.

.

Diagnostic of Nuclear In AIDS1

Uses Medicine

WilliamJ. Vanarthos, William I. Ganz, MD Jill C. Vanarthos, PA Aldo N. Serafini, MD Jamsbid Tebranzadeb,

Radionuclide useful

MD

imaging,

in the

pulmonary

if applied

diagnosis

drome)-related pected on the provide

MD

of the

an

organ

and

guidelines

concomitant

processes intensity

is

can and

various

and

syn-

be suspattern of

uptake

among

Gastrointestinal

approach,

immunodeficiency

nonpulmonary

for distinguishing

pathogens.

system

(acquired

complex. Specific pathologic basis ofuptake patterns. The

uptake

pulmonary

with AIDS

of gallium

opportunistic

extra-gastrointestinal

tract uptake of gallium aids distinction among fungal, mycobacterial, and viral infections and neoplasms. Patterns of spleen uptake of technetium-99m sulfur colloid and gallium allow differentiation between neoplasm

(Kaposi

sarcoma)

tal and soft-tissue ated on the basis

and

infection

(with

mycobacteria).

Skele-

can be characterized and differentiand other radionuclide scan findings. Thallium uptake in brain tumors (and not in areas of infection) allows brain lesion discrimination. In the proper clinical setting, AIDS nephropathy has a characteristic gallium uptake pattern. Cardiac abnormalities

(including

With

of these

studies,

appropriate

Index

AIDS

terms:

Acquired 60.2518 studies, 1992;

C

RSNA,

See

the

Bowman

organ-specific

assessed

with

patterns ofAIDS

immunodeficiency = methylene

syndrome, diphosphonate,

MDP

immunodeficiency 70. 1299

syndrome Heart,

(AIDS)

radionuclide

#{149}

Lung, radionuclide 10.1299, 30.1299

studies,

#{149}

of Diagnostic MedicalCenter Sciences,

Gray

School

Radiology,

and

can

HIV

60. 1299

=

RBC Bones,

be

human = red

scintigraphy.

with

correlative

differentiated

immunodeficiency blood cell, WBC

radionuclide

#{149}

5 1 . 1299

studies,

Division

(Wj.V., WIG., University ofCalifornia,

Laude award for a scientific exhibit 3; final revision received February diology,

be

and

Muscles,

#{149}

studies,

Kidney,

radionuclide

radionuclide

studies,

#{149}

=

virus, white

40. 1299

I-IMPAO blood cell

=

hex.

Gastrointestinal

#{149}

studies,

40. 1299

81.1299 Nervous

#{149}

sys-

12:731-749

the Department

UniversityofMiami ment of Radiological

also

instituted.

acquired

studies,

RadioGraphics From

=

can

manifestations

oxime,

radionuclide

Lung, diseases, tem, radionuclide

the

treatment

Abbreviations: amethyl-propyleneamine

I

functional)

knowledge

imaging

tract.

abnormalities of bone scan

at the 27,

ofMedicine,

1990

1992;

RSNA scientific

accepted 300

of Nuclear

A.N.S.); Camillus irvine Medical March

S Hawthorne

Medicine, Health Center,

assembly. 3. Address

Jackson Concern, Orange,

Received reprint

Rd. Winston.Salem,

Memorial Miami Calif

Hospital,

(J.C.V.); and UT.). Recipient

Miami, the

and

Depart. ofa Cum

May 21, 1991; revision requested requests to Wj.V., Department

July of Its-

NC 27103.

1992 commentary

by McAfee

following

this

article.

73i



Pusdo

J

Uco

11111

4,262

3.0004.999

0 Figure 1. the United

Figure

2.

Diagram depicts the geographic distribution States as ofJuly 31, 1990. (Source: Centers

Chart

shows

the

percentage

IVDA Centers

number Control,

ofAIDS

cases

reported

in

Atlanta.)

of

AIDS cases, according to risk or exposure group, in the United States as ofJuly 1990. The Unknown, Transfusion, and Hemophiliac categories include children. venous drug abuser. (Source: Disease Control, Atlanta.)

of the total for Disease

o-cc’

=

Intravenous

6.7%

Drug Abusers

Homosexual/IVDA Heterosexual

5%

21.1%

3.5%

intrafor

Unknown

58.8%

U

INTRODUCTION

The

diagnostic

acquired

mole of radionuclide

immunodeficiency

is becoming

Over

increasingly

6 million

infected

more

individuals

with

the

imaging

syndrome

are

human

in

(AIDS)

important.

(World

communication,

to be

immunodeficicncy

Health June

Organization,

1990).

At least

half

oral of

these cases have been in the United States, and as ofJuly 1990, mortality from AIDS had exceeded 60% in the United States (Centers for

Disease

Control,

oral

communication,

1990) (Figs 1, 2). Efforts to effectively detect and to thwart the progression of the disease are crucial, since approximately half of those infected

732

U

RadioGraphics

U

Vanarthos

et a!

the H1V will develop AIDS within iO (i). Scintigraphy can be used to detect

opportunistic

estimated

virus (HIV), and a cumulative total of over 260,000 cases ofAIDS has been reported

worldwide

with years

July

infections

radiologic studies ease activity before

when

are normal, and after

results

of other

to assess distherapy, and to

evaluate the extent of disease involvement. Thus, specific treatments may be implemented sooner in an effort to improve pmognosis.

In this article, the mole of radionuclide imaging is reviewed as it applies to the diagnosis of infectious diseases, tumors, and systemic disorders that are directly related to HIV infection. We describe our organ-system ap-

proach are

to identifying

diagnostic

patterns

of specific

of uptake

AIDS-related

that disor-

ders.

