Taner ERSELCAN, Zekiye HASBEK, Ayşegül ÖZDAL, Bülent TURGUT

Bone scintigraphy in acute myeloid leukemia patient with fungal vertebral osteomyelitis

Akut miyeloid lösemi (AML) nedeni ile 4 kür tedavi aldıktan sonra, bel ağrısı gelişen 63 yaşındakierkek hastada yapılan MR incelemesi raporu L2-L3 vertebrada primer hastalığın metastazı idi.Ağrı medikasyonlarına yanıt alınamayan hasta, nükleer tıp bölümüne kemik sintigrafisi içingönderildi. Tc-99m MDP ile yapılan kemik sintigrafisinde, enfeksiyon veya kırık şüphesiuyandıran, L2-L3 vertebralarda diffüz osteoblastik aktivite artışları bununla birlikte, sağ sakroiliakeklemde fokal, osteoblastik aktivite tutulumu izlendi. Bu sırada hastada bilateral progresif altextremitelerde güç kaybı ve bacaklarda uyuşma şikayetleri gelişti. Tekrarlanan MR L2-L3vertebra disk mesafesinde enfeksiyon ile uyumlu görünüm, belirgin tekal bası, L2-L3 vertebralardaosteomyelite bağlı yükseklik kaybı, paravertebral abse ve granülasyon dokusu ile uyumlu kitlegörünümü olarak rapor edildi. Hasta operasyona alındı ve L2-L3 dekompresyon ve diskmesafesinde küretaj yapılarak nekrotik doku temizlendi. Gönderilen numunenin kültürincelemesinde Candida albicans üredi. Amphotericin B ile antifungal tedavi başlandı. Tedaviyitakiben hastanın ağrılarında azalma oldu ve MRI bulguları absede gerileme gösterdi. Nörolojikmuayenede düzelme vardı. Ancak takipleri sırasında yapılan kemik iliği aspirasyonunda, AMLninnüks ettiği saptandı ve yeniden kemoterapiye başlandı. Kemoterapinin 2.gününde yüksek ateş, sağbacakta selülit gelişti. BUN ve kreatinin düzeylerinin yükselmesi nedeniyle hasta diyalize alındı.Akciğer ödemine bağlı solunum yetmezliği gelişti ve hasta kaybedildi. Fungal enfeksiyonlar,lösemili hastalarda en önemli klinik sorundur. Bununla birlikte fungal enfeksiyonlara sekondergelişen vertebral osteomyelit nadir bir durumdur ve tanı ve tedavideki gecikme ciddi nörolojiksorunlara neden olabilir. Bu tür vakalarda klinisyenler tarafından fungal enfeksiyondanşüphelenmesi hayati önem taşır. Lösemilerde kemik sintigrafisinin rutinde yeri yoktur. Bununlabirlikte, bu tür vakaların değerlendirilmesinde, kemik sintigrafisi diğer radyolojik tetkikler ilebirlikte ilk aşamada akılda tutulmalıdır ki biz üç fazlı kemik sintigrafisi ile değerlendirmeyapılmasının yararlı olacağını düşünmekteyiz.

Fungal vertebral osteomyelitli akut myeloid lösemi hastasında kemik sintigrafisi

The result of the magnetic resonance imaging (MRI) study was reported as metastasis of primarydisease on L2-L3 vertebrae in a 63-year-old male patient, who developed a back pain afterreceiving four courses of treatment for AML. The patient, who did not respond to pain medication,was sent to nuclear medicine department for a bone scintigraphy. Diffuse increased osteoblasticactivity was reported on L2-L3 vertebrae with a suspicion about infection or fracture, together witha focal osteoblastic activity involvement in the right sacroiliac joint in the bone scintigraphy whichwas made with Tc99m-MDP. In the mean time, the patient complained about progressive loss ofstrength on bilateral lower extremities and numbness in legs. Repeated MRI was reported asirregularities in L2-L3 vertebral disc region concordant with infection, prominent thecal pressure,loss of height in L2-L3 vertebrae associated with osteomyelitis and a mass concordant withparavertebral abscess and granulation tissue . The patient was operated and necrotic tissue wasremoved by curettage, relieving the compression on L2-L3 and on the disc distance. In cultureexamination of the sample candida albicans was isolated. Antifungal treatment withAmphotericin B was started. Patient's pain was reduced and MRI findings showed some regressionin abscess following the treatment. There was improvement in neurological examination.However, relapse in AML was observed in bone marrow aspiration, performed during follow-upand chemotherapy was started again. On the second day of chemotherapy high fever started andcellulitis developed on the right leg. The patient received hemodialysis treatment due to increase inBUN and creatinine levels. Pulmonary edema and associated respiratory insufficiency wasdeveloped and the patient died. Fungal infections are one of the most important clinical problemsin leukemia patients. However, vertebral osteomyelitis secondary to fungal infection is relatively arare condition and delay in diagnosis and treatment may led to serious neurological problems.Suspection of a probable fungal infection by clinicians seems vital in such cases. Bonescintigraphy has no place in routine evaluation of leukemia patients. However, we consider thatbone scintigraphy should be kept in mind in the first stage of evaluation of such cases, togetherwith other radiological examination, we think that evaluation with consideration of three-phasebone scintigraphy would be beneficial.

