Bone scan with MDP

Visualization of Wedge-Shaped Lesions by Bone Scan with MDP and MRI... 

Fig. 33. Bone scan with MDP. An uneven abnormal accumulation of an isotope was seen in the parenchyma of the bilateral kidneys...

This patient, who had autosomal dominant polycystic kidney disease (ADPKD), almost drowned and then developed ALPE. On July 20, 1990, he nearly drowned in the sea at 1500 hours, and was brought to our hospital by ambulance for dyspnea and severe loin pain at 1620 hours. On admission, metabolic acidosis was observed. His CRP, serum creatinine, CPK, amylase, and urinary protein levels were 1+, 1.5mg/dl, 116 U/l, 592IU/1 (derived from the salivary gland), and 2+, respectively. His body temperature was 37.7°C, and his blood pressure was 110/60 mmHg. His pulse and respiratory rate were 120/min and 22/min, respectively. Delayed CT 6h after the administration of contrast medium showed wedge-shaped contrast enhancement in the noncystic renal parenchyma (Fig. 34). On July 24, a bone scan with MDP revealed patchy lesions (Fig. 35). His serum creatinine level was 1.3 mg/dl, which had decreased to 1.0 mg/dl on July 27. The patient was then discharged. 

Fig. 40. Bone scan with MDP. The patchy findings were more marked in the left kidney...

This patient required hemodialysis for ALPE. Delayed CT and a bone scan with MDP in the recovery phase showed patchy lesions (these imaging procedures were performed in conjunction with another patient with myoglobin uric acute renal failure due to a malignant syndrome). On July 19, 1999, the patient fell into the water while fishing in a mountain stream, and was carried about 100 m in a few minutes while struggling all the time. As a precaution, he was admitted to a local clinic overnight. There were no abnormal laboratory data. However, at 0300 hours on July 21, he attended the Emergency Outpatient Unit of our hospital with severe bilateral loin... 

MRI and a bone scan with MDP showed wedge-shaped contrast enhancement in some patients, although these procedures were less sensitive than CT. Patchy lesions could be visualized by a bone scan with MDP in Patients 5 (Fig. 18), 12 (Fig. 33), 13 (Fig. 35), and 16 (Fig. 40). This visualization was achieved by MRI in Patients 6 [35] (Fig. 26), 16 (Fig. 22 and Fig. 39), and 21 (Fig. 45). In the future, ultrasonography with Levovist will facilitate the visualization of lesions. 

Fig. 75. Bone scan with MDP. In a patient with ALPE (left), there was no muscular uptake of MDP. However, muscular accumulation of MDP (arrows) was observed in a patient with myoglobinuric acute renal failure (right). In the ALPE patient, it was impossible to evaluate the presence or absence of patchy accumulation in the kidney...

In the patients with ALPE, plain CT of the kidney (delayed CT) a few hours, 24 h, and 48 h after the administration of 40 ml contrast medium showed wedge-shaped contrast enhancement. When physicians hesitate to administer a contrast medium, patchy accumulation can be sometimes detected by magnetic resonance imaging (MRI) with gadolinium-diethylenetriaminopentoacetic acid (Gd-DTPA), bone scan with MDP, or ultrasonography with Levovist. 

This patient was the first case of ALPE in which a bone scan with 99mTc-methylene diphosphonate (MDP) showed patchy findings (see Fig. 18) (the details are given in Chap. 3, Sect. 4). Severe abdominal pain developed after skiing. He consulted our hospital under a self-diagnosis of acute pancreatitis. 

Fig. 18. Bone scan images with methylene diphosphonate (MDP). Patchy accumulation was observed in the kidney (From [22], with permission)...

Fig. 35. Bone scan image with MDP in the same patient as in Fig. 34. A patchy lesion was observed. However, it was unclear whether this finding suggested ALPE or ADPKD...

In the patients with ALPE, bone scans showed no muscular uptake of methylene diphosphonate (MDP). However, upper/lower limb muscle uptake of MDP was found in the patients with myoglobinuric acute renal failure (Fig. 75). 

DPD was developed at Hochst, Germany (Schwarz and Kloss 1981 Schwarz et al. 1991), and compared favorably with MDP (Buell et al. 1982 Godart et al. 1986 Hale et al. 1981 Pauwels et al. 1983 Schroth et al. 1984). DPD is another efficient phosphonate complex that has been widely used as Teceos. The merits of available diphosphonate bone scanning agents have been discussed by Fogelman 1982. 

---