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Nuclear Medicine Imaging of Diabetic Foot

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Radionuclide Imaging of Infection and Inflammation

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Abstract

About 25% of the patients with diabetes will develop diabetic foot ulcers in their lifetime, with an incidence of 2–7% per year. The risk factors that concur to the development of a foot ulcer in diabetic patients are mostly the neuropathic foot and the vascular or ischemic foot. Infection may involve the soft tissues only (cellulitis and phlegmon) or deeper tissues and bone (osteomyelitis).

The techniques for diagnosing osteomyelitis include “probe to bone” probing, standard X-ray, MRI, and bone biopsy with microbiologic culture. Nuclear medicine techniques to diagnose infections in diabetic foot include three-phase bone scintigraphy, scintigraphy with radiolabeled leukocytes, and PET/CT with [18F] FDG.

The 2012 guidelines of the American College of Radiology suggest the use of leukocyte scintigraphy as the first-line nuclear medicine technique to evaluate patients with diabetic foot infection. When relying on single-photon emission imaging, SPECT/CT imaging provides advantages over planar scintigraphy, such as improved spatial resolution, better soft tissue contrast, and more precise anatomical localization of the infection.

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Author information

Authors and Affiliations

  1. Nuclear Medicine Department, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy

    Napoleone Prandini

  2. Infectious Diseases Unit, Department of Medical and Surgical Sciences for Children and Adults, University Hospital “Policlinico di Modena”, Modena, Italy

    Andrea Bedini

Authors
  1. Napoleone Prandini
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Editor information

Editors and Affiliations

  1. Regional Center of Nuclear Medicine, University Hospital of Pisa, Pisa, Italy

    Elena Lazzeri

  2. Department of Medical-Surgical Sciences and of Translational Medicine, Sapienza University of Rome, Roma, Italy

    Alberto Signore

  3. Department of Translational Research and Advanced Technologies in Medicine and Surgery, Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy

    Paola Anna Erba

  4. Nuclear Medicine Department, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy

    Napoleone Prandini

  5. Nuclear Medicine, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy

    Annibale Versari

  6. Nuclear Medicine Department, Private Hospital “PIO XI”, Roma, Italy

    Giovanni D´Errico

  7. Department of Translational Research and Advanced Technologies in Medicine and Surgery, Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy

    Giuliano Mariani

Clinical Cases

Clinical Cases

12.1.1 Case 12.1

  • Chiara Peterle &
  • Lorenzo Fantini 

A 58-year-old female with history of type 1 diabetes (chronic therapy with insulin). Various amputations in the left foot (third and fourth metatarsal bones); wee** wound in the left foot treated by hyperbaric oxygen therapy and antibiotics (amoxicillin clavulanate + levofloxacin) until 10 days before bone scintigraphy (June 2011).

12.1.1.1 Clinical Presentation

Pain and loss of function of left foot; scar of previous wee** wound; red and swollen skin in left foot.

12.1.1.2 Previous Diagnostic Work-Up

X-rays of left foot; angio-CT and morphologic CT of the left foot; the patient needs a differential diagnosis between Charcot’s foot and osteomyelitis (Figs. 12.10 and 12.11). MRI cannot be performed because of spinal cord implantable stimulator.

Fig. 12.10
figure 10

X-ray of left foot: Previous bone amputations can be observed

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Fig. 12.11
figure 11

Angio-CT: Increased vascularity near second metatarsal bone (sign of inflammation) can be observed

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12.1.1.3 Suspected Site of Infection

Anterior part of left foot, near previous amputations.

12.1.1.4 Radiopharmaceutical Activity

Bone scan (740 MBq); 99mTc-HMPAO-leukocyte scan (814 MBq).

12.1.1.5 Imaging

Gamma camera type: Gamma camera that combines variable angle dual-detector with a dual slice CT scanner (Symbia-T2); parallel holes collimator (low energy); Zoom: 1; SPECT matrix: 256 × 256. CT slice thickness: 1 mm. Display used for SPECT/CT fusion: 2D orthogonal MPR (multiplanar reformatting) (Figs. 12.12, 12.13, 12.14 and 12.15). Bone scan: (a) early scan (5 min after injection, 300 s) feet laid upon collimator; (b) late scan (3 h after injection, 498 s); leukocyte scan: (a) early scan, pool scan (1 h after injection, scan from pelvis to feet, 617 s); second scan (3 h after injection, scan from pelvis to feet, 928 s); late scan (20 h after injection, scan from pelvis to feet, 1856 s); SPECT/CT (20 h after injection).