Volume

12

Number

4

Table 1 Gallium Uptake

Patterns

in the

Suggested Diagnosis

Chest

in AID5

Patients

Lung Uptake Pattern

Pneumocystis pneumonia MAI infection

carinli

Tuberculosis

Nodal Uptake Pattern

Diffuse

intense

Patchy

or lobar

Common trahilar)

(hilar

Patchy

or lobar

Common

(hilar)

Characterizing Feature

None and

Radiographic appearance may be normal Less common outside United States, more common than tubercubosis in homosexual or bisexual men Occasional unilateral

ex-

parotid common infection Lymphoid interstitial pneumonia Cytomegalovirus infection

Diffuse

low-grade

None

Diffuse

bow-grade

None

Bacterial

Lobar

pneumonia

Classic

None

on chest radiographs Bone uptake

Multilobar

Kaposi

None

None

None

Bulky

Lymphoma

nous drug abusers Bilateral parotid uptake common Bilateral eye and adrenal uptake, colon and esophageal uptake

None

Invasive bacterial pneumonia (eg, actinomycosis or fungal infections)

sarcoma

uptake

-MM

Mycobacterium

=

AIDS-related lines

Table

disorders,

criteria

arc

most of

and

use-

in

1.

Pneumocystis

Pneumonia

Carinii

in 85%-95%

pneumonia.

whom

of cases

In asymptomatic

results

of chest

ofP

for

arc nor-

mal,

gallium scintigraphy will often reveal P carinli pneumonia (3-5) (Fig 3). This point is crucial because early detection and therapy (when radiographic findings are normal) provide a better prognosis (7). At the stage when plain chest madiographs appear abnormal, pub-

monary

uptake

scintigrams

July

1992

may,

of gallium-67 in fact,

in chest

appear

almost

next few months If pulmonary chest radiography that

ing

certain

(4). gallium are

pulmonary

number

and

death

uptake and both normal,

some

have

clearance

is

in the

results

abnormalities

Although

abnormal

in the

lymphocytes

of

it is un-

are

reported

observ-

of technetium-99m-

labeled diethylene aerosol in patients we do not use this

triamincpentaacetic acid with normal gallium scans, method. Instead, we use a

quantitative

of gallium

index

to soft

tissue

uptake (8) to detect bow-grade P carinii pneumonia to prevent false-positive diag-

carinii

patients

radiography

a decrease

functioning with

present.

P carinii pneumonia is usually the first pulmonary manifestation in AIDS patients, and, with time, more than 80% of these patients develop the infection (2). Findings from gallium scintigraphy are ab-

normal

reflects

associated

guide-

provided

likely

of immune

likely

.

than

avium-intracellulare.

is probably the for differentiation

pulmonary

for diagnostic

infiltrate

on chest radiograph More common in abdo-

nodal

state

U LUNG Gallium scintigraphy ful imaging method

bobar

Thallium-201 chloride uptake at site of mass

men Note

uptake, more than MM in intrave-

decreases,

and

normal.

This

noses with

and

to monitor

pulmonary

therapy

in AIDS

patients

infections.

The pattern of either uniform form, diffuse, increased bilateral uptake of Ga-67 of an intensity that in the liver (without nodal

Vanarthos

et a!

or nonunipulmonary greater than or parotid up-

U

RadioGraphics

U

733

.-

b. Figure

3. (a) Chest radiograph of a patient with AIDS and P carinii pneumonia has a normal appearance. (b) Gallium scans depict bilateral diffuse intense uptake, characteristic ofP cannii pneumonia. (Reprinted, with permission, from reference 8.) a.

Figures

4, 5. (4) Gallium scans of a patient with AIDS and lymphoid interstitial pneumonia show symmetric abnormally increased uptake in the parotid glands (small arrows) and diffuse low-grade uptake in the lungs (large arrow). (5) Anterior (a) and posterior (b) gallium scans obtained 72 hours after radionuclide injection show uptake in the eyes (small arrow in a), adrenal gland (arrowhead b), and colon (large arrow a), with low-grade activity the lungs (arrows in b). printed, with permission, from reference 8.)

4-

in in in

(Re.

5a

4-

take) has a specificity of 90% for P carinii pneumonia (3) The presence of heterogeneous diffuse lung uptake may have a predictive value higher than that of homogeneous uptake (5), and, when results of concurrent chest radiography are normal, the specificity approaches 100% (6). .

.

5b.

Lymphoid

interstitial

RadioGraphics

U

Vanarthos

et a!

pneumonia

symmetric

low-grade

U

Pneumonia

appearance

of lymphoid

may

be

normal

or

mc-

semble that ofP caninii pneumonia, viral infections, or miliary tuberculosis. Ganz et al (9) have reported a Ga-67 scintigraphic pattern diagnostic for lymphoid interstitial pneumonia:

734

Interstitial

The radiographic

increased

diffuse

parotid

pulmonary

Volume

uptake

uptake

12

and

a

without

Number

4

gtient ecific litient ye of

with AIDS asymmetric depict ster-

ieference

actinomyco8.)

a

nodal

uptake

(Fig 4). Uptake

cases of sarcoidosis lymphoid interstitial osis

.

is rare

in AIDS

presence

should graphic uptake

(due

in

Infection

to the frequent retinitis),

infection

occurrence adrenal

a superimposed

pneumonia .

