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Technetium-99M-DMSA Renal SPECT in Diagnosing and Monitoring Pediatrie Acute Pyelonephritis

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Technetium-99M-DMSA Renal SPECT in Diagnosing and Monitoring Pediatrie Acute Pyelonephritis 9. Moon DH, Ryu JS, Lee MH, et al. Clinical value of DMSA planar and single-photon piglet using single-photon emission computerized tomography dimercaptosuccinic emission eomputed tomography as an initial diagnostic tool in adult women with acid scintigraphy: a pathological correlation. J Ural 1993:150:759-762. recurrent acute pyelonephritis. Nephron 1994:67:274-279. 13. Majd M. Rushton G. Chandra R, et al. Tcchnetium-99m-DMSA renal cortical 10. Rehm PK, Atkins FB, Tall JG. Ziessman HA. SPECT tcchnetium-99m-DMSA renal scintigraphy for the detection of acute pyelonephritis in piglets: comparison of planar scans: comparison of native versus reoriented axes [Abstract]. J NucíMetí1993:34: and SPECT imaging. Eur J NucíMed I994;21:343. 227P. 14. Williams ED. Renal single-photon emission computed tomography: should we do it? 11. Buscombe JR, Hilson AJW. Hall ML, et al. Looking for renal scars with technetium- Semin NucíMed 1992;22:112-121. 99m-DMSA SPECT: is it worth the effort? [Abstract]. J NucíMed 1993:34:138P. 15. Rossleigh MA. The interrenicular septum. A normal anatomical variant seen on 12. Giblin JG, O'Connor KP. Kildes RD. et al. The diagnosis of acute pyelonephritis in the DMSA SPECT. Clin NucíMed 1994:19:953-955. Technetium-99m-DMSA Renal SPECT in Diagnosing and Monitoring Pediatrie Acute Pyelonephritis Tzu-Chen Yen, Wei-Perng Chen, Shu-Lian Chang, Ren-Shyan Liu, Shin-Hwa Yeh and Ching-Yuang Lin Department and Division of Nuclear Medicine and Department and Division of Pediatrics, Veterans General Hospital-Taipei and School of Medicine, National Yang-Ming University, Taipei, Taiwan This study compares the sensitivity of 99mTc-dimercaptosuccinic by calyceal distortion of intravenous urography (IVU), repeated bouts of UTI, renal hypertension and even renal failure (7). It acid (DMSA) renal SPECT with planar scintigraphy, concluding the importance of 99nrTc-DMSA renal SPECT for the early diagnosis of has been reported that in children, APN will cause renal acute pyelonephritis (APN) in patients under 3 yr of age. Methods: scarring in 47% to 68% of patients through different modalities Twenty-seven children under 3 yr of age, with clinical and/or of imaging study (2) and recurrent episodes of APN will cause laboratory suspicion of APN, were investigated. All 99nTc-DMSA in one-third of patients progressive renal scarring, contracted, renal SPECT and planar images and voiding cystoureterogram distorted or small kidneys (3). In most children, diagnosing (VCUG) were obtained within 3 days of hospitalization. Results: In APN does not require complex and expensive procedures. From the first examination, renal cortical defects were detected in 23 our previous study, 99mTc-dimercaptosuccinic acid (DMSA) patients (42 kidneys) with SPECT and in 9 patients (11 kidneys) with renal SPECT scan has been found to be a useful diagnostic tool planar scintigraphy. One year after treatment, constant renal cortical in children (>3 yr old) with APN (4). However, in neonates lesions were observed in 11 patients (14 kidneys) with SPECT and 4 and infants with equivocal or negative urine cultures or with patients (4 kidneys) with planar scintigraphy. The high grades of vesicoureteral reflux (VUR) (grade >3) correlate better with APN recurrent cystitis and no evidence of pathologic vesicoureteral diagnosed by SPECT (34 kidneys) than by planar scintigraphy (8 reflux (VUR) proved by voiding cystoureterogram (VCUG), kidneys). Multiple renal cortical defects (number of lesions >4) were asserting or ruling out this diagnosis is mandatory for effective only seen in patients under 1.5 yr old and none of those with a management. In addition, following and monitoring the effect negative 99mTc-DMSA renal SPECT had a positive 99mTc-DMSA of treatment are also very important for determining the renal planar scintigraphy at any time. There is a significant difference prognosis of patients after APN. (p < 0.05) between the diagnostic ability of these two methods of Recent studies have compared the sensitivity and specificity examination. Conclusion: Our results suggest that "Tc-DMSA of various imaging modalities, including the WmTc-DMSA renal SPECT should be used, where possible, instead of planar renal scan, IVU, CT, ultrasonography (US) and MRI in detect DMSA in routine examination of children with clinical suspicion of ing renal lesions in children. SPECT renal imaging has proved APN, especially for those under 3 yr of age. to be superior to the other diagnostic modalities (4-10). Key Words: pediatrie acutepyelonephritis; SPECT; technetium- However, to the best of our knowledge, no report is known that 99m-dimercaptosuccinic acid uses the WmTc-DMSA renal SPECT technique to diagnose and J NucíMed 1996; 37:1349-1353 monitor APN in infants. In this research, we extend our previous studies using both WmTc-DMSA renal planar scintig Ur 'rinary tract infection (UTI), the admission diagnosis for raphy and