Fig. 12.12
figure 12

99mTc-MDP scintigraphy, planar posterior images of the feet. Two-phase bone scan: Increased vascularity in pool scan (left) and increased bone turnover in late scan (right); signs of inflammation (septic or aseptic?)

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Fig. 12.13
figure 13

99mTc-HMPAO-leukocyte scintigraphy. Anterior scan images: In the first view on the left, we can see an increased uptake of leukocytes (inflammation) in the left foot that decreases in the 3 and 20 h scans (signs of aseptic inflammation, like in Charcot’s foot disease)

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Fig. 12.14
figure 14

99mTc-HMPAO-leukocyte scintigraphy. 2D-orthogonal MPR SPECT/ CT fused images (coronal, left; sagittal, middle; transaxial, right): A little uptake in soft tissues only, common in inflamed tissues can be observed

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Fig. 12.15
figure 15

99mTc-HMPAO-leukocyte scintigraphy. 2D-orthogonal MPR SPECT/CT fusion: CT images (coronal, left; sagittal, middle; transaxial, right) only demonstrates the signs of amputation

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12.1.1.6 Conclusion/Teaching Point

Since the patient only had inflammation of the left foot (Charcot’s foot) with no infection, she did not go back to her hyperbaric and antibiotic therapy. She is still well now.

12.1.2 Case 12.2

  • Chiara Peterle &
  • Ilaria Rambaldi 

A 55-year-old male with the history of type 1 diabetes. Several amputations in both the feet; wee** wound in the left foot. Patient underwent no treatment until the examination was performed.

12.1.2.1 Clinical Presentation

Pain and loss of function of the left foot; red and swollen skin in the left foot.

12.1.2.2 Previous Diagnostic Work-Up

A tampon culture was performed; Pseudomonas aeruginosa was found. Patient needs a differential diagnosis, between infection of soft tissues only and osteomyelitis, to develop an appropriate treatment plan.

12.1.2.3 Suspected Site of Infection

Anterior part of the back of left foot, near previous amputations.

12.1.2.4 Radiopharmaceutical Activity

99mTc-HMPAO-leukocyte scintigraphy. Activity injected, 740 MBq.

12.1.2.5 Imaging

Gamma camera type: Gamma camera that combines variable angle dual-detector with a dual slice CT scanner (Symbia-T2); parallel holes collimator (low energy); Zoom, 1; SPECT matrix, 256 × 256; CT slice thickness, 1 mm; display used for SPECT/CT fusion, 2D orthogonal MPR (Figs. 12.16, 12.17, 12.18, and 12.19). Leukocyte scan: (a) early scan, pool scan (1 h after injection, scan from pelvis to feet, 636 s); second scan (3 h after injection, scan from pelvis to feet, 958 s); late scan (20 h after injection, scan from pelvis to feet, 1917 s); SPECT/CT (20 h after injection).

Fig. 12.16
figure 16

99mTc-HMPAO-leukocyte scintigraphy. 3D fusion volume rendering: (a) right anterior oblique view of the feet; (b) anterior view and (c) right lateral view of the feet. The spot in rainbow color shows site of infection. Bilateral amputations of bones in feet can be seen

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Fig. 12.17
figure 17

99mTc-HMPAO-leukocyte scintigraphy scan. An increased uptake of leukocytes (inflammation) can be seen (left) that rises and focuses in the 3 h (middle) and 20 h (right) scans in the left foot (signs of septic inflammation, as in osteomyelitis). In the left groin, we can see another spot of leukocytes in the 20 h scan, which may be reactive lymph nodes

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Fig. 12.18
figure 18

99mTc-HMPAO-leukocyte scintigraphy. 2D orthogonal MPR SPECT/CT fused images (coronal, left; sagittal, middle; transaxial, right): Focused uptake in soft tissues, which involves second metatarsal bone , can be seen

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Fig. 12.19
figure 19

2D orthogonal MPR SPECT/CT. CT images (coronal, left; sagittal, middle; transaxial, right) demonstrate the normal structure of bones in the foot

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12.1.2.6 Conclusion/Teaching Point

Scintigraphy with radiolabeled leukocytes demonstrated osteomyelitis of the second metatarsal bone , in addition to the infection of soft tissues by Pseudomonas aeruginosa. The patient underwent an antibiotic specific therapy (imipenem + cilastatin). Finally, hyperbaric oxygen therapy was performed.

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Prandini, N., Bedini, A. (2021). Nuclear Medicine Imaging of Diabetic Foot. In: Lazzeri, E., et al. Radionuclide Imaging of Infection and Inflammation. Springer, Cham. https://doi.org/10.1007/978-3-030-62175-9_12

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  • DOI: https://doi.org/10.1007/978-3-030-62175-9_12

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