Background
Bone scintigraphy is an appropriate tool in the management of cancers for the detection of bone metastasis. Technetium 99 m-methylene diphosphonate (99mTc-MDP) is commonly used as a bone-seeking agent. The bones take up 99mTc-MDP through a process called chemisorption, which is more evident in areas of increased osteoblastic activities. Nevertheless, extra-osseous 99mTc-MDP uptake is an infrequent occurrence, which warrants a thorough clinical assessment to evaluate such findings. An example of extraosseous uptake discovery is rhabdomyolysis, which requires prompt recognition and immediate management. Rhabdomyolysis secondary to an adverse reaction towards iodinated contrast material is a rare condition that warrants a high index of clinical suspicion.
Case presentation
We present a case of a 75-year-old gentleman with underlying benign prostatic hypertrophy, and chronic kidney disease who had undergone a coronary angiography examination and intervention for ischemic heart disease. Pre-scheduled bone scintigraphy with 99mTc-MDP for the work-up of raised serum prostate-specific antigen (PSA) was performed 2 weeks post coronary angiography examination. Whole-body bone scan with single-photon emission computed tomography/computed tomography (SPECT/CT) images showed an unexpected finding of extensive extra-osseous uptake in the muscles and soft tissues. Additional investigations confirmed the diagnosis of rhabdomyolysis. Nevertheless, despite the prompt recognition, administration of treatment and supportive care, the patient succumbed to life-threatening complications.
Conclusion
This case highlights the importance of recognising and identifying the pattern of extra-osseous uptake on bone scintigraphy imaging to ensure early intervention of severe and life-threatening conditions such as rhabdomyolysis.
Kounis syndrome is defined by the occurrence of an acute coronary syndrome with conditions associated with mast cell activation, involving interrelated and interacting inflammatory cells, and including allergic or hypersensitivity and anaphylactic or anaphylactoid attacks. 34 years old gentleman with a history of young hypertension came with a complaint of wasp sting over his left eyelid. Post sting, he developed shortness of breath associated with sweating, palpitation however no shortness of breath. He was unconscious shortly after that. During the casualty review, the patient has cold and clammy peripheries with the swollen left eyelid. He is hypotensive and tachycardic. Respiratory and cardiovascular examination was unremarkable. Electrocardiography (ECG) showed ST depression over lead 1 and aVL with ST-elevation at lead V1-V3 and T inversion lead 1, aVL, V4 – V6. Repeated ECG showed evolving changes of ST-elevation over lead V1-V3. Troponin I, 3 hours post wasp sting was not elevated. The patient was given intravenous hydrocortisone, intramuscular adrenaline, antihistamine, and intravenous fluids challenge. Blood pressure normalized and repeated ECG showed resolved ST elevation changes. This patient fits the criteria for Kounis syndrome type 1 secondary to an anaphylactic reaction towards wasp sting. The ECG changes were attributed to the coronary artery vasospasm secondary to an anaphylactic reaction. Type 1 Kounis syndrome can happen with or without raised cardiac enzyme or troponin. It resolved by itself when proper medications were given to reverse the anaphylactic reaction. Early recognition of Kounis syndrome leads to correct treatment approach.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S13
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