Bacterial

Unusual

(due

infection

to the

local

1992

is

carinii

may

bone

7).

fcction

suspected

invasion

or

if pulmonary

are noted

in AIDS

of bacterial

in sug-

pneumonia

Infection avium-intracellulare disease in 25%50%

that than

Because bacterial

as actinomycosis

diagnosis

Mycobacterial

morbidity

such be

the

(Fig

apy

Infection

patients (Fig 6). This tern may be the only since results of needle tive in actinomycosis

July

ofF

be considered.

infections

nocardiosis

and

must

gests

uptake in a lobar configuration of nodal and parotid uptake

causes patients (1 1). Many who are treated fomP caninii pneumonia or tuberculosis have atypical mycobacterial infections such as M avium-intracellulare infection and do not respond to therapy (12). Patchy lung uptake and hilar (as well as nonhilar) nodal Ga-67 uptake patterns suggest less treatable, atypical mycobacterial in-

of cytomega-

uptake

Intense absence

Mycobactenium widespread

scintipulmonary eye uptake

frequent occurrence of cytomegabovirus admenalitis), renal uptake at 48 hours after madionuclide injection, and persistent colon uptake associated with diarmheal symptoms (Fig 5) (6). If high-grade pulmonary uptake seen,

the

.

of a cytomcgabovirus

be suspected if the following pattern is seen: low-grade with perihilar prominence,

lovirus

seen

to those of but sarcoid-

patients.

Cytomegalovirus

The

patterns

may be similar pneumonia,

requires

is used

a more for

aggressive

tuberculosis

(Fig

delays in diagnosing infections contribute associated

with

ofAIDS

atypical to the these

them8).

mycohigh

conditions,

routine evaluation of nonhilar (particularly axillary and inguinal) nodes on Ga-67 scans may prompt earlier, appropriate therapy.

implicative uptake patclue to the diagnosis, biopsy are often nega(10).

Vanarthos

et a!

U

RadioGrapbics

U

735

-

:.

. .

.

,,

,

..

#{149}v#{149}

,.

a.

b.

Figure 7. (a) Chest radiograph of a patient with AIDS and the left lower lobe (arrow). (b) Gallium scans show increased out

nodal

uptake,

corresponding

to the

lesion

seen

bacterial

pneumonia

uptake

demonstrates

(arrows)

in a. (Reprinted,

with

in a lobar

permission,

an opacity

configuration from

in

with-

reference

8.)

Figure 8. (a) Chest radiograph of a patient with AIDS and M avium-Intracellulane infection shows hilar (open arrow) and

right paratracheal (solid arrow) adenopathy and clear lungs. (b) Gallium scan demonstrates the hibar and extrahilar adenopathy (arrows), which proved

to be M avium-intnacellulane infection.

a.

Gallium

uptake

in the

is characteristic

hilar

b.

nodes

of tuberculosis

(Figs

and lungs 9, 10)

U

. Neoplasms AIDS-related lymphoma affects the lung frequently than mycobacterial infection, the neoplasm can be distinguished from by its characteristic

bulky

ofuptake In cases

(Figs 11, of Kaposi

12) (13). sarcoma,

is usually

seen,

gallium

but

distinguishing

Thus,

feature

an ill-defined

associated

with

scintigraphy (Fig

13).

also

uptake

normal

is suggestive This

diagnosis ofTb-201

and

tools.

In uncertain

is not

or mediastinal results

from

of Kaposi is very

(a

tic

gallium sarcoma

likely

iftherc

in the

mass.

is

RadioGrapbics

U

Vanarthos

et a!

that

are

Ga-67

cells other

scintigraphy

may or

esophagus,

In-i

11

it is

infections

present

be

111-labeled

If Ga-67

the

opportunistic

are

diagnostic

or indium-

because candidiasis ofcandidiasis cases,

infections

tract

adequate

(WBCs).

outside

patients

gastrointestinal

cases,

with

are the most

in AIDS

arc

is rarely systemic. other opportunis(14).

Diarrhea, which is often debilitating in the immunodeficient individual, is most commonly caused by infection with the protozoan Cryptosponidium (1 5). Because the organism is shed

the

U

upper

endoscopy

is seen

present In 60%

(6). mass

an

blood

uptake

uptake

lymphoma)

chloride

series

white

candidiasis infections

Usually

likely uptake

fungal

performed

pattern

thallium

from

lung

nodal

less but infec-

TRACT

esophageal

(14).

tions

736

and

common

(3-6).

tion

GASTROINTESTINAL

Oral

intermittently, or

bowel

diagnosis.

multiple biopsies

arc

stool needed

examinato make

If no organism

is noted

examinations,

the

of a cytomegalo-

virus

becomes

infection

possibility more

Volume

in these

likely.

12

Number

4

Figures

9, iO.

(9)

Gallium

scan of a patient with AIDS and tuberculosis shows prominent hilar and extrahilar bymphadenopathy (arrow). (iO) Lateral chest radiograph (a) and gallium scan (b) ofa patient with AIDS and tuberculosis demonstrate hilar adenopathy (arrows).

11.

12.

Figures ii, i2. (ii) Gallium scans obtained 48 hours after radionuclide injection in a patient demonstrate a bulky pattern of mediastinal adenopathy (arrows), a finding indicative oflymphoma cubosis). (12) Gallium scans demonstrate a diffuse, bulky nodal pattern (arrows), characteristic

Ga-67

or greater fies

over

uptake

than time

in the

liver

bowel

uptake

represents

that and

infection

is equal that

to

intensi-

in over

50% of patients (6) However, severe constipation, nonspecific inflammation, or tumors .

may

also have this pattern. In-i 1 i-labeled studies have been shown to have a higher sensitivity and specificity than Ga-67 scintigraphy in the assessment of suspected gastrointestinal tract infections (16).

WBC

Causes to be considered in the presence of abnormal bowel uptake on Ga-67 and In-i iilabeled WBC scans can be suggested by uptake location. Prominent uptake in the sig-

July

1992

moid

colon

is indicative

and

cecum

that

of delayed

with

AIDS (vs tuberof lymphoma.

changes

excretion

over due

time

to con-

stipation. Increased uptake in the proximal small bowel is usually due to Cryptosporidium organisms, although other causes should be considered if the patient has traveled to areas endemic for Giardla or Isospora proto-

zoa.

