Diagnostic Imaging of Infections and Infl ammatory Diseases Diagnostic Imaging of Infections and Infl ammatory Diseases A Multidisciplinary Approach EDITED BY Alberto Signore , MD, PhD Professor of Nuclear Medicine, Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, “Sapienza” University, Rome, Italy Ana María Quintero , MD Radiologist, Department of Radiology, Clinica Reina Sofi a, Clinica Colsanitas, Bogotá, Colombia Copyright © 2014 by John Wiley & Sons, Inc. All rights reserved Published by John Wiley & Sons, Inc., Hoboken, New Jersey Published simultaneously in Canada No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 750-4470, or on the web at www. copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions . The contents of this work are intended to further general scientifi c research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specifi c method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifi cally disclaim all warranties, including without limitation any implied warranties of fi tness for a particular purpose. In view of ongoing research, equipment modifi cations, changes in governmental regulations, and the constant fl ow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. For general information on our other products and services or for technical support, please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic formats. For more information about Wiley products, visit our web site at www.wiley.com . L ibrary of Congress Cataloging-in-Publication Data Diagnostic imaging of infections and infl ammatory diseases : a multidisciplinary approach / edited by Alberto Signore, Ana Maria Quintero. p. ; cm. Includes bibliographical references and index. ISBN 978-1-118-48441-8 (alk. paper) – ISBN 978-1-118-48435-7 (print) – ISBN 978-1-118-48438-8 (print) – ISBN 978-1-118-48439-5 (print) – ISBN 978-1-118-48443-2 (print) I. Signore, A. (Alberto), 1959- editor of compilation. II. Quintero, Ana Maria, editor of compilation. [DNLM: 1. Diagnostic Imaging–methods. 2. Communicable Diseases–radiography. 3. Communicable Diseases–radionuclide imaging. 4. Infl ammation–radiography. 5. Infl ammation–radionuclide imaging. WN 180] 616.07 ' 54–dc23 2013001677 Cover images: Main cover image © Baran Özdemir iStockphoto.com #17280971. Inset image courtesy of Professor Signore. Cover design by Matt Kuhns Printed in the United States of America 10 9 8 7 6 5 4 3 2 1 Contents List of Contributors, vii Part III Nuclear Medicine Imaging Foreword, ix 9 Nuclear Medicine Imaging of Infections: Techniques, Acquisition Protocols and Preface, x Interpretation Criteria, 149 Alberto Signore Part I Infections and Host Response 10 Nuclear Medicine Imaging of Osteomyelitis: 1 Epidemiology of Infections in the New White Blood Cell, Monoclonal Antibody, or Century, 3 Bacterial Imaging?, 168 Nicola Petrosillo Christopher J. Palestro 2 Bacterial Osteomyelitis: The Clinician’s Point 11 Nuclear Medicine Imaging of Spondylodiscitis: of View, 15 The Emerging Role of PET, 187 Ilker Uçkay, Nicolas Christian Buchs, Elena Lazzeri, Paola Anna Erba, Martina Sollini Khalid Seghrouchni, Mathieu Assal, and Giuliano Mariani Pierre Hoffmeyer and Daniel Lew 12 Nuclear Medicine Imaging of Soft Tissue Infections, 199 Part II Radiological Imaging Bárbara Morales Klinkert 3 Radiological Imaging of Osteomyelitis, 29 13 Nuclear Medicine Imaging of Infections and Jenny T. Bencardino, Zoraida Restrepo-Velez, Infl ammatory Diseases of the Abdomen, 216 Randall Bujan and Diego Jaramillo Josep Martín Comín, Alba Rodríguez Gasén and Christophe Van de Wiele 4 Radiological Imaging of Spine Infection, 54 14 Nuclear Medicine Imaging of Vascular Ana María Quintero and Roy Riascos Graft Infection: The Added Role of Hybrid Imaging, 241 5 Radiological Imaging of Soft Tissue Ora Israel Infections, 75 Carolina Whittle and Giancarlo Schiappacasse 15 Nuclear Medicine Imaging of Tuberculosis and Human Immunodefi ciency Virus, 255 6 Radiological Imaging of Abdominal Infections Mike Sathekge, Christophe Van de Wiele and and Infl ammatory Disease, 91 Alberto Signore Carolina Whittle, Giancarlo Schiappacasse and Francesca Maccioni 16 Nuclear Medicine Imaging of Fever of Unknown Origin, 273 7 Radiological Imaging of Vascular Graft François-Xavier Hanin and François Jamar