The Contribution of SPECT/CT Bone Scintigraphy in the Localization of an Infective (Purulent) Sacroiliitis – A Case Report

Nevena Manevska; Neron Popovski; Tanja Makazlieva; Hristina Popovska; Aleksandra Pesevska-Todorcevska; Sinisa Stojanoski

doi:10.3889/oamjms.2020.4740

Authors

Nevena Manevska Institute of Pathophysiology and Nuclear medicine, Acad. Isak S. Tadzer, Medical faculty, University of Ss Cyril and Methodius, Skopje, Republic of Macedonia
Neron Popovski University Clinic of Ortopedics, Medical faculty, University of Ss Cyril and Methodius, Skopje, Republic of Macedonia
Tanja Makazlieva Institute of Pathophysiology and Nuclear medicine, Acad. Isak S. Tadzer, Medical faculty, University of Ss Cyril and Methodius, Skopje, Republic of Macedonia
Hristina Popovska University Clinic of Neurology, Medical faculty, University of Ss Cyril and Methodius, Skopje, Republic of Macedonia
Aleksandra Pesevska-Todorcevska Institute of Pathophysiology and Nuclear medicine, Acad. Isak S. Tadzer, Medical faculty, University of Ss Cyril and Methodius, Skopje, Republic of Macedonia
Sinisa Stojanoski Institute of Pathophysiology and Nuclear medicine, Acad. Isak S. Tadzer, Medical faculty, University of Ss Cyril and Methodius, Skopje, Republic of Macedonia; Lazarski University, Medical faculty, Warsaw, Poland

DOI:

https://doi.org/10.3889/oamjms.2020.4740

Keywords:

sacroiliitis, SPECT/CT, MRI, Diagnostic imaging modalities, Hybrid imaging

Abstract

BACKGROUND: Infectious sacroiliitis (ISI) is an inflammation of one or both of the sacroiliac (SI) joints, relatively rare disorder, affecting between 1% and 2% of all patients with septic arthritis. The variety of symptom presentation makes the diagnosis quite challenging. Combination of laboratory hematological tests, together with diagnostic imaging tools, such as magnetic resonance imaging (MRI), computed tomography (CT), and bone scan (BS), as well as microbiological tests contribute the final diagnosis, which may take up to several months.

CASE REPORT: We present a case of a 33-year-old male patient with a history of lower back pain with propagation of the pain in the right leg, accompanied by febrility and hematuria. Laboratory tests showed high values of C-reactive protein, high degradation products and hyperkalemia, leading to a diagnose of acute renal failure stage 3. MRI of the lower spine and pelvis revealed hetero- signal change more to the right where the spinal canal was expanded, accumulating contrast and involved the caudate and the right radix. Тhe displayed sequences were accompanied by an altered morphology of the spinal musculature, with intense accumulation of contrast in parts of the muscle. Paravertebral abscess was detected in the intercaudal and iliac muscles, along with inflammatory edema of the right SI with a suspicion of a sacroiliitis. One week after, a three phase BS showed positive accumulation in the right SI joint in all three phases. The SI index for the right SI joint was 2.09, while for the left SI joint was 1.125. The patient underwent surgical intervention for drainage of the paravertebral abscess.

CONCLUSION: The condition of ISI may be sometimes very difficult to be recognized in many patients. Considering the diversity of the clinical manifestations, it is of great importance to select the right imaging modality. The nuclear medicine technique triple phase bone and the hybrid imaging SPECT/CT have been suggested to improve the sensitivity and specificity of the bone scan, providing better characterization of equivocal lesions, especially in the acute form for disease localization.

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References

Hermet M, Minichiello E, Flipo RM, Dubost JJ, Allanore Y, Ziza JM, et al. Infectious sacroiliitis: A retrospective, multicentre study of 39 adults. BMC Infect Dis. 2012;12:305. https://doi. org/10.1186/1471-2334-12-305 PMid:23153120

Wu MS, Chang SS, Lee SH, Lee CC. Pyogenic sacroiliitis-a comparison between pediatric and adult patients. Rheumatology. 2017;46(11):1684-7. https://doi.org/10.1093/rheumatology/ kem201 PMid:17901064

Cinar M, Sanal HT, Yilmaz S, Simsek I, Erdem H, Pay S, et al. Radiological follow up of the evolution of inflammatory process in sacroiliac joint with magnetic resonance imaging: A case with pyogenic sacroiliitis. Case Rep Rheumatol. 2012;2012:509136. https://doi.org/10.1155/2012/509136 PMid:23050188

Abelson A. Septic Arthritis. Cleveland Clinic; 2010. Available from: http://www.clevelandclinicmeded.com/medicalpubs/ diseasemanagement/rheumatology/septic-arthritis. [Last accessed on 2016 Oct 28].

