Short communication

The use of bone scintigraphy to detect active Hansens disease in mutilated patients
Francisco Jos H.N. Braga1,2, Norma T. Foss3, Eduardo Ferriolli3, Cludia Pagnano4, Jos Ricardo de A. Miranda2, Rogrio de Moraes2
1 2

Seco de Medicina Nuclear do Hospital das Clinicas da Faculdade de Medicina de Ribeiro Preto, USP, Brazil Departamento de Fsica e Biofsica, Instituto de Biocincias, UNESP, 18.618-000 Botucatu, Brazil 3 Departamento de Clnica Mdica da Faculdade de Medicina de Ribeiro Preto, USP, Brazil 4 Secretaria da Sade, Ribeiro Preto, Brazil Received 15 June and in revised form 30 June 1999

Abstract. Mutilation of extremities was very frequent in patients affected by leprosy in the past; although it is now much less common, it is still seen, mainly in patients with long-term disease. In general, mutilation of the nose and ears is caused by the bacillus and mutilation of the hands and feet a consequence of chronic trauma. Leprosy must be chronically treated and any decision to interrupt therapy is based on laboratory tests and biopsy. Scintigraphy is a non-invasive procedure which could be of great value in to determining disease activity. We studied eight patients (five males and three females, aged 6473 years) who presented with mutilation of the nose (2), ear (1), feet (3) or foot and hand (2). Conventional three-phase bone scintigraphy (750 MBq) and X-ray examinations of the affected areas were performed in all patients. Bone scintigraphy was abnormal in four patients (the presence of bacilli was confirmed by biopsy in two of them), and normal in the other four. In all patients except for the one with ear mutilation, radiography only showed the absence of bone. We conclude that bone scintigraphy is very useful to determine disease activity in cases of mutilation caused by leprosy. It seems to be superior to conventional radiography and may enable bone biopsies to be avoided. Key words: Leprosy Hansens disease Scintigraphy Mutilation Technetium-99m methylene diphosphonate Eur J Nucl Med (1999) 26:14971499

extremities was very frequent in the past, and is still found today, mainly in patients with long-term multibacillary disease [2]. In general, mutilation of the nose and ears is caused by destruction by the bacillus itself while mutilation of the hands and feet is a consequence of chronic trauma [1]. The treatment of leprosy is chronic, and the decision to interrupt therapy is based on laboratory tests and biopsy. Scintigraphy is a technique that allows functional evaluation of organs and systems; consequently it complements commonly used radiological techniques, which allow only anatomical evaluation. Nuclear medicine techniques have already been used successfully in several granulomatous diseases [35], and it has also been shown that scintigraphy is a good tool both to detect active Hansens disease [611] and to evaluate affected organs and systems [12, 13]. The aim of this work was to determine the role of bone scintigraphy in patients with mutilation caused by leprosy and its capability to detect active disease in such cases. Materials and methods
We studied eight patients (five males and three females, aged 6473 years) who presented with mutilation of the nose (2), ear (1), feet (3) or foot and hand (2). Patients presenting recent trauma were excluded from the study. Subjects were injected with 750 MBq of technetium-99m methylene diphosphonate. Images were acquired during injection (every 3 s) and 5 and 120 min thereafter (500,000 counts per image, anterior and posterior whole-body images, three-phase bone scintigraphy). A Siemens Orbiter scintillation camera linked to a computer and equipped with a low-energy collimator was used. Patients also underwent conventional radiographic evaluation of the affected areas.

Introduction Leprosy (or Hansens disease) is a chronic infectious granulomatous disease caused by Mycobacterium leprae, a bacillus that has a strong positive neurotropism [1]. The incidence of the disease is increasing again, primarily in countries of the developing world. Mutilation of the

Results A patient with mutilation of the foot had mildly increased perfusion to the area, but normal uptake in the
European Journal of Nuclear Medicine Vol. 26, No. 11, November 1999 Springer-Verlag 1999

1498 Fig. 1. Extensive mutilation of several fingers of both hands. Left: initial image (5 min after injection, 500,000 counts). The blood pool is increased to both hands, but more prominently to the right one. Right: late image (2 h after injection, 500,000 counts). Five areas of very important abnormal uptake of the radiopharmaceutical (four in the right hand and one in the left) and four areas of moderately abnormal uptake (three in the right hand and one in the left) are seen; all of them indicate active disease

affected extremity 2 h after injection. Nevertheless, the distal third of the tibia presented with focally increased uptake of MDP and the contralateral tibia was also abnormal in its mid third. This indicated that the mutilated extremity, but not the tibiae, was free of disease. The second patient with foot mutilation had an abnormal three-phase scintigraphy appearance in a toe. One patient with foot and hand mutilation had an abnormal initial phase of the examination in both regions, and late images showed focal and increased uptake of MDP in both the hands (figure) and the feet, indicating active bone disease. A patient with mutilation of the nose presented increased uptake of MDP in the area, and biopsy showed active disease. Three-phase bone scintigraphy was normal in the other patients. In all patients except for the one with ear mutilation, radiography only showed the absence of bone. Discussion While Mycobacterium leprae has a strong and positive neurotropism, leprosy is known to affect many organs and systems although there is disagreement over the involvement of some, such as the lungs [1, 2]. Nuclear medicine techniques allow functional evaluation and have been used to study patients with leprosy [613], although other modalities such as magnetic resonance imaging may represent an alternative [14]. Bone is not the most frequently affected site, but bone leprosy does exist and can be considered as osteomyelitis. Mutilation of the extremities (ears, nose, feet and hands) is less and less frequently seen, as a consequence of both treatment efficacy and public health policy. Nevertheless, it still can be observed, mostly in old patients with long-term disease, and particularly those who have not complied with treatment adequately. In addition, it is possible that such mutilation will again become more frequent in the fu-

ture, as a consequence of the present increase in the incidence of leprosy. One of the problems that clinicians face in patients with leprosy is the decision on whether to maintain or interrupt treatment, as disease reactivation very frequently occurs some time after therapy withdrawal. In fact, this is itself the most important explanation for mutilation, as patients often discontinue treatment without medical authorisation when lesions are no longer seen. In the present study, three-phase bone scintigraphy was abnormal in four mutilated patients (biopsy was performed in one case and confirmed the presence of bacilli) and we interpreted this finding as active disease. Scintigraphy was normal in the other four patients. All conventional X-ray studies of affected bones were also abnormal (except in the patient with ear mutilation), but only showed the absence of bone and were not able to differentiate active from inactive disease. The scintigraphic pattern we detected in cases of foot and hand mutilation with active disease is similar to that seen in chronic or treated osteomyelitis, with mildly increased arterial perfusion and focal abnormal uptake in the affected areas. Differential diagnosis should include other infectious and inflammatory diseases, although the very important uptake we detected is infrequently seen in the former. A negative scan should always be interpreted as absence of disease. Mutilation associated with active disease in the nose was seen in one case, but the normal distribution of MDP in the face makes interpretation difficult. Therefore, gallium-67 scintigraphy was performed additionally in the two patients with nose mutilation. It was positive in one case (confirmed by biopsy) and negative in the second. We conclude that bone scintigraphy is very useful and superior to conventional radiography for the evaluation of mutilation in leprosy patients and for the differentiation of active from inactive disease. It may also permit the avoidance of some invasive procedures, such as bone

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biopsy. 67Ga scintigraphy may be necessary in patients with facial mutilation.

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European Journal of Nuclear Medicine Vol. 26, No. 11, November 1999