Ileal,

cecal,

and

nodal

nent with mycobacterial colonic uptake that does

due

to cytomegalovirus

Vanarthos

uptake

is promi-

infections. not change

infection

et a!

Diffuse can be

(when

U

stool

RadioGraphics

U

737

a.

b.

Figure cific tent

Table

i3.

(a) Chest

radiograph

opacity in the left with the diagnosis

of a patient

lower lobe of Kaposi

(arrows). sarcoma

with

AIDS and

(b) Results (cf Fig 7).

of the

Kaposi

sarcoma

gallium

scan

shows are

a nonspe-

normal,

consis-

2

Scintigraphic

Patterns

in the

Gastrointestinal

Tract

In AIDS

Uptake

Diagnosis

Location

+ +

Candida

Usually limited esophagus

Cytomegalo-

Esophagus, lung, colon, retina,

virus

to

of Radionuclide In-ill WBC*

Ga-67

Infection

Patients

Pattern

Tc-99m RBC

+ + +

Tl-20i

-

-

Need oblique view to visualize esophagus

well Peripheral lung distribution

Negative

adrenal gland Small bowel

Cryptosponid-

lum Giardia Salmonella on Shigella Mycobactenium

Comments

cultures

May need study

bowel

Duodenum, jejunum Colon (diffusely) Ileum,

colon

Hilar and nonhibar nodal

uptake Antibiotic-associated colitis Tumor Kaposi sarcoma

Colon

I

+

-

due

to

-

+ +

+ +

-

-

+ +

obstruction Lymphoma

+

Note.-= no uptake, + = mild * Preferred agent for infection. t Positive criteria: gastrointestinal the

738

U

RadioGrapbics

same

location,

U

uptake

Vanarthos

noted

et a!

uptake, tract at 2-6

+ +

=

moderate

uptake

more

intense

h after

injection.

uptake, than

+ + +

liver

=

uptake,

high-grade persistent

Volume

uptake. visualization

12

Number

at

4

a.

Figure

Anterior adrenal

b.

14.

Correlative

(a) and gland

images

posterior

(arrows

enlarged

left adrenal

periaortic esophagus

adenopathy (arrow),

c.

of a patient

(b) gallium in b),

as well

gland

with

scans as hilar

(arrow).

AIDS,

demonstrate and

extrahilar

(d) Another

CT scan

(e) Image from a barium typical ofcytomegalovirus

(arrow) a finding

.

cultures are negative), bacterial infections such as salmonellosis or shigellosis, or antibiotic-induced colitis. The pattern of uptake in the rest of the body (Table 2) may help in making a more definitive diagnosis (Fig 14). Eye, adrenal, esophageal, and low-grade pulmonary uptake in the

presence

of colon

of cytomcgalovirus cal (right paratracheal indicative

pared fections

July1992

uptake

(Fig

and

bowel)

of mycobacterial

with such

the

diffuse

are

infection

infection,

activity

as salmonelbosis

Multifo-

activity

cytomegabovirus

increased adenopathy

obtained swallow

infection,

uptake

in the distal

(arrow

in a). (c)

and

tuberculosis.

esophagus

and

CT scan

shows

left the

at the level of the renal hiba demonstrates study shows a single ulcer in the distal

infection.

Other ferential

correlative

studies

diagnosis.

For

are

example,

useful

for dif-

a Tc-99m-

labeled detect

red blood cell (RBC) study done to gastrointestinal bleeding may show RBC pooling in the same area that showed uptake during a thallium scan. On the basis these

findings,

seen at computed sound is Kaposi

suggestive

5).

proved

one

may

suspect

tomography sarcoma.

that

(CT)

of

a mass

or ultra-

is

com-

of bacterial (Fig 15).

in-

Vanarthos

et a!

U

RadioGrapbics

U

739

Figure i5. (a) Gallium scan of a patient with AIDS and mycobacterial infection demonstrates

right

bowel with

AIDS

more seen

paratracheal

uptake. and

diffuse

(arrow)

(b) Gallium

scan

salmoneblosis

activity,

and

of a patient

demonstrates

compared

with

that

in a.

a.

Figure

16.

b.

Sulfur

colloid scan (a) and gallium scans (b) of two different patients

with AIDS and sarcoma demonstrate en-

Kaposi

barged spleens with reduced uptake (arrows in b), characteristic of this neo-

plasm. b.

U LIVER AND SPLEEN In scintigraphy of the liver and spleen, the finding of an enlarged spleen with reduced

more

uptake

rial

in AIDS

sarcoma bulky

740

U

RadioGraphics

of Tc-99m patients

sulfur is usually

(Fig 16). When nodes are present,

U

Vanarthos

colloid large

liver

of Kaposi

defects

the diagnosis

et a!

or

is

with

to be lymphoma. a small

infiltrative

or of gallium

indicative

likely

fects

hypoactivc

inflammations

infection

are

On liver-spleen scans,

pattern

linear

suggest

such

more

likely

scans

defects

that

small are

in a biliary

cholangitis.

tobiliary

scans

show

that

filling

and

are also

delayed

bowel

excretion

3).

hepatobiliary

join

delayed

deseen,

as mycobacte(Table

and

scbemosing

When spleen

these

defects

associated

tree

Hepahave

with

(i7).

Volume

12

Number

4

Table 3 Scintigraphic

Patterns

in the

Diagnosis

Liver Hepatic

Infection (mycobactenial) Cholangitis Tumor Pre-AIDS AIDS without KS AIDS with KS

Note-KS *In

and

Splee

n in AIDS

Size

Increased Increased Increased Normal Increased* Incneased*

Patients

Hepatic

Defects

Multiple, Linear Large

Splenic

small

.

.

.

.

.

.

.

.

.

