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Utility of PET/CT with fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes for diagnosing diabetic foot osteomyelitis in patients with Charcot’s neuroarthropathy

Rastogi, Ashu; Bhattacharya, Anish; Prakash, Mahesh; Sharma, Sarika; Mittal, Bhagwant R.; Khandelwal, Niranjan; Bhansali, Anil

doi: 10.1097/MNM.0000000000000603

Objective Diabetic foot osteomyelitis (DFO) is difficult to diagnose in the presence of Charcot’s neuroarthropathy (CN) and bone biopsy is not always possible. We aimed to assess the efficacy of PET/computed tomography using 18F-fluoride (18F-fluoride PET/CT) and fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes (18F-FDG-LL PET/CT) in comparison with contrast-enhanced MRI (CEMRI) for the detection of DFO.

Patients and methods Thirty-two patients with chronic CN and foot ulcer suspected of having DFO were prospectively evaluated. All patients underwent radiography, CEMRI, 18F-fluoride PET/CT, and 18F-FDG-LL PET/CT of the feet. Bone biopsy and microbiological culture from the suspected site of osteomyelitis was considered the gold standard.

Results Twenty-three patients fulfilled the inclusion criteria. Bone culture was suggestive of DFO in 12 patients. CEMRI identified 10 of the 12 cases of osteomyelitis. 18F-fluoride PET/CT and 18F-FDG-LL PET/CT showed increased tracer uptake (SUVmax=22.7±18.1 and 8.4±4.7, respectively) at the clinically involved site in 10 of the 12 patients (TP). Among 11 biopsy-negative patients, CEMRI reported DFO in four (false positive); there were no false positives with 18F-FDG-LL PET/CT. The sensitivity and specificity of 18F-FDG-LL PET/CT was 83.3 and 100% compared with 83.3 and 63.6% for CEMRI, respectively, for the diagnosis of DFO in the background of CN.

Conclusion 18F-FDG-LL PET/CT has high specificity for the diagnosis of DFO in complicated diabetic foot. The 18F-fluoride PET/CT helps in the characterization the extent of underlying CN. An early and accurate diagnosis with 18F-FDG-LL PET/CT aids the rational initiation of antibiotics for DFO.

Departments of aEndocrinology

bNuclear Medicine

cRadiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Data from this study were presented as an oral presentation on 5 March 2015 at ENDO2015, the Endocrine Society’s 97th Annual Meeting and Expo at San Diego, USA) as per the details below: ORO 6: 18F-fluoride PET/CT and 18F-FDG-labeled autologous leukocyte PET/CT for diagnosis of osteomyelitis in diabetic Charcot’s neuroarthropathy of foot (Ashu Rastogi and Anil Bhansali, PGIMER, Chandigarh, India). The abstract details are available at

Correspondence to Anish Bhattacharya, MD, PhD, Department of Nuclear Medicine, PGIMER, Chandigarh 160012, India Tel: +91 987 248 6816; fax: +91 172 274 4401; e-mail:

Received January 20, 2016

Received in revised form August 10, 2016

Accepted September 13, 2016

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