Incremental Value of Three-Phase Bone Scintigraphy and Single-Photon Emission Computed Tomography-Computed Tomography in a Case of Postpartum PUO in the Wake of The Antibiotic-Resistance Era

Abstract

Postpartum methicillin-resistant Staphylococcus aureus (MRSA) infection occurs in patients with complicated vaginal delivery or cesarean section. The infection can manifest as mastitis, endometritis, and if untreated may lead to toxic shock syndrome. We report a case of postpartum MRSA osteomyelitis diagnosed by 99mtechnetium-methylene diphosphonate skeletal scintigraphy and single-photon emission computed tomography-computed tomography (CT) that was further confirmed by magnetic resonance imaging and CT-guided biopsy. This multimodal imaging approach helped reach the diagnosis and in further management of the patient.

Keywords: Multimodal approach; postpartum methicillin-resistant Staphylococcus aureus; single-photon emission computed tomography–computed tomography; toxic shock syndrome.

Figure 1

(a) 99mtechnetium-methylene diphosphonate three-phase c perfusion-phase skeletal scintigraphy in posterior view shows abnormal perfusion in the region corresponding to the right sacroiliac joint. (b) 99mtechnetium-methylene diphosphonate blood-pool phase scintigraphy in posterior view shows mild tracer pooling in the right sacroiliac region. (c) Increased tracer uptake in the delayed phase seen in the region corresponding to the right sacroiliac region (bold arrow) and symphysis pubis (arrow). (d) 99mtechnetium-methylene diphosphonate delayed whole-body sweep showing increased tracer concentration in the sacroiliac joints (R > L, marked by bold arrow) and mildly increased tracer concentration was seen in the symphysis pubis (arrow). Injection site is noted near the right elbow

Figure 2

(a) Single-photon emission computed tomography with low-dose screening computed tomography of the pelvic region showing increased tracer concentration in the articular margin erosions with adjoining sclerosis in bilateral sacroiliac joints. (b) Computed tomography scan acquired with single-photon emission computed tomography for attenuation correction showing soft-tissue involvement in the right sacroiliac joint. (c) Single-photon emission computed tomography with low-dose screening computed tomography of the pelvic region showing increased tracer concentration corresponding to healed fracture in the left inferior pubic ramus

Figure 3

(a) STIR coronal section of the pelvis showing bilateral sacroiliitis with peripherally enhancing collection around bilateral sacroiliac joints (Right > Left). (b) T1-weighted magnetic resonance imaging image showing bilateral sacroiliitis with peripherally enhancing collection around bilateral sacroiliac joints (Right > Left)

Figure 4

T2 SPAIR axial section showing hyperintensity in the right iliopsoas muscle