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Calciphylaxis, a cause of 99mTc-diphosphonate soft-tissue uptake
G Model REMNIM-630; No. of Pages 2
ARTICLE IN PRESS Rev Esp Med Nucl Imagen Mol. 2014;xxx(xx):xxx–xxx
Interesting image
Calciphylaxis, a cause of 99m Tc-diphosphonate soft-tissue uptake Calcifilaxis, una causa de captación de 99m Tc-difosfonatos en partes blandas C. Ramos-Font a,∗ , E. Sanchez de Mora a , J. López Martín a , C. Salgado-García a , M. Benitez-Sanchez b , A. Jimenez-Heffernan a a b
Nuclear Medicine Department, Hospital Juan Ramón Jiménez, Huelva, Spain Nephrology Department, Hospital Juan Ramón Jiménez, Huelva, Spain
a r t i c l e
i n f o
Article history: Received 30 April 2014 Accepted 29 June 2014 Available online xxx
Calciphylaxis is a rare vascular disorder almost exclusive of end-stage renal disease with a high morbi-mortality.1 It consists in a progressive vascular calcification and subsequent necrosis of skin and soft tissues. It causes skin lesions that can start as painful erythematous lesions and progress rapidly into violaceous discoloration and well-demarcated nonhealing ulcers that become necrotic and gangrenous.2 Hypercalcemia and hyperphosphoremia, secondary hyperparathyroidism, hypoalbuminemia, obesity, high dose of vitamin D metabolites or warfarin use are considered risk factors for the development of this entity.1 The diagnosis is mainly clinical as biopsy is not recommended due to the risk of ulceration and infection of the skin lesion subsequent risk of septicemia. Moreover, pathology results can be unspecific.3 Bone scintigraphy has shown to be highly sensitive helping in the diagnosis by showing subcutaneous uptake of 99m Tc-biphosphonates in the plaques, due to bone matrix protein osteopontin deposits.2 It could also be proposed as a prognostic indicator because systemic involvement appears to be associated with a poor prognosis.2 A whole body scan (WBS) and SPECT-CT was performed after the injection of 20 mCi of 99m Tc-HPD in a 64 year-old-woman with chronic renal failure of more than 25 years of evolution, morbid obesity, arterial hypertension and secondary hyperparathyroidism. She has been on hemodialysis for the last 5 years. She presented with abdominal skin lesions. Calciphylaxis was suspected. WBS showed a metabolic pattern due to hyperparathyroidism, and radiopharmaceutical uptake in the abdominal wall (Fig. 1). SPECTCT (Fig. 2) confirmed subcutaneous uptake in the abdominal wall corresponding with changes in the tissue density on CT images. The patient was then treated with sodium thiosulfate which stabilized the lesions.1 Serial bone scanning can also be used to monitor progression or regression of disease.2
Fig. 1. Anterior and posterior views of a whole body scan 150 min after the injection of 20 mCi 99m Tc-HPD, which shows a typical distribution pattern of metabolic processes, such as hyperparathyroidism with diffuse uptake of the radiopharmaceutical in skull, cortical of long bones (tibia and fibula), and calcification of the costal cartilages. Also there is an increased uptake in shoulders, sacroiliac joints and knees, suggesting degenerative/inflammatory arthropathy. Incidental scattered an irregular focal deposits of radiopharmaceutical is seen in the abdomen, predominant in flanks (arrows).
∗ Corresponding author. E-mail address: [email protected] (C. Ramos-Font). http://dx.doi.org/10.1016/j.remn.2014.06.004 2253-654X/© 2014 Elsevier España, S.L.U. and SEMNIM. All rights reserved.
Please cite this article in press as: Ramos-Font C, et al. Calciphylaxis, a cause of 99m Tc-diphosphonate soft-tissue uptake. Rev Esp Med Nucl Imagen Mol. 2014. http://dx.doi.org/10.1016/j.remn.2014.06.004
G Model REMNIM-630; No. of Pages 2
ARTICLE IN PRESS C. Ramos-Font et al. / Rev Esp Med Nucl Imagen Mol. 2014;xxx(xx):xxx–xxx
2
Fig. 2. SPECT tomographic axial sections (A), hybrid (B) and CT (C) in which the deposit f the radiopharmaceutical is seen in the abdominal wall together with changes in the density of subcutaneous tissue, including some calcium densities, that could suggest the diagnosis of calciphylaxis.
References 1. Torregrosa JV, Bover J, Cannata Andía J, Lorenzo V, de Francisco ALM, Martínez I, et al. Spanish Society of Nephrology recommendations for controlling mineral and bone disorders in chronic kidney disease patients (S.E.N.–M.B.D.). Nefrologia. 2011;31 Suppl. 1:3–32.
2. Han MM, Pang J, Shinkai K, Franc B, Hawkins R, Aparici CM. Calciphylaxis and bone scintigraphy: case report with histological confirmation and review of the literature. Ann Nucl Med. 2007;21:235–8. 3. Latus J, Kimmel M, Ott G, Ting E, Alscher MD, Braun N. Early stages of calciphylaxis: are skin biopsies the answer? Case Rep Dermatol. 2011;3:201–5.
