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99m Tc-ethambutol Uptake In Case Of Leprosy Case Report

99m Tc-ethambutol Uptake In Case Of Leprosy Case Report
AH Gunawan, AHS Kartamihardja
Universitas Padjadjaran, Poster Presentation 4th International Conference on Radiopharmaceutical Therapy New World Hotel, Ho Chi Minh City, Vietnam 28 Nov – 2 Dec 2011
Bahasa Inggris
Universitas Padjadjaran, Poster Presentation 4th International Conference on Radiopharmaceutical Therapy New World Hotel, Ho Chi Minh City, Vietnam 28 Nov – 2 Dec 2011

Introduction: 99m Tc–Ethambutol scintigraphy has recently been used for active Mycobacterium tuberculosis infection imaging, both pulmonary and extrapulmonary infection. Ethambutol is taken up by mycobacteria’s cell wall based on the drug inhibitory ability on arabinosyl transferase, an essential enzyme which is involved in polymeryzation reaction of arabinoglycan, an important component of mycobacterial cell wall. We present a case of leprosy patient suffering low back pain that was referred to our department. Case: A 53-year-old females who suffered low back pain and lower limb paralysis with unknown etiology, was referred to our department for ethambuthol scintigraphy to investigate any tuberculosis infection. No trauma history was recorded, neither was tuberculosis history or treatment. The patient had been diagnosed as leprosy and being treated with multidrug of antileprosy. Prior X-ray examination showed destructive lesions on the thoracal and lumbar spines, as well as lytic lesion on head of the left hip bone and acetabulum. We performed an MDP (methylene-diphosphonate) bone scintigraphy, that showed pathological uptake on multiple thoracal and lumbar spines. The Tc-99m-Ethambuthol scintigraphy. performed two days later showed pathological uptake on multiple lumbar vertebrae consistent with the X-Ray and bone scintigraphy result, with another additional uptake seen on soft tissue of the left elbow. Discussion: Leprosy is a disease affecting skin and nerves caused by M. leprae. Its distribution is widespreading in tropical or subtropical regions, including in Indonesia. The diagnosis is considered based on clinical signs (i.e. existence of neurologic and cutaneous lesions) and laboratory findings (acid-fast bacilli on slit-smear or biopsy of the skin). Several years after a person afflicted with leprosy, especially with multibacillary spectrum of this disease, bone changes can occur. In this case, the diagnosis of Hansen’s disease had been confirmed by laboratory. No clinical sign of skin tuberculosis was noted. Regarding to patient complaint of back pain and lower limb weakness, bone scintigraphy was then performed during the reactive phase of leprosy (ENL) to find any bone changes. The positive bone scintigraphy result showed some bones/spines involvement, consistent with the prior X-Ray result. There were not any indicator or findings that supported any malignancies. The bone involvement was seen as osteolytic with predominantly sclerotic pattern in the affected spines. This pattern could refer to Charcot/neuropathic osteoarthropathy, a spectrum of bone or joint destructive processes associated with neurosensory deficit. This manifestation in spine is one of non-spesific bone changes in leprosy. Interestingly, there was ethambutol uptake on soft tissue of the left elbow scintigraphy showed possible uptake by M. leprae. There were no ethambutol uptake seen in spines. This indicated that the bone changes recorded in bone. scintigraphy was not caused by direct involvement of mycobacteria, and supported the suggestion of Charcot osteoarthropathy in the prior bone scintigraphy result. Unfortunately, there were no further examination we could perform to ensure the absence of direct bone invasion. Concluding Remark: Soft tissue uptake in this case might be caused by direct infection of Mycobacterium leprae. Bone scintigraphy can detect any bone involvement, while ethambutol scintigraphy can detect infection caused by mycobacteria.

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