Infection, 118 Alejandro Romero, Tobias Zander, 17 Nuclear Medicine Imaging of Infl ammatory Jorge Lopera, Sergi Quiroga and Diseases, 291 Manuel Maynar Marco Chianelli, Gaurav Malviya, Andor W.J.M. Glaudemans and Alberto Signore 8 Radiological Imaging of Tuberculosis and Human Immunodefi ciency Virus, 135 Jorge Carrillo Index, 323 v List of Contributors Mathieu Assal, MD François-Xavier Hanin, MD Department of Orthopedic Surgery, Geneva University Nuclear Medicine Physician, Centre of Nuclear Medicine, Hospitals a nd Faculty of Medicine, University of Geneva, Molecular Imaging, Experimental Radiotherapy and Geneva, Switzerland Oncology (MIRO) Unit, Université Catholique de Louvain, Brussels, Belgium Jenny T. Bencardino, MD Associate Professor of Radiology, Department of Radiology, Pierre Hoffmeyer, MD NYU Hospital for Joint Diseases, New York, NY, USA Department of Orthopedic Surgery, Geneva University Hospitals a nd Faculty of Medicine, University of Geneva, Nicolas Christian Buchs, MD Geneva, Switzerland Department of Orthopedic Surgery, Geneva University Hospitals a nd Faculty of Medicine, University of Geneva, Ora Israel, MD Geneva, Switzerland Professor of Nuclear Medicine, Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel Randall Bujan, MD Assistant Radiologist, Don Bosco Radiologic Clinic, San Jose, François Jamar, MD, PhD Costa Rica Professor of Nuclear Medicine, Centre of Nuclear Medicine, Molecular Imaging, Experimental Radiotherapy and Jorge Carrillo, MD Oncology (MIRO) Unit, Université Catholique de Louvain, Brussels, Belgium Professor of Radiology, Universidad Nacional de Colombia, Bogotá, Colombia Diego Jaramillo, MD Marco Chianelli, MD, PhD Radiologist-in-Chief, Children ’ s Hospital of Philadelphia, Professor of Radiology, University of Pennsylvania, Nuclear Medicine Physician and Endocrinologist, Philadelphia, PA, USA Department of Endocrinology, Regina Apostolorum Hospital, Albano, Rome, Italy Bárbara Morales Klinkert, MD, MSc Josep Martín Comín, MD Nuclear Medicine Physician, Nuclear Medicine and PET/CT Center, Fundación López Perez (FALP), Santiago, Chile Professor of Nuclear Medicine, Department of Nuclear Medicine, Hospital Universitari de Bellvitge, L ’ Hospitalet de Llobregat, Barcelona, Spain Elena Lazzeri, MD, PhD Nuclear Medicine Physician, Regional Center of Nuclear Paola Anna Erba, MD Medicine, University of Pisa, Medical School, Pisa, Italy Nuclear Medicine Physician, Regional Center of Nuclear Medicine, University of Pisa, Medical School, Pisa, Italy Daniel Lew, MD Department of Infectious Diseases, Geneva University Alba Rodríguez Gasén, MD Hospitals a nd Faculty of Medicine, University of Geneva, Geneva, Switzerland Nuclear Medicine Physician, Department of Nuclear Medicine, Hospital Universitari de Bellvitge, L ’ Hospitalet de Llobregat, Barcelona, Spain Jorge Lopera, MD Professor of Radiology, The University of Texas Health Andor W.J.M. Glaudemans, MD Science Center, San Antonio, TX, USA Nuclear Medicine Physician, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands vii viii List of Contributors Francesca Maccioni, MD Alejandro Romero, MD Professor of Radiology, Department of Radiological Sciences, Radiologist, Servicio de Radiodiagnóstico, Hospital Faculty of Medicine and Dentistry, “Sapienza” University, Universitario Valle Hebrón, Barcelona, Spain Rome, Italy Mike Sathekge, MBChB, MMed (Nucl Med), PhD, Gaurav Malviya, PhD MASSAf Department of Nuclear Medicine and Molecular Imaging, Professor & Head of Nuclear Medicine Department, University Medical Center Groningen, University of University of Pretoria and Steve Biko Academic Hospital, Groningen, Groningen, The Netherlands a nd Pretoria, South Africa Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine Giancarlo Schiappacasse, MD and Psychology, “Sapienza” University, Rome, Italy Associate Professor of Radiology, Clínica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile Giuliano Mariani, MD Professor of Nuclear Medicine, Regional Center of Nuclear Khalid Seghrouchni, MD Medicine, University of Pisa, Medical School, Pisa, Italy Department of Orthopedic Surgery, Geneva University Hospitals a nd Faculty of Medicine, University of Geneva, Manuel Maynar, MD, PhD Geneva, Switzerland Radiologist, Centro de Diagnóstico