Size

Splenic

Decreased Decreased Decreased Normal Normal Increased

Uptake

Decreased Decreased Decreased Increased Decreased* Decreased

Kaposi

sarcoma. of patients.

=

two-thirds

a.

b.

Figure i7. low attenuation topic changes.

uptake

(a)

CT scan of a patient with AIDS and multifocal in the right anterior iliac crest (arrow), with (b) Bone scan demonstrates the corresponding

osteomyelitis shows an area adjacent osteolytic and heteroasymmetric area of increased

of

(arrow).

U MUSCULOSKELETAL Although the musculoskeletal

are not

SYSTEM changes in AIDS as pulmonary or central

as common

nervous

system

manifestations,

and

of soft-tissue

bone

a wide

changes

have

17-19) elitis

may

been

. rial

organisms

may

and

cause

nonoppor-

infection

follow

ofthc

in some

hands

cases

is rela-

osteomy-

(i8).

of the

Angiomatosis angiomatosis

infectious

in AIDS

of opportunistic

and

Badiliary

Bacillary

. Infection A wide mange

Infection

common,

mange

described.

tunistic

(i8-20).

tively

patients.

17 patients

(35%) ofwhom

is a multisystcm,

disease with

that

Baron bacillary

had

has

bacte-

been

et al (2 i)

observed described

angiomatosis,

osteobytic

lesions

six on ma-

skin, subcutaneous tissue, muscles, bones, and joints. As a result, cellulitis, skin ulcers, soft-tissue myclitis,

July

phlegmon and

1992

septic

and arthritis

abscesses, can

ostcooccur

(Figs

Vanarthoseta!

U

RadioGrapbics

U

741

U

1

Figure

i8.

Anterior

(a) and

me-

dial (b) Tc-99m methybene diphosphonate (MDP) scans of a patient with AIDS and streptococcal group B multifocal strate diffuse

the ankle

osteomyelitis increased

joint

(open

two skip lesions (solid arrows).

in the

demonactivity in

arrow)

and

distal

tibia

a.

a. Figure

b. 19.

(a) Anteropostenior

radiograph

demonstrates asymmetric

severe erosive and sclerotic uptake in the sacroiliac joints.

diographs. to be very volvement

Tc-99m helpful (21).

.

b.

Kaposi

MDP scanning was in detection of bone

of a patient changes

shown in-

Sarcoma

Kaposi sarcoma, which is the first diagnosis considered in AIDS patients with cutaneous vascular lesions, rarely causes skeletal changes. However, bone changes arc more

in the

with

AIDS and right sacroiliac

common

in the

(2 1). Cutaneous

posi

sarcoma

demonstrate

U

Vanarthos

et a!

and syphilis scan shows

of Ka-

type lesions

of Ka-

increased

RBC

pooling at Tc-99m-labeled RBC imaging, increased Tl-201 uptake, and absent gallium uptake, contrary to infections and other tumors, which would have high gallium uptake. Hence, scintigraphy can help suggest the type of abnormality and pinpoint specific sites for

tion

RadioGraphics

African

sarcoma

sions

U

endemic

posi

biopsy

742

a history of tuberculosis joint. (b) Anterior bone

on not

can

the

skin

appreciated

be seen

(Fig

20). at the

by imaging

Volume

Also,

occult

physical

the

whole

12

Icexamina-

body.

Number

4

Figure 20. Medial Tc-99mlabeled RBC scan of a patient with AIDS and Kaposi sarcoma shows multiple cutaneous besions

shows

a normal

uptake ment.

in the

pelvis.(b) sacroiliac

Tc-99m MDP scan demonstrates joints, a finding indicative of arthritic

intense involve-

(arrows).

.

Arthritis

Semonegative arthritis is a common musculoskeletal manifestation ofAIDS (22) and may be seen as bilateral, symmetric uptake in the sacroiliac joint on bone scans (although plain radiographs may be normal) (Fig 21). The association

ofAIDS

psoriasis

in

scribed

in

with

i2

patients

1987

(23).

of arthritides such of spondyloarthropathy, thritis,

and

described

.

seen

,,

enon

-,

.

phoma Figure

scan minant

22.

of a patient arthritis

eral symmetric joints.

July

Anterior

1992

with

Tc-99m

AIDS and

demonstrates

uptake

MDP

fubbilat-

in multiple

and

then,

dea wide

arthritides

Reitem

has

syndrome

remain

the

most

in AIDS

patients

mange

forms polyarbeen

and

pso-

common (24).

Lymphoma

Occurrence ,

22).

however,

arthritides

Since

syndrome

originally

as undifferentiated oligoarthritis,

rheumatoid

(Fig

riasis,

Reitem was

other osteolytic

of lymphoma

in AIDS

patients. is most common

forms,

including bone

changes,

is a known

phenom-

AIDS-related lymin the abdomen,

but

Bumkitt

with

have

lymphoma been

reported

(25).

Vanarthos

et a!

U

RadioGraphics

U

743

.w.. ,

..

-

. ..



..,,

L

.

--

a.

b. Figure 23. (a) Gallium scan of a patient with AIDS and myositis ossificans shows increased uptake in the muscles in both legs and a focal area of increased activity (arrow). (b) CT scan demonstrates the characteristic concentric muscle ossification (best seen in the left leg) and a low-attenuation abscess in the right leg (arrow) that corresponded to the focal uptake noted at scintigraphy.

.,

.&-

_

a.

c.

Figure

24. Posterior gallium scans of an adult (a), child (b), and infant (c) with AIDS demonstrate increased renal size and uptake, findings suggestive of nephropathy.

