British Journal of Radiology (2004) 77, 801-802
© 2004 British Institute of Radiology
doi: 10.1259/bjr/77749521
A patient with back pain and unusual appearances on bone scintigraphy
S Chilab, MB BS
E Macias, MB BS
and
N W Garvie, MSc, FRCP, FRCR
Radioisotope Department, The Royal London Hospital, Whitechapel, London E1 1BB, UK
A 42-year-old male presented with low back pain, urinary retention and persistent intractable fever. On admission he was found to be suffering from acute renal failure. The creatinine kinase (CCK) level was raised, eventually reaching a value of 2834 U l–1. The urine contained myoglobin. Ultrasound showed the kidneys to be hyperechoic and also demonstrated bilateral pleural effusions and a small amount of ascites. Bone scintigraphy appearances are shown in Figure 1
.
The bone scan shows extensive skeletal muscle uptake, with absent definition of the skeletal system. As a result, the possibility of widespread muscle necrosis was raised and rhabdomyolysis was confirmed on subsequent muscle biopsy. The patient was receiving statin treatment for raised cholesterol, and this was assumed to be the causative agent. A repeat bone scan 5 weeks after discontinuation of the particular statin showed reversion towards the normal uptake pattern (Figure 2).
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Figure 2. Repeat bone scintigraphy 5 weeks after discontinuation of statin. Reversion towards the normal uptake pattern is seen.
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Rhabdomyolysis is an uncommon condition with an annual incidence of 1 per 10 000 population in the USA and a mortality of 5%. It is a rare cause of renal failure. It affects males more frequently than females, and presents clinically with muscle pain, tenderness and weakness. Raised levels of CCK, potassium and myoglobin are found in the peripheral blood owing to muscle cell breakdown. Statins are a cause of particular concern because of their widespread and increasing use [1]. Myotoxicity occurs in approximately 0.1% of cases.
Diffuse skeletal muscle uptake is extremely rare on bone scintigraphy and rhabdomyolysis is one of the principal causes [2, 3]. Other causes include dermato/polymyositis, amyloidosis, HIV-associated myositis, paraneoplastic syndrome and uraemic myositis [4]. Focal skeletal muscle uptake may be seen in myositis ossificans, soft tissue sarcomas, following electrical burns or iron dextran injection, or as a result of infarction (sickle cell disease, peripheral vascular disease).
Rhabdomyolysis may occur as a result of significant blunt trauma and prolonged immobilization. It may also develop following excessive muscular activity, myoclonal seizures or after ingestion of toxins (e.g. ethanol, isopropanol) or drugs such as barbiturates, antihistamines and salicylates. Environmental causes of rhabdomyolysis include both hyperthermia and hypothermia. It may occur as a complication of diabetic ketoacidosis or other metabolic disorders such as hypokalaemia and hypothyroidisim. Infective causes include viruses (e.g. influenza types A and B, HIV and Ebstein-Barr virus), bacteria (e.g. Streptococci) and fungi (e.g. candida and aspergillus). Inherited disorders may also cause rhabdomyolysis (e.g. enzyme deficiencies in carbohydrate or lipid metabolism).
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References
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- Lane R, Phillips M. Rhabdomyolysis. BMJ 2003;327:115–6.[Free Full Text]
- Blair RJ, Schroeder ET, McAfee JG, Duxbury CE. Skeletal muscle uptake of bone seeking agents in both traumatic and non traumatic rhabdomyolysis with acute renal failure. J Nucl Med 1975;16:515–6.
- Sagar VV, Meckelnburg RL, Chaikin HL. Bone scan in rhabdomyolysis. Clin Nucl Med 1980;5:321–2.[CrossRef][Medline]
- Datz FL. Gamuts in nuclear medicine (3rd edn). Mosby-Year Book, 1995.
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