y Terapéutica Endoluminal CD y TE, Las Palmas de Gran Canaria Alberto Signore, MD, PhD University, Canary Islands, Spain Professor of Nuclear Medicine, Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Christopher J. Palestro, MD Translational Medicine, Faculty of Medicine and Psychology, Professor of Radiology, Hofstra North Shore-LIJ School of “Sapienza” University, Rome, Italy Medicine, Hempstead, NY, USA a nd Chief, Division of Nuclear Medicine and Molecular Imaging, Martina Sollini, MD North Shore Long Island Jewish Health System, Manhasset Nuclear Medicine Physician, Regional Center of Nuclear & New Hyde Park, NY, USA Medicine, University of Pisa, Medical School, Pisa, Italy Nicola Petrosillo, MD Ilker Uçkay, MD Director, 2nd Infectious Diseases Division, National Institute Department of Orthopedic Surgery, Department of for Infectious Diseases, “L. Spallanzani”, IRCCS, Rome, Italy Infectious Diseases, Geneva University Hospitals a nd Faculty of Medicine, University of Geneva, Geneva, Switzerland Ana María Quintero, MD Radiologist, Department of Radiology, Clinica Reina Sofi a, Christophe Van de Wiele, MD, PhD Clinica Colsanitas, Bogotá, Colombia Professor and Head of Department of Nuclear Medicine, University Hospital Ghent, Ghent, Belgium Sergi Quiroga, MD Radiologist, Servicio de Radiodiagnóstico, Hospital Carolina Whittle, MD Universitario Valle Hebrón, Barcelona, Spain Professor of Radiology, Clínica Alemana, Facultad de Medicina, Universidad del Desarrollo, Santiago, Chile Zoraida Restrepo-Velez, MD Research Fellow, NYU Medical Center, NYU Hospital for Joint Tobías Zander, MD, PhD Diseases, New York, NY, USA Radiologist, Centro de Diagnóstico y Terapéutica Endoluminal CD y TE, Las Palmas de Gran Canaria Roy Riascos, MD University, Canary Islands, Spain Associate Professor of Radiology, Department of Radiology, The University of Texas Medical Branch, Galveston, TX, USA Foreword The care of patients presenting with signs of infec- The book is an excellent illustration of the synergy tious or infl ammatory diseases is often diffi cult that can be achieved between specialties and in the because their symptoms are frequently non-spe- imaging specialties collaboration is of the utmost cifi c; the diagnosis, differential diagnosis and deci- importance. Both radiology and nuclear medicine sion about appropriate therapy is often a real contribute, often in a complementary way, to challenge for the clinician. The implemen tation of obtaining the correct diagnosis and the timely eval- the available diagnostic methods is complex and uation of the therapeutic answer. The clear and the evaluation of their results also complex and objective comparison of the diagnostic value and frequently contradictory. Many of these methods performance of available methods in solving clinical are not familiar to clinicians; therefore the decision problems allows us to defi ne clear, precise, fast and about their role in the diagnostic process and the less expensive diagnostic algorithms to assist clini- strategy to be adopted may be delayed. Most of the cians for the benefi t of our patients. guidelines generally available still do not refl ect Representing our respective European profes- consensual diagnostic strategies. sional–scientifi c communities (the European Asso- The editors of this book had the merit to involve ciation of Nuclear Medicine and the European clinicians, radiologists and nuclear physicians Society of Radiology), we congratulate the editors with the objective to review this diffi cult area and authors on their excellent work and recom- disease by disease, to defi ne the appropriate clinical mend its exploitation by radiologists, nuclear physi- questions that may arise in everyday practice cians and clinicians. and to compare the accuracy and diagnostic value of the available diagnostic methods. Their efforts Patrick Bourguet have resulted in clear, didactic content that sup- Past President of the EANM ports consultation in clinical practice, suggests CRLCC Centre Eugène Marquis solutions to the most frequently encountered Rennes, France pathological situations (osteomyelitis, spondy- lodiscitis, abdominal, soft tissue and vascular András Palkó graft infections, HIV and chronic infl ammatory dis- Past President