. Myositis AIDS-rebated

myositis

or myositis

ossificans

is

occasionally seen in AIDS patients at scintigraphy. Uptake of both bone agent and gallium occurs in the muscles (Fig 23). Ifthere is no gallium uptake in an involved muscle group in an AIDS

represents see focal

patient,

the

abnormality

Kaposi sarcoma. ostcomyelitis.

probably

It is unusual

. Hypertrophic Osteoarthropathy A single case tcoarthmopathy with

HIV

changes months

Pulmonary of hypertrophic has been

infection.

preceded (26).

In this

the

.

Differential

RadioGrapbic.s

U

Vanarthos

et a!

the

disease

bone

by several

Diagnosis

can distinguish

the basis of radionuclide take location. If uptake

U

case,

lung

to

One

744

pulmonary osdescribed in a child

among

bone

lesions

on

agents used and upon a bone scan is jux-

Volume

12

Number

4

Figure 25. Nuclear cardiologic rebated congestive cardiomyopathy. time activity curve (top) indicates dilatation

with

row of images (right)

tom timated

taarticular, septic

one joints

must

may

consider

have

arthritis.

normal

uptake

Nonon

In-

1 1 1 WBC scans except in areas of marrow formation as delineated on Tc-99m sulfur colloid scans (Palestro CJ, unpublished data, 1989). Muscle uptake may represent myositis, tumor (such as Kaposi sarcoma), or lymphoma. One can distinguish among these possible diagnoses by means of gallium and thallium scmtigraphy; that is, myositis would demonstrate gallium

avidity,

Kaposi

sarcoma

would

onstrate only thallium avidity, could take up both agents.

Ifbone

uptake

and

on delayed

is less

intense

phase

(5-iO-minutcs)

than

dem-

lymphoma

(3-hour)

soft-tissue

images

row of images by means

pool

one

should

blood eitis,

pool

phase

or

trauma.

thallium

uptake sarcoma

(which

tive)

or lymphoma In-i

is tumor,

suggests

posi

positive).

uptake A concomitant

(which i 1 WBC

suggests

infection.

phoma

may have

such

is usually

is usually

images

July

activity

due

1992

is usually

to hyperemia

and

systole

contraction.

may

to Tc-99m

(Palestro

Bot-

being

es-

line).

uptake

WBC

be present,

sulfur

colloid

CJ, unpublished

includes

as lymphoma

recent often

infection

in the

The rest

patient’s

cause.

Asymmetric

of tumor

(WBC

or

distribution of the

to drug obstruc-

The

the

nco-

leukemia,

transfusions.

is suggestive

or

avid).

uptake

infiltrative and

(often related nephritis,

indicates

uptake avid)

globulin

U

HIV

nega-

gallium uptake such as lym-

but

it is less

increased

but

hum

Ka-

intense than thallium uptake. Reduced WBC uptake occurs in a small percentage of active infections. In trauma and in certain infections, thallium

(cursored

acute tubular necrosis toxicity), cytomegalovirus

of

WBC

tumors

uptake,

as

gallium

or Tc-99m

Rarely, WBC

and end

poor

(thaI-

gamma-G

of gallium

body

may

suggest

the

of infection.

osteomyfinding

tumor

such

history

5-iO-minute

computer

diagnosis

plasms

type

than

of ventricular of 25%. Middle

the size of the left ventricle

Differential

hour)

greater

(left) with

AIDS-

the

U GENITOURINARY TRACT The findings of increased radionuclide uptake and increased renal size on gallium scans in the immunodeficient individual raise the suspicion ofAIDS-melated nephropathy (Fig 24).

gallium

uptake

shows of the

diastole

ventricle

delayed images. but it corresponds marrow activity data, 1989).

consider a diagnosis of cellulitis. In cellulitis, the soft-tissue uptake is greater on early blood pool images than it is on skeletal images. The differential diagnosis for delayed (3-

bone

left

with

from

the presence fraction (EF)

at end

a dilated

of a patient

Computation

ejection

obtained

shows

tion,

blood

uptake,

a reduced

study

decreases

on

HEART infection commonly and often is manifested myocarditis tients,

in the ventricular

ejection gestive

unpublished

fraction

heart mild

pre-AIDS

state.

In AIDS

dilatation

with

a reduced

occurs

cardiomyopathy

data,

involves the as a transient

in AIDS-related (Fig

25)

pacon-

(Morales

AR,

1991).

early

on

Vanarthos

et a!

U

RadioGraphics

U

745

26.

27.

Figures

26-28. (26) Gallium scan of a patient effusion, which occurs as a complication uptake surrounding the heart (arrows).

pericardial increased ANT

anterior.

=

creased

28.

(28)

activity

in the

Gallium left

side

scan

obtained

of the

heart

with

AIDS shows a photopenic halo (arrows), indicative of ofAIDS. (27) Gallium scan ofa patient with AIDS shows The patient proved to have tubercubous pericarditis.

48 hours (arrow),

after

radionuclide

a finding

that

injection

proved

demonstrates

to represent

focal

in-

myocarditis.

0 flhl$1

flfl

Figure 29. Radionuclide scans with AIDS and myocarditis show antimyosin antibody myocardial rows).

Gallium sion

or

uptake

is seen

inflammatory

of a patient increased activity (am-

in pericardial

pcricamditis

*3

effu-

(Figs

26,

27), myocarditis (Fig 28), endocarditis, and neoplasms such as lymphoma (but not Kaposi sarcoma). Thallium uptake occurs in lymphoma and Kaposi sarcoma but not in inflammatory cardiac conditions. Cardiac dysfunction in myocarditis may sometimes be subtle, and gated cardiac studics

746

U

RadioGraphics

may

demonstrate

U

only

Vanarthos

diastolic

et a!

dysfunc-

Figure 30. Images from a single photon computed tomographic study demonstrate

emission uptake

ofTl-20l chloride in an active paraventricubar mor (arrows). (Reprinted, with permission, reference 8.)

tion.

