.
.
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!
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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
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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.
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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
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15.
16.
17.
NuclMed Glickeb acquired
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19.
1990;
SZ.
24.
171-176.
25.
26.
27.
16:103-118.
Hand
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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
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U
749