Bone scintigraphy in acute myeloid leukemia patient with fungal vertebral osteomyelitis

Abstract

Abstract The result of the magnetic resonance imaging (MRI) study was reported as “metastasis of primary disease on L2-L3 vertebrae” in a 63-year-old male patient, who developed a back pain after receiving 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 osteoblastic activity was reported on L2-L3 vertebrae with a suspicion about infection or fracture, together with a focal osteoblastic activity involvement in the right sacroiliac joint in the bone scintigraphy which was made with Tc99m-MDP. In the mean time, the patient complained about progressive loss of strength on bilateral lower extremities and numbness in legs. Repeated MRI was reported as “irregularities 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 with paravertebral abscess and granulation tissue”. The patient was operated and necrotic tissue was removed by curettage, relieving the compression on L2-L3 and on the disc distance. In culture examination of the sample “candida albicans” was isolated. Antifungal treatment with Amphotericin B was started. Patient's pain was reduced and MRI findings showed some regression in abscess following the treatment. There was improvement in neurological examination. However, relapse in AML was observed in bone marrow aspiration, performed during follow-up and chemotherapy was started again. On the second day of chemotherapy high fever started and cellulitis developed on the right leg. The patient received hemodialysis treatment due to increase in BUN and creatinine levels. Pulmonary edema and associated respiratory insufficiency was developed and the patient died. Fungal infections are one of the most important clinical problems in leukemia patients. However, vertebral osteomyelitis secondary to fungal infection is relatively a rare 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. Bone scintigraphy has no place in routine evaluation of leukemia patients. However, we consider that bone scintigraphy should be kept in mind in the first stage of evaluation of such cases, together with other radiological examination, we think that evaluation with consideration of three-phase bone scintigraphy would be beneficial. Keywords: Candida, acute myeloid leukemia, bone scintigraphy, vertebrae osteomyelitis Ozet Akut miyeloid losemi (AML) nedeni ile 4 kur tedavi aldiktan sonra, bel agrisi gelisen 63 yasindaki erkek hastada yapilan MR incelemesi raporu “L2-L3 vertebrada primer hastaligin metastazi” idi. Agri medikasyonlarina yanit alinamayan hasta, nukleer tip bolumune kemik sintigrafisi icin gonderildi. Tc-99m MDP ile yapilan kemik sintigrafisinde, enfeksiyon veya kirik suphesi uyandiran, L2-L3 vertebralarda diffuz osteoblastik aktivite artislari bununla birlikte, sag sakroiliak eklemde fokal, osteoblastik aktivite tutulumu izlendi. Bu sirada hastada bilateral progresif alt extremitelerde guc kaybi ve bacaklarda uyusma sikayetleri gelisti. Tekrarlanan MR “L2-L3 vertebra disk mesafesinde enfeksiyon ile uyumlu gorunum, belirgin tekal basi, L2-L3 vertebralarda osteomyelite bagli yukseklik kaybi, paravertebral abse ve granulasyon dokusu ile uyumlu kitle gorunumu” olarak rapor edildi. Hasta operasyona alindi ve L2-L3 dekompresyon ve disk mesafesinde kuretaj yapilarak nekrotik doku temizlendi. Gonderilen numunenin kultur incelemesinde “Candida albicans” uredi. Amphotericin B ile antifungal tedavi baslandi. Tedaviyi takiben hastanin agrilarinda azalma oldu ve MRI bulgulari absede gerileme gosterdi. Norolojik muayenede duzelme vardi. Ancak takipleri sirasinda yapilan kemik iligi aspirasyonunda, AML’nin nuks ettigi saptandi ve yeniden kemoterapiye baslandi. Kemoterapinin 2.gununde yuksek ates, sag bacakta selulit gelisti. BUN ve kreatinin duzeylerinin yukselmesi nedeniyle hasta diyalize alindi. Akciger odemine bagli solunum yetmezligi gelisti ve hasta kaybedildi. Fungal enfeksiyonlar, losemili hastalarda en onemli klinik sorundur. Bununla birlikte fungal enfeksiyonlara sekonder gelisen vertebral osteomyelit nadir bir durumdur ve tani ve tedavideki gecikme ciddi norolojik sorunlara neden olabilir. Bu tur vakalarda klinisyenler tarafindan fungal enfeksiyondan suphelenmesi hayati onem tasir. Losemilerde kemik sintigrafisinin rutinde yeri yoktur. Bununla birlikte, bu tur vakalarin degerlendirilmesinde, kemik sintigrafisi diger radyolojik tetkikler ile birlikte ilk asamada akilda tutulmalidir ki biz uc fazli kemik sintigrafisi ile degerlendirme yapilmasinin yararli olacagini dusunmekteyiz. Anahtar sozcukler: Candida, Akut myeloid losemi, kemik sintigrafi, vertebra osteomyelit