Please cite this article in press as: Ramos-Font C, et al. Calciphylaxis, a cause of 99m Tc-diphosphonate soft-tissue uptake. Rev Esp Med Nucl Imagen Mol. 2014. http://dx.doi.org/10.1016/j.remn.2014.06.004
ARTICLE IN PRESS Rev Esp Med Nucl Imagen Mol. 2014;xxx(xx):xxx–xxx
Interesting image
Calciphylaxis, a cause of 99m Tc-diphosphonate soft-tissue uptake Calcifilaxis, una causa de captación de 99m Tc-difosfonatos en partes blandas C. Ramos-Font a,∗ , E. Sanchez de Mora a , J. López Martín a , C. Salgado-García a , M. Benitez-Sanchez b , A. Jimenez-Heffernan a a b
Nuclear Medicine Department, Hospital Juan Ramón Jiménez, Huelva, Spain Nephrology Department, Hospital Juan Ramón Jiménez, Huelva, Spain
a r t i c l e
i n f o
Article history: Received 30 April 2014 Accepted 29 June 2014 Available online xxx
Calciphylaxis is a rare vascular disorder almost exclusive of end-stage renal disease with a high morbi-mortality.1 It consists in a progressive vascular calcification and subsequent necrosis of skin and soft tissues. It causes skin lesions that can start as painful erythematous lesions and progress rapidly into violaceous discoloration and well-demarcated nonhealing ulcers that become necrotic and gangrenous.2 Hypercalcemia and hyperphosphoremia, secondary hyperparathyroidism, hypoalbuminemia, obesity, high dose of vitamin D metabolites or warfarin use are considered risk factors for the development of this entity.1 The diagnosis is mainly clinical as biopsy is not recommended due to the risk of ulceration and infection of the skin lesion subsequent risk of septicemia. Moreover, pathology results can be unspecific.3 Bone scintigraphy has shown to be highly sensitive helping in the diagnosis by showing subcutaneous uptake of 99m Tc-biphosphonates in the plaques, due to bone matrix protein osteopontin deposits.2 It could also be proposed as a prognostic indicator because systemic involvement appears to be associated with a poor prognosis.2 A whole body scan (WBS) and SPECT-CT was performed after the injection of 20 mCi of 99m Tc-HPD in a 64 year-old-woman with chronic renal failure of more than 25 years of evolution, morbid obesity, arterial hypertension and secondary hyperparathyroidism. She has been on hemodialysis for the last 5 years. She presented with abdominal skin lesions. Calciphylaxis was suspected. WBS showed a metabolic pattern due to hyperparathyroidism, and radiopharmaceutical uptake in the abdominal wall (Fig. 1). SPECTCT (Fig. 2) confirmed subcutaneous uptake in the abdominal wall corresponding with changes in the tissue density on CT images. The patient was then treated with sodium thiosulfate which stabilized the lesions.1 Serial bone scanning can also be used to monitor progression or regression of disease.2
Fig. 1. Anterior and posterior views of a whole body scan 150 min after the injection of 20 mCi 99m Tc-HPD, which shows a typical distribution pattern of metabolic processes, such as hyperparathyroidism with diffuse uptake of the radiopharmaceutical in skull, cortical of long bones (tibia and fibula), and calcification of the costal cartilages. Also there is an increased uptake in shoulders, sacroiliac joints and knees, suggesting degenerative/inflammatory arthropathy. Incidental scattered an irregular focal deposits of radiopharmaceutical is seen in the abdomen, predominant in flanks (arrows).
∗ Corresponding author. E-mail address: [email protected] (C. Ramos-Font). http://dx.doi.org/10.1016/j.remn.2014.06.004 2253-654X/© 2014 Elsevier España, S.L.U. and SEMNIM. All rights reserved.
Please cite this article in press as: Ramos-Font C, et al. Calciphylaxis, a cause of 99m Tc-diphosphonate soft-tissue uptake. Rev Esp Med Nucl Imagen Mol. 2014. http://dx.doi.org/10.1016/j.remn.2014.06.004
G Model REMNIM-630; No. of Pages 2
ARTICLE IN PRESS C. Ramos-Font et al. / Rev Esp Med Nucl Imagen Mol. 2014;xxx(xx):xxx–xxx
2
Fig. 2. SPECT tomographic axial sections (A), hybrid (B) and CT (C) in which the deposit f the radiopharmaceutical is seen in the abdominal wall together with changes in the density of subcutaneous tissue, including some calcium densities, that could suggest the diagnosis of calciphylaxis.
References 1. Torregrosa JV, Bover J, Cannata Andía J, Lorenzo V, de Francisco ALM, Martínez I, et al. Spanish Society of Nephrology recommendations for controlling mineral and bone disorders in chronic kidney disease patients (S.E.N.–M.B.D.). Nefrologia. 2011;31 Suppl. 1:3–32.
2. Han MM, Pang J, Shinkai K, Franc B, Hawkins R, Aparici CM. Calciphylaxis and bone scintigraphy: case report with histological confirmation and review of the literature. Ann Nucl Med. 2007;21:235–8. 3. Latus J, Kimmel M, Ott G, Ting E, Alscher MD, Braun N. Early stages of calciphylaxis: are skin biopsies the answer? Case Rep Dermatol. 2011;3:201–5.
Please cite this article in press as: Ramos-Font C, et al. Calciphylaxis, a cause of 99m Tc-diphosphonate soft-tissue uptake. Rev Esp Med Nucl Imagen Mol. 2014. http://dx.doi.org/10.1016/j.remn.2014.06.004