patients further improved diagnostic accuracy/confidence. DI SPECT/CT is a highly accurate modality that considerably improves detection and discrimination of STI and OM while providing precise anatomic localization in the diabetic foot. This combined imaging technique promises to beneficially impact diabetic patient care.
authors.affiliation: Nuclear Medicine Service, Nuclear Medicine Division, Mount Sinai School of Medicine, New York, NY 10029-6574, USA. Sherif.Heiba@mssm.edu
authors.forename: Sherif I
authors.initials: SI
authors.lastname: Heiba
authors.forename: Dov
authors.initials: D
authors.lastname: Kolker
authors.forename: Bharat
authors.initials: B
authors.lastname: Mocherla
authors.forename: Karan
authors.initials: K
authors.lastname: Kapoor
authors.forename: Manli
authors.initials: M
authors.lastname: Jiang
authors.forename: Hongju
authors.initials: H
authors.lastname: Son
authors.forename: Balasubramanya
authors.initials: B
authors.lastname: Rangaswamy
authors.forename: Lale
authors.initials: L
authors.lastname: Kostakoglu
authors.forename: Ina
authors.initials: I
authors.lastname: Savitch
authors.forename: Maria
authors.initials: M
authors.lastname: DaCosta
authors.forename: Josef
authors.initials: J
authors.lastname: Machac
mesh_terms: D017719:Diabetic Foot / Q000382:microbiology*; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007205:Indium Radioisotopes; D007958:Leukocyte Count; D008297:Male; D008875:Middle Aged; D010019:Osteomyelitis / Q000175:diagnosis*; D011237:Predictive Value of Tests; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018461:Soft Tissue Infections / Q000175:diagnosis*; D013669:Technetium Tc 99m Medronate / Q000031:analogs & derivatives; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed
chemical_list: D007205:Indium Radioisotopes; D019275:Radiopharmaceuticals; C024226:technetium Tc 99m hydroxymethylene diphosphonate; D013669:Technetium Tc 99m Medronate