of the ESR eases), and summarizes the consensual diagnostic University of Szeged strategies. Szeged, Hungary ix Preface Having dedicated most of our scientifi c and clinical vant, thus providing different information from activity to the diagnosis of infections and infl amma- radiology, often complementary. Nuclear medicine tory diseases we always had in mind to write a text- examinations are closer to physiology and histopa- book on this topic. An initial book of this kind was thology, while radiological examinations are closer published by one of us (AS) in early 2002, followed to anatomy. Again, in nuclear medicine a physiolog- by a pictorial atlas and several chapters in other ical/histopathological abnormality is not always books dedicated to nuclear medicine and molecular associated with a disease state. It is therefore impor- imaging or to specifi c diseases. However, the multi- tant to defi ne the threshold of normality for most disciplinary approach to diagnostic imaging of examinations and the qualitative and quantitative infections and infl ammatory diseases has not been analysis of images is not always helpful in this. treated before in the systematic way that it is here. As a consequence, clinicians, radiologists and We therefore combined our expertise and planned nuclear medicine physicians have different ways of this multidisciplinary book by involving clinicians describing diseases and different ways of writing (infective disease specialists, endocrinologists, medical textbooks. orthopedists and others), radiologists and nuclear It was important for us to attempt to give uniform- medicine physicians. After initial enthusiasm we ity to the way in which the clinical problems are faced the diffi culty of fi nding a common language described in the different chapters. All chapters have among the contributors. Indeed, the way in which the same structure and authors were “forced” to clinicians, radiologists and nuclear medicine physi- adhere to a common way of approaching the disease. cians face and describe the same topic is very differ- This was not just an editorial exercise. In our view, it ent, not only from a linguistic or medical point of refl ects the merging of the different disciplines in view but, most importantly, in the way a patient is clinical practice and emphasizes the collaboration approached and images interpreted. within multidisciplinary teams to reach the correct Clinicians tend to interpret images as “signs” and diagnosis for fast and effi cient cure of the disease. combine these with symptoms and other tests to In the past 10 years in particular, nuclear medi- reach the fi nal diagnosis. Therefore, when describ- cine and radiology have merged considerably with ing images, they do it in the context of other tests, the introduction of hybrid imaging (SPECT/CT, signs and symptoms, giving much less emphasis to PET/CT and, more recently, PET/MRI). Therefore, the raw content of the image and all the possible for most patients the diagnostic imaging work-up is functional–anatomical information that can be completed by the fusion of the two specialties and gained from images. physicians are becoming more and more used to Radiologists usually prioritize a detailed anatomi- interpreting images using a common language. cal description, some of which detail is irrelevant to Therefore, this textbook is also a milestone in the the clinician, and aim to determine the diagnosis formulation of common diagnostic fl ow charts for from identifying a multitude of anatomical fea- the diagnosis of infections and infl ammatory dis- tures. When analyzing images, they carefully eases. It is addressed to medical students as well as describe what they see and generally, will make a specialists in nuclear medicine and radiology, and diagnosis only if anatomical abnormalities are also to all clinicians involved in infectious/infl am- found. But an anatomical abnormality is not always matory diseases who require an up-to-date view of synonymous with disease and vice versa. integrated diagnostic imaging in this fi eld. By contrast, in nuclear medicine, functional At the end of each chapter, we asked the authors aspects and tissue characterization are more rele- to include three to fi ve clinical cases to better x