Brought to you by Nuclear Education Online (NEO)                    Volume One              February 2003

Chief Complaint

    JF is a 78 year old white male who was presented with a chief complaint of left elbow pain.  JF’s problems began a few weeks ago while gardening.  A bone scan was requested for evaluation of osteomyelitis.

Past Medical History

  • Renal Failure
  • Multiple Myeloma
  • Primary Amyloidosis
  • Pneumonia (March 2001)
  • Tuberculosis exposure
  • CHF & cardiomyopathy
  • Hypertension x 20 yrs
  • Arrhythmia x 12 yrs
  • Diabetes
  • Partial Thyroidectomy
  • Hemorrhoidectomy (1980)
  • Angioplasty (1998)
  • Cataract Removal (2000)

Meds Prior to Admission

  • Coumadin 2.5 mg
  • Prednisone 20 mg
  • Lasix 80 mg
  • Zaroxolyn 5mg
  • Actos 15 mg
  • Synthroid 300 mcg
  • Prilosec 20 mg
  • ASA 21 mg
  • Phoslo 1 tablet qid
  • Iron supplement
  • Melphalan 50 mg/m plus peripheral blood stem cell support

Patient’s Social/Family History

  • Mother- died at age 42 during childbirth
  • Father- died at 97 of natural causes
  • Brother- insulin dependent diabetes mellitus
  • Married 52 years with 3 daughters all healthy

Physical Findings

  • No acute distress
  • Jugular Venous Distention
  • Loss of 40 lbs over past year
  • Muscle wasting
  • Blurred vision
  • Shortness of breath upon minimal physical exertion

Laboratory Findings

  • K= 3.3 mEq/L
  • BUN= 81 mg/dL
  • Creatinine= 2.7 mg/dL
  • Cr/Cl=34 ml/min
  • Bilirubin= 1.3 mg/dL
  • LDH= 477 u/L otherwise LFT’s normal

Conclusion

    In summary, we have a 78 year old white male with multiple myeloma, amyloidosis, and CHF who was presented with left elbow bone pain.  He has been managed by drug therapy which include the addition of Samarium-153.

 

 
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© 2002 Nuclear Education Online

Click to view image.

Bone Scan Interpretation

Due to technical problems, the first phase of the triple phase bone study was not performed.  A delayed image over the elbow demonstrates no focal activity in the left elbow consistent with osteomyelitis.  Whole body images demonstrate minimal renal and bladder activity.  Extensive soft tissue uptake is identified.  Intense activity seen in the lungs.  Also identified is intense activity in the left ventricular myocardium, which would be consistent with amyloidosis.

Impression:

  1. Left elbow demonstrating no uptake consistent with osteomyelitis.

  2. Amyloid uptake of bone tracer agent in the heart.

  3. Extensive soft tissue metastatic apposition due to presumed hypercalcemia.

Click to see image

 

Myocardial Stress / Rest Test Interpretation

Patient was informed and consent obtained for the procedure.  Patient was given 10 mCi of 99mTc Tetrofosmin intravenously, and rest images in the standard three projections were obtained.  Then, Persantine was infused I.V. at a rate of .14mg/kg/min for a total of 4 minutes, and a total of 45 mg Persantine.  Resting heart rate was 99 bpm and blood pressure was 122/69 mmHg.  Resting EKG showed diffuse ST-T wave changes and atrial fibrillation.  Following Persantine, EKG showed no significant change.  After the Persantine was infused, approximately 31 mCi of 99mTc Tetrofosmin was given and stress images were obtained at 30 minutes in the standard 3 projections.

The left ventricle is symmetrically enlarged and dilated.  There is no significant reversible or fixed defects within the ventricular wall.  A calculated ejection fraction was noted to be 28%

Impression:

  1. Dilated left ventricle without evidence of fixed or reversible defect.
  2. Left ventricle ejection fraction of 28%.

 

Images courtesy of UAMS Dept of Nuclear Medicine.