The ideal dual-isotope imaging combination in evaluating patients with suspected infection of pelvic pressure ulcers

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The successful management of infected pelvic pressure ulcer patients (PPUP) depends on the distinction between infections limited to soft tissue (STI) and those with underlying osteomyelitis (OM), which can be difficult to determine clinically. Dual-isotope (DI) comprehensive imaging has excellent accuracy in localizing diabetic foot infection and differentiating OM from STI with SPECT/CT utilization. In this study, we assess the accuracy and confidence of the different DI SPECT/CT imaging steps in PPUP with confirmed diagnoses.

Patients and methods

Pelvic flow and blood pool imaging were followed by labeled white blood cell reinjection and Tc-99m hydroxymethylene-diphosphonate bone (bone scan) and In-111-leukocytes (white blood cell scan) DI planar and SPECT/CT (step 1) acquisitions. Tc-99m sulfur colloid (bone marrow scan)/WBCS SPECT/CT (step 2) images were obtained on the following day. DI step 1 planar, step 1 SPECT/CT, step 2 SPECT/CT, and combined step 1/step 2 SPECT/CT were reviewed separately for diagnosis and diagnosis confidence. The final diagnosis was confirmed by culture/pathology in 21 patients and clinical/imaging follow-up in 12 patients.


There were 19 OM patients, three STI patients, and 11 patients with no infection. The final diagnosis agreement to DI combined step 1/step 2 SPECT/CT was higher than DI step 2 or step 1 SPECT/CT alone, or DI step 1 planar, as assessed by λ and error reduction %, respectively. Combined DI step 1/step 2 SPECT/CT was more sensitive than DI step 2 SPECT/CT and more specific than DI step 1 SPECT/CT, and showed higher diagnostic confidence than both imaging techniques.


DI SPECT/CT is highly useful in evaluating PPUP with suspected infection. DI step 1 is more sensitive, whereas step 2 is more specific. Both step 1 and step 2 DI SPECT/CT images are needed to accurately and confidently assess for infection and distinguish OM from STI, which are crucial for optimal management.

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