Use of Subtraction PET to Identify the Source of Recurrent Sepsis After Bomb Blast Injury. Case Report
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Use of Subtraction PET to Identify the Source of Recurrent Sepsis After Bomb Blast Injury. Case Report Beniamino Forte 1,2 & Serena Martin 3 & Chris Hill 3 & Tom Lynch 4 Accepted: 16 April 2020 / Published online: 5 May 2020 # Springer Nature Switzerland AG 2020
Abstract Timely diagnosis of osteomyelitis is essential for its successful treatment but it is often difficult to recognise despite extensive radiological workup. We outline a case of recurrent sepsis over a 7-year period in a patient injured by a car bomb blast and the use of an innovative imaging technique to localise two culprit foci of osteomyelitis. This was a prolonged and difficult diagnosis due to extensive shrapnel injury and associated inflammation as well as significant anatomical disruption from the blast. Sites of inflammation associated with shrapnel injury acted as decoys to the true foci of active infection on fluorodeoxyglucose (FDG), positron emission tomography/computed tomography (PET/CT) and an additional technique was required to differentiate these. This involved administering a course of antibiotics between two separate FDG-PET/CT scans and is known as subtraction PET. Two sites of osteomyelitis were identified among 20–30 other sites of benign granulomatous inflammation and calcification. These two sites of infection were characterised by a significant drop in tracer uptake on FDG-PET/CT after a course of antibiotics while tracer uptake at the remaining sites remained relatively unchanged. This ultimately guided surgical excision of the sequestra, and at follow-up of 2 years, the patient has experienced no further septic episodes. Keywords Bomb blast . Sepsis of unknown origin . Nuclear medicine . Case report
Introduction Osteomyelitis can be difficult to identify in patients who have sustained bomb blast injury [1]. This is due to an alteration in the normal anatomy and penetration by foreign bodies causing deep-seated infections with unusual organisms [2, 3]. FDGThis article is part of the Topical Collection on Imaging Presented at Irish Association of Plastic Surgeons Annual Scientific Meeting, Summer 2019 Presented at the 88th Annual Meeting of American Society of Plastic Surgeons, September 2019. Awarded ‘Top 100 Global Poster’. Presented at NIMDTA/Ulster Medical Society Trainee Research Day, October 2019. * Beniamino Forte
1
Royal Victoria Hospital, Belfast, UK
2
Hillsborough, UK
3
Department of Plastic Surgery, Ulster Hospital, Dundonald, Belfast, UK
4
Department of Nuclear Medicine, Cancer Centre, Belfast City Hospital, Belfast, UK
PET/CT is useful in musculoskeletal infection due to FDG accumulation in the inflammatory leukocytes of both acute and chronic infection [4, 5]. However, the combination of high sensitivity and relatively low specificity can make differentiation between aseptic inflammation and infective inflammation difficult [6]. Here, we report the use of subtraction PET to overcome these limitations and differentiate osteomyelitis from benign, shrapnel-associated inflammation.
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