SPECT to diagnose and follow up infants with a about 140 patients hospitalized per year in the Veterans General clinical suspicion of APN (4) and compare the results with the Hospital-Taipei, is most often due to Escherichia coli infection VCUG. of the renal parenchyma and collecting system. Although certain characteristics may help to differentiate acute pyelone METHODS phritis (APN) from cystitis, their clinical presentations are often similar. Sometimes it is difficult to distinguish between them. Patients The diagnosis of APN is very important for pediatrie patients, This study was performed between August I, 1992 and August especially for neonates and infants, because improper or de 30, 1994. Three hundred and nine patients were referred to by Pediatrie Ncphrologists of the Veterans General Hospital-Taipei. layed treatment of APN is often associated with the develop APN was defined as being present if they had all of the following: ment of renal scarring and/or chronic pyelonephritis, evidenced there was fever (>38.5°C), pyruia (WBC counts/HPF >10), a positive urinary culture and/or a positive blood culture. Twenty- Received June 12, 1995; revision accepted Dec. 13, 1995. For correspondence or reprints contact: Dr. Tzu-Chen Yen. Department of Nuclear seven of them were under 3 yr of age (from 1 wk old upward) and Medicine, Veterans General Hospital-Taipei, Taipei, Taiwan. clinically and/or laboratory diagnosed to have APN. The other 282 TECHNETIUM-99M-DMSARENALSPECT ANDAPN •Yen et al. 1349 patients, aged above 3 yr (from 3 to 12 yr), were diagnosed as TABLE 1 suffering from cystitis, acute or chronic pyelonephritis, high-grade Comparison of APN Detection Reliabilitybetween Planar VUR and small kidney(s). Technetium-99m-DMSA renal SPECT, Scintigraphy and SPECTin 27 Patientswith APN planar scintigraphy and VCUG were performed, with informed consent of the patients' parents, within 3 days after hospitalization Number of patients Number of patients with positive scan with negative scan for those with clinical impression of UTI including APN. After Method initial treatment for APN, all patients received prophylactic anti biotics until their second investigation 3 mo later. DMSA scans Planar scintigraphy 9(33) 18(67) were performed again 3 mo and 1 yr later. None had a recurrent SPECT 23 (85) 4(14) infection during that time. Only 3 of the 27 patients needed sedation by oral chlorohydrate (8.3 mg/kg), as the technicians were RESULTS experienced in handling and imaging pediatrie patients. The 27 infants (^3 yr old) ranged in age from 1 wk to 2.8 yr old (median, 0.7 yr) and the ratio of boys to girls was 12:15. A Technetium-99m-DMSA Renal Scan Method total of 23 patients (42 kidneys) with clinical impression of The 99rnTc-DMSA was prepared from a commercial kit and the APN were shown to have renal cortical lesions by WmTc- 99mTc-DMSA dose was based on the adult dose of 100 MBq and DMSA renal SPECT. Seventeen of the 23 positive children had corrected for the patient's age in years by the following formula: bilateral multiple (5:4) small lesions and all these 17 patients were under 1.5 yr of age. From the planar scintigraphic studies, (Age+ 1) X Adult dose only 9 children (11 kidneys) were changes of APN (Table 1). Of Dose = (Age + 7) ' the 27 children (54 kidneys), 38 kidneys had high-grade VUR. Thirty-four of the 38 high-grade VUR kidneys were shown to have cortical lesions by DMSA renal SPECT and in only 5 The minimum dose was 18 MBq (//). patients (8 kidneys) were cortical lesions detected by DMSA Imaging was done 3 hr after injection of the """Tc-DMSA. All renal planar scintigraphy (Table 2). During two follow-up studies were performed on digital gamma camera with an inter examinations, 3 mo and 1 yr later, changes were recognized in faced computer. Planar images were acquired first, in the posterior the DMSA renal SPECT studies. Twelve children (20 kidneys) projection with a total of 300,000 counts per image using a became normal and 11 patients (22 kidneys) had persistent renal low-energy, high-resolution collimator. SPECT images were ob cortical defects (Fig. 1, 2). Nine patients (11 kidneys) revealed tained immediately after planar imaging and using 60 projections at positive results by planar scintigraphy initially. On follow-up 360°with 20 sec per stop. Following the application of a Matz studies, 5 patients (7 kidneys) showed normal by planar prefilter, transverse images were reconstructed with backprojection scintigraphy, but 2 of them (2 kidneys) were detected to have and a ramp filter. Coronal and sagittal views with respect to the scar formation by SPECT. The other 4 children (4 kidneys) patient were reconstructed from transverse slices without any showed new scar formation by both planar scintigraphy and additional filtering. Any photopenic area seen in the DMSA scan SPECT. If we took the positive scan identified by DMSA renal was evaluated to exclude the possibility of a cystic lesion or dilated SPECT as a standard, the occurrence of renal scarring after tubules by US and this was reconfirmed in the follow-up exami treatment for APN was 48% as detected by SPECT, which is nations.
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