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1. Shalaby-Rana E, Majd M. (99m)Tc-MDP scintigraphic findings in children with leukemia: value of early and delayed whole-body imaging. J Nucl Med 2001; 42: 878-83.
2. Bernard EJ, Nicholls WD, Howman-Giles RB, Kellie SJ, Uren RF. Patterns of abnormality on bone scans in acute childhood leukemia. J Nucl Med 1998; 39: 1983-6.
3. Menzin J, Lang KM, Friedman M, Dixon D, Marton JP, Wilson J. Excess mortality, length of stay, and costs associated with serious fungal infections among elderly cancer patients: findings from linked SEER-Medicare data. Value Health 2005; 8: 140-8.
4. Aytekin A, Peksarı Y. Immunology of candidal infections. T Klin Dermatol 2002; 12: 229-36.
5. Eggimann P, Garbino J, Pittet D. Epidemiology of Candida species infections in critically ill non-immunosuppressed patients. Lancet Infect Dis 2003; 3:685-702.
6. Kume H, Yamazaki T, Abe M, Tanuma H, Okudaira M, Okayasu I. Increase in Aspergillosis and Severe mycotic infection in patients with leukemia and MDS: Comparison of the data from the annual of the pathological autopsy cases in Japan in 1989, 1993 and 1997. Pathol Int 2003; 53: 744-50.
7. Gursel T, Kaya Z, Kocak U, Erbaş G, Akyurek N, Tali ET. Candida vertebra osteomyelitis in a girl with factor X deficiency. Hemophilia 2005; 11: 629-32.
8. Shaikh Z, Shaikh S, Pujol F, Trauber D, Sam M. Candida tropicalis osteomyelitis: Case report and review of literature. Am J Med 2005; 118: 795-8.
9. Özdemir N, Çelik L, Oğuzoğlu S, Yıldırım L, Bezircioğlu H. Cervical vertebral osteomyelitis and epidural abscess caused by Candida albicans in a patient with chronic renal failure. Turk Neurosurg 2008; 18: 207-10.
10. Tew CW, Han FC, Jureen R, Tey BH. Aspergillus vertebral osteomyelitis and epidural abscess. Singapore Med J 2009; 50: e151-4.
11. Zhu LP, Chen XS, Wu JQ, Yang FF, Weng XH. Aspergillus vertebral osteomyelitis and ureteral obstruction after liver transplantation. Transpl Infect Dis 2011; 13: 192-9.
12. Cha JG, Hong HS, Koh YW, Kim HK, Park JM. Candida albicans osteomyelitis of the cervical spine. Skeletal Radiol 2008; 37: 347-50.
13. Hendrickx L, Van Wijngaerden E, Samson I, Peetermans WE. Candidal vertebral osteomyelitis: report of 6 patients, and a review. Clin Infect Dis 2001; 32: 527- 33.
14. Williams RL, Fukui MB, Meltzer CC, Swarnkar A, Johnson DW, Welch W. Fungal spinal osteomyelitis in the immunocompromised patient: MR findings in three cases. AJNR Am J Neuroradiol 1999; 20: 381-5.
15. Ferra C, Doebbeling BN, Hollis RJ, Pfaller MA, Lee CK, Gingrich RD. Candida tropicalis vertebral osteomyelitis: A late sequela of fungemia. Clin Infect Dis 1994; 19: 697-703.
16. Miller DJ, Mejicano GC. Vertebral osteomyelitis due to Candida Species: Case Report and Literature Review. Clin Infect Dis 2001; 33: 523-30.
17. Johnson JL, Moscinski L, Zuckerman K. Value of positron emission tomography scan in staging cancers, and an unusual presentation of acute myeloid leukemia. Case 3. Acute myeloid leukemia presenting with lytic bone lesions. J Clin Oncol 2004; 15; 22: 2968-70.
18. Lima CS, Pinto Neto JV, da Cunha ML, Vassallo J, Cardinalli IA, De Souza CA. Osteolytic lesions as a presenting sign of acute myeloid leukemia. Haematologia 2000; 30: 325-31.