Myocarditis

basis

of diffuse

scmntigraphy imaging

may (Fig

(Fig

be

cardiac 28)

suspected

uptake or

tufrom

on seen

antimyosin

the

at gallium antibody

29).

U CENTRAL NERVOUS SYSTEM Kaposi sarcoma and lymphoma arc the most common tumors seen in AIDS patients. Although gallium scmntigmaphy often does not demonstrate Kaposi sarcoma, it does depict bymphoma, making it an extremely useful technique in distinguishing Kaposi sarcoma from lymphoma and in demonstrating addi-

Volume

12

Number

4

IS VERSE

p

b. Figure scans

31. of the

mom that

(a) Transverse, brain demonstrate

proved

to be a thalamic

right), coronal (b), and MR images clearly show

(Fig

30)

and

published

usually

data,

central

WBC

( 1 6)

imaging

size arc

tional This

sites

of lymphoma

capability

is particularly

processes

such as lymphoma, may have similar

CT and

magnetic

tumors,

resonance

amenable

to biopsy.

valuable,

since

and inflammatory enhancement on

(MR)

images

and

oflesions, positive

.

In the

studies

leneamine for masses

However,

of In-i

in only

20%

high uptake edema, (W.I.G., un-

detection

of ac-

infection,

In-i

than

1 1 WBC

of these

small imaging

infections

tumors larger than therapy, we suggest be performed; addi-

Tc-99m

1i

gallium

of the

because

results

with

to distinguish

accurate

(27). Thus, to exclude cm, which need early thallium scintigraphy tional

Axial (a, upper

one

system more

Tl-20l in a tu-

gadolinium-enhanced

allows

1992). arc

sagittal activity

its maintained (Fig 31), from and infection

nervous

studies

glioma.

sagittal (c) the tumor.

active tumor, with on delayed images postthemapy effects, tive

coronal, and increased

2 that

hexamethyl-propy-

oxime (HMPAO) may with atypical patterns.

be needed

brain biopsy is invasive. In our experience with brain tumors in genera!, early and delayed Tl-20i brain scintigraphy appears to be specific for brain tumors

July

1992

Vanarthos

et a!

U

RadioGrapbic.s

U

747

Figure tient

ple, that (b)

32. (a) MR image of a pawith AIDS demonstrates multisolid, enhancing lesions (arrows) proved to be toxoplasmosis.

Tb-20l

chloride

near-normal

scan

activity

shows

in the infected

sites.

a

Unlike

active

tumors,

active

normal thallium activity In early HW dementia, creased Tc-99m HMPAO ganglia

and

observed

thalami,

In later

peripheral

these

activity. uptake

matter

may also

HIV

dementia

(Fig

this

controversial

creased

thallium,

U

(29). are

4.

do

may 5.

of late to resolve In de-

not

show

6.

in-

uptake.

or WBC

CONCLUSION

Use

of radionuclide

for treatment lead to earlier tions.

The

scintigraphy

is valuable

ofAIDS patients because detection of tumors and

advantage

of scintigraphy

7.

it can infec-

from

these

history,

scans,

clinical

moborative differential

in conjunction and

with

laboratory

radiologic diagnosis.

data,

studies,

help

travel and

8.

2.

9. the

Morgan M, Curran JW, Berkelman RL. The future course ofAIDS in the United States. JAMA 1990; 263:1539-1540. MurrayJF, Felton CP, Garay

monary

complications

11. SM, et al.

of acquired

Pub-

immuno-

deficiency syndrome: a report of a National Heart, Lung, and Blood Institute Workshop. N EnglJ Med 1987; 320: 1682-1688.

748

U

RadioGrapbics

U

Vanarthos

et a!

Radiology

C, Weinstein

R, et al.

D, PatubboJ. citrate

Utility uptake

12.

of lung-to-thigh ratio as an index In: Fernandez-Ulloa

in clinical

medicine

in the acquired

of

nuclear

medicine. Cincinnati: Southeastern Society ofNuclear Medicine, 1991. Ganz WI, Serafini AN. The diagnostic

nuclear

REFERENCES 1.

imaging.

pulmonary inflammation. M, ed. Decision making

10. U

Larson SM, syn-

Kramer EL, SangerJJ, Garay SM, Grossman RJ, Tiu 5, Banner H. Diagnostic implications of Ga-67 chest-scan patterns in human immunodeficiency vimus-seropositive patients. Radiology 1989; 170:671-679. Tow TWY, Rosen MJ, Teirstein AS. Normal chest roentgenogmam as a prognostic factor in Pneumocystis caninii pneumonia in patients with acquired immunodeficiency syndrome (abstr). Am Rev Respir Dis 1984; l29:A54. Ganz WI, Faldas MG, Limpios N, Landress U,

Ferteb

com-

narrow

citrate

1987; 162:383-387. BitranJ, Beckerman

gallium-67

is in its

ability to demonstrate functional and physiologic changes, which usually precede the structural changes shown by other madiobogic modalities. Total body scans can provide diagnostic patterns of uptake that are highly suggestive of specific pathologic entities. Results

Ga-67

CarrasquilbojA, immunodeficiency

Patterns ofgallium-67 scintigraphy in patients with acquired immunodeficiency syndrome and AIDS related complex. J NucI Med 1987; 28:1103-1106.

in cortical

pending.

WoolfendenJM, et al. Acquired

drome:

been

regions

Studies

scans gallium,

3.

tomography

same

be characteristic

33) issue

radioisotopic

has

irregularities

gray

have

A pattern of reduced in white matter, with

low-uptake

mentia,

to what

emission

stages,

show decreased Tc-99m HMPAO

infections

(Fig 32). theme may be inactivity in the basal

similar

at positron

(28).

b.

