British Journal of Radiology (2004) 77, 679-680
© 2004 British Institute of Radiology
doi: 10.1259/bjr/28830361
Thrombophlebitis diagnosed on indium-111 labelled white cell scan
P J English, MBChB, MRCP (UK)
B E Eyes, DMRD, FRCR
and
G Gill, MD, FRCP
University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK
 |
Abstract
|
|---|
A 64-year-old lady with type 2 diabetes and a non-resolving right foot ulcer, had an indium-111 labelled white cell scan (indium-111 WCS) to investigate the possibility of underlying osteitis. The scan suggested the possibility of infective thrombophlebitis. Unknown to the clinical team who requested the scan and the radiologist who performed it, the lady was admitted to hospital 2 days following the procedure with cellulitis and septic thrombophlebitis in the right leg. There is only one previous report in the literature of septic thrombophlebitis being diagnosed in this way. Perhaps indium-111 WCS has something to offer in the diagnosis of this condition and in determining those who require antibiotic treatment.
|
Case report
|
|---|
A 64-year-old lady with type 2 diabetes, peripheral neuropathy and recurrent foot ulcers was seen in a Diabetic Foot Clinic with a non-resolving ulcer on the tip of her right great toe. She had received oral antibiotics for 1 month with little improvement and was receiving ciprofloxacin 750 mg twice daily (she was intolerant of co-amoxiclav) in addition to her usual insulin therapy and diltiazem 60 mg twice daily. Her CRP was slightly raised at 20 mg l–1, plain X-rays of the toe were unremarkable and an indium-111 labelled white cell scan (indium-111 WCS) was requested to investigate the possibility of underlying osteitis.
She attended for the indium scan 2 weeks later. 50 ml of blood was taken at 0900 h and white cells were separated and labelled with indium-111 tropolonate according to a standard protocol (http://www.ukrg.org.uk/rphandbook/white.htm). 5 ml of white cells labelled with 15 MBq of indium-111 were then injected at 1230 h, and the patient was scanned with 2 views (dorsiplantar and lateral) at 4 h and 24 h post injection. A medium energy general purpose collimator, set to accept energies 10% each side of 170 KeV and 250 KeV, and using a 128 x 128 matrix and a magnification of 1, was used for image acquisition. Each image took 600 s to acquire.
Unknown to us, the patient was admitted with cellulitis of the foot with marked inflammation over the dorsum of the foot and a line of erythema and hyperaesthesia running up the lateral aspect of the right lower calf 2 days after the indium scan was performed. She was febrile and systemically unwell with a white blood count of 9.3 x 106 l–1, and was diagnosed as having a streptococcal cellulitis of the lower foot and associated septic thrombophlebitis. She was treated with intravenous and then oral antibiotics with complete resolution of these clinical findings after 2 weeks of therapy.
4 weeks later the patient was seen in the Foot Clinic with the indium scan report describing intense increased uptake of labelled white cells in the right big toe and in a linear area over the lateral aspect of the right foot and distal leg, in a region appearing to correspond to the short saphenous vein (Figures 1 and 2
). The report suggested the possibility of an infective thrombophlebitis. The patient informed us of the hospital admission and we confirmed that a diagnosis of septic thrombophlebitis had been made, although the hospital team had been unaware of the report at that time.
View larger version (57K):
[in this window]
[in a new window]
|
Figure 1. Indium-111 labelled white cell scan. Right lateral view of right lower leg and foot showing intense uptake in the right great toe and increased uptake over the dorsum and lateral aspect of the foot. Large arrow=R great toe, small arrow=lateral aspect R lower leg.
|
|
View larger version (60K):
[in this window]
[in a new window]
|
Figure 2. Indium-111 labelled white cell scan. Posterior view of both lower legs showing increased uptake over the lateral aspect of the right lower leg. Arrow=lateral aspect R calf.
|
|
|
Discussion
|
|---|
We had not seen thrombophlebitis diagnosed in this way previously and so performed a literature search on Medline from 1967 to the present day using the terms "thrombophlebitis" and "indium". We identified one previous case report [1] where lower extremity septic deep venous thrombophlebitis was diagnosed using indium-111 WCS in a paraplegic patient with accompanying lower limb thrombus formation, but no other reports documenting either deep or superficial thrombophlebitis diagnosed in this way. Interestingly, we found three reports where indium-111 WCS had identified unsuspected deep venous thrombosis [2–4]; however this diagnosis is extremely unlikely in this case on clinical grounds alone. First, the patient's symptoms were typical of thrombophlebitis and resolved following administration of antibiotics and analgesia; and second, the patient has remained under regular review by our team in the diabetic foot clinic and endocrine clinic for more than 2 years subsequently with no clinical suggestion of venous thromboembolism.
Superficial thrombophlebitis is usually diagnosed clinically and although antibiotics are commonly utilized in its treatment alongside non-steroidal anti-inflammatory agents, it is rarely infective in origin. Infective thrombophlebitis may be implied from systemic symptoms and raised inflammatory markers though this is not always entirely accurate. Sometimes presentation is less typical and pain may be present in the absence of obvious erythema over the course of the veins. Perhaps indium-111 WCS has something to offer in the diagnosis of this condition and determining who requires antibiotic treatment.
Received for publication January 24, 2003.
Revision received October 3, 2003.
Accepted for publication November 19, 2003.
|
References
|
|---|
- Fancher M, Abghari R, Bartold K. Initial detection of lower extremity septic deep venous thrombophlebitis by indium-111 WBC imaging in a patient with bacteremia. Clin Nucl Med 1986;11:206–8.[CrossRef][Medline]
- Blount CL, Balon HR. Deep venous thrombosis shown on In-111 labeled white blood cell imaging. Clin Nucl Med 1997;22:261–2.[Medline]
- Carvalho P, Banerjee AK, Cheah FK, Jewkes RF. Case report: deep venous thrombosis diagnosed on indium-111 labelled white cell scanning. Clin Radiol 1991;43:276–7.[Medline]
- D'Alonzo WA Jr, Alavi A. Detection of deep venous thrombosis by indium-111 leukocyte scintigraphy. J Nucl Med 1986;27:631–3.[Abstract/Free Full Text]
Top
Abstract
Case report
