Multiple inflammation foci as a cause of undiagnosed fever: value of whole body 99mTc(V)-DMSA scintigraphy.

Hellenic Journal of Nuclear Medicine • September December 2009 291 To the Editor: The Hell J Nucl Med has printed an article comparing technetium-99m pentavalentdimercapto succinic acid (99mTc(V)-DMSA) as an effective agent diagnosing acute bone and joint infection [1]. We now report that 99mTc(V)-DMSA can identify foci of infection in a case of fever of unknown origin. 99mTc(V)-DMSA, as a tumor-seeking agent, has been developed by Yokoyama et al. in 1981 [2] and many other related studies have followed [3-5]. We performed 99mTc(V)-DMSA whole body scintigraphy (WBS) in a 60 years old female patient admitted to our hospital with fever, fatigue, and right leg pain. Clinical diagnosis was cellulitis. Staphylococcus aureus was detected in blood cultures and treatment with antibiotics was initiated. After two days, the patient had joint pain, cough and dyspnea. Pneumonia and septic arthritis were diagnosed, antibiotic treatment was modified, but fever continued. A whole body scintigraphy was performed 4-5h after the intravenous administration of 740MBq of freshly prepared 99mTc(V)-DMSA using a dual head gamma camera (Siemens, E-Cam Dual Head, USA). The scan revealed increased tracer uptake in the right sternoclavicular region, the right lateral iliac wing, the left major trochanter and, the lower lumbar vertebrae (Fig. 1). Magnetic resonance imaging (MRI) of the lumbar spine-pelvis and computerized/tomography (CT) of the thorax were performed and multiple abscesses were shown in the right lateral gluteal region in an area of 8x2.5cm (Fig. 2) and the right sternoclavicular joint, in an area of 2.5x2cm (Fig. 3). In addition, appearance concordant to spondylodiscitis, an anterior epidural phlegmon at the level of L3-S1 vertebrae and a lesion concordant to bursitis in the left major trochanter were observed. All abscesses were drained but the patient was operated because there was no local improvement and neurologic symptoms appeared. Serious pyogenic infection as a cause of undiagnosed fever is common [6]. The most widely and also currently used radionuclide agents for the detection and location of pathology in patients with undiagnosed fever are gallium 67 (67Ga-C) citrate, labeled leucocytes and recently fluorine-18 fluorodeoxyglucose (18FFDG) [7]. Recently, uptake 99mTc(V)-DMSA by inflammatory tissues has been reported [4, 5]. It is suggested that Correspondence