Chapter, role

of

immunode-

ficiency syndrome. J Nucl Med 1989; 30: 1935-1945. Ganz WI, Serafini AN, Ganz SS, et al. Diagnostic pattern of Ga-67 uptake in bymphocytic interstitial pneumonitis (abstr). J NucI Med 1988; 29:887-888. Waldman RH, Fisher MA. Actinomycetes. In: Waldman RH, Kluge RM eds. Textbook of infectious diseases. New York: Medical Examination Publishing, 1984; 925-931. Barron TF, Birnbaum NS, Shane LB, Goldsmith SJ, Rosen MJ. Pneumocystls caninli pneumonia studied by gallium-67 scanning. Radiology 1985; 154:791-793. Pitchenik AE, Cole C, Russell BW, et al. Tuberculosis, mycobacteriosis, and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in south Florida. AnnlnternMed 1984; 101:641-643.

Volume

12

Number

4

20.

Zimmerman B III, Erickson AD, Mikolich DJ. Septic acromioclavicular arthritis and osteomyelitis in a patient with acquired immunodeficiency syndrome. Arthritis Rheum 1989; 32:1175-1178. Baron AU, Steinbach LS, Leboit PE, Mills CM, Gee JH, Berger TG. Osteolytic lesions of

21.

Figure

33.

scans

Sequential

demonstrate

sagittal

a pattern

Tc-99m

bacillary

uptake

of HP/-induced

logic

in

the white matter with peripheral, irregular low uptake in cortical gray matter thought to be characteristic

angiomatosis in HIV infection: radiodifferentiation from AIDS-related Kaposi sarcoma. Radiology 1990; 177:77-81. Calabrese LH. The rheumatic manifestations

HMPAO

of reduced

22.

of infection with the human immunodeficiency virus. Semin Arthritis Rheum 1989; 18: 225-239. Winchester R, Bernstein DH, Fischer HD, Enlow R, Solomon G. The co-occurrence of Reiter’s syndrome and acquired immunodeficiency. Ann Intern Med 1987; 106: 19-26. Rosenberg ZS, Norman A, Solomon G. Arthritis associated with HIV infection: radiographic manifestations. Radiology 1989; 173:

dementia.

23. 13.

Goodman PC. Pulmonary manifestations of AIDS. Curr Probl Diagn Radiol 1988; 17:8 185. Klein RS, Harris CA, Shell CB, et al. Oral candidiasis in high risk patients as the initial manifestation of the acquired immunodeficiency syndrome. N EngI J Med 1987; 311: 354-358. Soare R, Johnson WD Jr. Cryptosponidlum and Isospona belli infections. J Infect Dis 1988; 157:225-229. Fineman DS, Palestro CJ, Kim CK, et al. Dctection of abnormalities in febrile AIDS patients with In-i 1 1-labeled leukocyte and Ga-67 scintigraphy. Radiology 1989; 170: 677-680. Miller RF. Nuclear medicine and AIDS. EurJ

14.

15.

16.

17.

NuclMed Glickeb acquired

18.

19.

1990;

SZ.

24.

171-176.

25.

26.

27.

16:103-118.

Hand

with

28.

immunodeficiency syndrome. J Hand Surg [Ami 1988; 13:770-775. Goh BT, Jawad AS, Chapman D, Winceslaus SJ, Forster GE, PerryJD. Osteomyebitis presenting as a swollen elbow in a patient with

29.

the acquired Ann

Invited

infections

immune

Rheum

Radin DR, Rosenstein H, Boswell WD, Ralls PW, HallsJM. Burkitt lymphoma in acquired immune deficiency syndrome. J Comput Assist Tomogr 1984; 8:173-174. AmodioJB, Abramson 5, Berdon WE, LevyJ. Pediatric AIDS. Semin Roentgenol 1987; 22: 66-76. Palestro CJ, Swyer AJ, Kim CK, Goldsmith SS. Relative efficacy of In-i 1 i-leukocyte and Ga-67 imaging of HIV(+) patients (abstr). J Nucl Med 1991; 32:1003. Masdeu JC, Yudd A, Van Heertum RL, et al. Single photon emission computed tomography in human immunodeficiency virus encephalopathy: a preliminary report. J NucI Med 1991; 32: 1471-1475. Rottenberg DA, MoelberJR, Stotler SC, et al. The metabolic pathology of the AIDS dementia complex. Ann Neurol 1987; 22:700-706.

Dis

in patients

deficiency

1988;

syndrome.

47:695-696.

Commentary

From:

John

G. McAfee,

Department Washington,

The

preceding

summarizes

disease

increases,

volving

any organ

merous

and

plications

complex. is directly

many

that

imaging.

The

are

As our

1992

knowledge

The

become frequency

rebated

to

the

by

puter

techniques

of

clearance from the

nu-

of comseverity

is highest lymphocyte

In detecting have

in-

more

University

workers

com-

its complications

system

Washington

et al aptly of the

demonstrable

the immunosuppression and patients with a CD4 (helper) count bess than 200/p.L (1).

July

George

by Vanarthos

illustrates

ofAIDS

radionuclide this

article and

plications

MD

of Radiology, DC

of

in the

Medical

Center

P carinii been

pneumonia,

using

gamma

to measure

some camera

com-

the half time

of

of Tc-99m-babelcd DTPA aerosol lungs after 4 or 5 minutes of inhalation. In patients with P caninii pneumonia, increased alveolar permeability beads to an aerosol clearance that is abnormally fast com-

pared with that in healthy even that in smokers who with

the

HIV.

Several

Vanarthos

workers

nonsmokers and are not infected have

et a!

empha-

U

RadioGraphics

U

749

Diagnostic uses of nuclear medicine in AIDS.

Radionuclide imaging, if applied with an organ system approach, is useful in the diagnosis of the AIDS (acquired immunodeficiency syndrome)-related co...
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