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Abstract. Mutilation of extremities was very frequent inpatients affected by leprosy in the past; although it isnow much less common, it is still seen, mainly in pa-tients with long-term disease. In general, mutilation of the nose and ears is caused by the bacillus and mutilationof the hands and feet a consequence of chronic trauma.Leprosy must be chronically treated and any decision tointerrupt therapy is based on laboratory tests and biopsy.Scintigraphy is a non-invasive procedure which could beof great value in to determining disease activity. Westudied eight patients (five males and three females, aged64–73 years) who presented with mutilation of the nose(2), ear (1), feet (3) or foot and hand (2). Conventionalthree-phase bone scintigraphy (750 MBq) and X-ray ex-aminations of the affected areas were performed in all

patients. Bone scintigraphy was abnormal in four pa-tients (the presence of bacilli was confirmed by biopsy intwo of them), and normal in the other four. In all patientsexcept for the one with ear mutilation, radiography onlyshowed the absence of bone. We conclude that bonescintigraphy is very useful to determine disease activityin cases of mutilation caused by leprosy. It seems to besuperior to conventional radiography and may enablebone biopsies to be avoided.

Key words: Leprosy – Hansen’s disease – Scintigraphy –Mutilation – Technetium-99m methylene diphosphonate

Eur J Nucl Med (1999) 26:1497–1499

Introduction

Leprosy (or Hansen’s disease) is a chronic infectiousgranulomatous disease caused by Mycobacterium leprae,a bacillus that has a strong positive neurotropism [1].The incidence of the disease is increasing again, primari-ly in countries of the developing world. Mutilation of the

extremities was very frequent in the past, and is stillfound today, mainly in patients with long-term multiba-cillary disease [2]. In general, mutilation of the nose andears is caused by destruction by the bacillus itself whilemutilation 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 labora-tory tests and biopsy. Scintigraphy is a technique that al-lows functional evaluation of organs and systems; conse-quently it complements commonly used radiologicaltechniques, which allow only anatomical evaluation. Nu-clear medicine techniques have already been used suc-cessfully in several granulomatous diseases [3–5], and ithas also been shown that scintigraphy is a good tool bothto detect active Hansen’s disease [6–11] and to evaluate

affected organs and systems [12, 13]. The aim of thiswork was to determine the role of bone scintigraphy inpatients with mutilation caused by leprosy and its capa-bility to detect active disease in such cases.

Materials and methods

We studied eight patients (five males and three females, aged

64–73 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.

Results

A patient with mutilation of the foot had mildly in-creased perfusion to the area, but normal uptake in the

Short communication

The use of bone scintigraphy to detect active Hansen’s disease

in mutilated patients

Francisco José H.N. Braga1,2, Norma T. Foss3, Eduardo Ferriolli3, Cláudia Pagnano4, José Ricardo de A. Miranda2,

Rogério de Moraes2

1 Secção de Medicina Nuclear do Hospital das Clinicas da Faculdade de Medicina de Ribeirão Preto, USP, Brazil2 Departamento de Física e Biofísica, Instituto de Biociências, UNESP, 18.618-000 Botucatu, Brazil3 Departamento de Clínica Médica da Faculdade de Medicina de Ribeirão Preto, USP, Brazil4 Secretaria da Saúde, Ribeirão Preto, Brazil

Received 15 June and in revised form 30 June 1999

European Journal of Nuclear Medicine

Vol. 26, No. 11, November 1999 – © Springer-Verlag 1999



affected extremity 2 h after injection. Nevertheless, thedistal third of the tibia presented with focally increaseduptake of MDP and the contralateral tibia was also ab-normal in its mid third. This indicated that the mutilatedextremity, but not the tibiae, was free of disease. Thesecond patient with foot mutilation had an abnormalthree-phase scintigraphy appearance in a toe. One patientwith foot and hand mutilation had an abnormal initialphase of the examination in both regions, and late imag-es showed focal and increased uptake of MDP in boththe hands (figure) and the feet, indicating active bonedisease. A patient with mutilation of the nose presentedincreased uptake of MDP in the area, and biopsy showedactive disease. Three-phase bone scintigraphy was nor-

mal in the other patients. In all patients except for theone with ear mutilation, radiography only showed theabsence of bone.

Discussion

While Mycobacterium leprae has a strong and positiveneurotropism, leprosy is known to affect many organsand systems – although there is disagreement over theinvolvement of some, such as the lungs [1, 2]. Nuclearmedicine techniques allow functional evaluation andhave been used to study patients with leprosy [6–13], al-

though other modalities such as magnetic resonance im-aging may represent an alternative [14]. Bone is not themost frequently affected site, but bone leprosy does existand can be considered as osteomyelitis. Mutilation of theextremities (ears, nose, feet and hands) is less and lessfrequently seen, as a consequence of both treatment effi-cacy and public health policy. Nevertheless, it still canbe observed, mostly in old patients with long-term dis-ease, and particularly those who have not complied withtreatment adequately. In addition, it is possible that suchmutilation will again become more frequent in the fu-

ture, as a consequence of the present increase in the inci-dence of leprosy. One of the problems that cliniciansface in patients with leprosy is the decision on whetherto maintain or interrupt treatment, as disease reactivationvery frequently occurs some time after therapy with-drawal. In fact, this is itself the most important explana-tion for mutilation, as patients often discontinue treat-ment without medical authorisation when lesions are nolonger seen.

In the present study, three-phase bone scintigraphywas abnormal in four mutilated patients (biopsy was per-formed in one case and confirmed the presence of bacil-li) and we interpreted this finding as active disease. Scin-tigraphy was normal in the other four patients. All con-

ventional X-ray studies of affected bones were also ab-normal (except in the patient with ear mutilation), butonly showed the absence of bone and were not able todifferentiate active from inactive disease. The scinti-graphic pattern we detected in cases of foot and handmutilation with active disease is similar to that seen inchronic or treated osteomyelitis, with mildly increasedarterial perfusion and focal abnormal uptake in the af-fected areas. Differential diagnosis should include otherinfectious and inflammatory diseases, although the veryimportant uptake we detected is infrequently seen in theformer. A negative scan should always be interpreted asabsence of disease. Mutilation associated with active dis-

ease in the nose was seen in one case, but the normal dis-tribution of MDP in the face makes interpretation diffi-cult. Therefore, gallium-67 scintigraphy was performedadditionally in the two patients with nose mutilation. Itwas positive in one case (confirmed by biopsy) and neg-ative in the second.

We conclude that bone scintigraphy is very useful andsuperior to conventional radiography for the evaluationof mutilation in leprosy patients and for the differentia-tion of active from inactive disease. It may also permitthe avoidance of some invasive procedures, such as bone

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

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 im-

portant abnormal uptake of theradiopharmaceutical (four in

the right hand and one in the

left) and four areas of moder-

ately abnormal uptake (three in

the right hand and one in the

left) are seen; all of them indi-

cate active disease



biopsy. 67Ga scintigraphy may be necessary in patientswith facial mutilation.

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