Malhotra A, Kalil R, Jones R, Schwartz D, Qadeer AH, Huang M, et al. Infectious sacroiliitis: A radiographic no touch lesion. J Gen Pract (Los Angel). 2017;5:336. https://doi. org/10.4172/2329-9126.1000336

Tsoi C, Griffith JF, Lee RK, Wong PC, Tam LS. Imaging of sacroiliitis: Current status, limitations and pitfalls. Quant Imaging Med Surg. 2019;9(2):318-335https://doi.org/10.21037/ qims.2018.11.10 PMid:30976556

Song IH, Carrasco-Fernandez J, Rudwaleit M, Sieper J. The diagnostic value of scintigraphy in assessing sacroiliitis in ankylosing spondylitis: A systematic literature research. Ann Rheum Dis. 2008;67(11):1535-40. https://doi.org/10.1136/ ard.2007.083089 PMid:18230629

Morsi A, Sallam A, Saoud A. Infectious sacroiliitis (ISI). World Spinal Column J. 2015;6(1): 27-35

Stürzenbecher A, Braun J, Paris S, Biedermann T, Hamm B, Bollow M. MR imaging of septic sacroiliitis. Skeletal Radiol. 2000;29(8):439-46. https://doi.org/10.1007/s002560000242 PMid:11026711

Ahmed H, Siam AE, Gouda-Mohamed GM, Boehm H. Surgical treatment of sacroiliac joint infection. J Orthopaed Traumatol 2013;14(2):121-9. https://doi.org/10.1007/s10195-013-0233-3 PMid:23558792

Oostveen J, Prevo R, den Boer J, van de Laar M. Early detection of sacroiliitis on magnetic resonance imaging and subsequent development of sacroiliitis on plain radiography. J Rheumatol. 1999;26(9):1953-8. PMid:10493676

Doita M, Yoshiya S, Nabeshima Y, Tanase Y, Nishida K, Miyamoto H, et al. Acute pyogenic sacroiliitis without predisposing conditions. Spine (Phila Pa 1976). 2003;28(18):E384-9. https:// doi.org/10.1097/01.brs.0000092481.42709.6f PMid:14501940

Klein MA, Winalski CS, Wax MR, Piwnica-Worms DR. MR imaging of septic sacroiliitis. J Comput Assist Tomogr. 1991;15(1):126- 32. https://doi.org/10.1097/00004728-199101000-00020 PMid:1987181

Cusi M, Saunders J, Van der Wall H, Fogelman I. Metabolic disturbances identified by SPECT-CT in patients with a clinical diagnosis of sacroiliac joint incompetence. Eur Spine J. 2013;22(7):1674-82. https://doi.org/10.1016/j.joca.2012.02.368 PMid:23455953

Yildiz A, Gungor F, Tuncer T, Karayalcin B. The evaluation of sacroiliitis using 99mTc-nanocolloid and 99mTc-MDP scintigraphy. Nucl Med Commun. 2001;22(7):785-94. https:// doi.org/10.1097/00006231-200107000-00010 PMid:11453052

Koç ZP, Cengiz AK, Aydın F, Samancı N, Yazısız V, Koca SS, et al. Sacroiliac indicis increase the specificity of bone scintigraphy in the diagnosis of sacroiliitis. Mol Imaging Radionucl Ther. 2015;24(1):8-14. https://doi.org/10.4274/mirt.40427 PMid:25800592

Gheita TA, Azkalany GS, Kenawy SA, Kandeel AA. Bone scintigraphy in axial seronegative spondyloarthritis patients: Role in detection of subclinical peripheral arthritis and disease activity. Int J Rheum Dis. 2015;18:553-9. https://doi. org/10.1111/1756-185x.12527

Battafarano DF, West SG, Rak KM, Fortenbery EJ, Chantelois AE. Comparison of bone scan, computed tomography, and magnetic resonance imaging in the diagnosis of active sacroiliitis. Semin Arthrit Rheum. 1993;23(3):161-76. https://doi.org/10.1016/ s0049-0172(05)80037-x PMid:8122119

Scott KR, Rising KL, Conlon LW. Infectious sacroiliits. J Emerg Med. 2014;47(3):83-4.