The benefits of multiculturalism

No case today.

One of the problems of a multicultural country such as Australia is that we sometimes have a language barrier with the patients. This is reflected by an incident that happened a few years ago.

I was wandering back into the department after getting lunch when I noticed an old Chinese woman at the front desk who was having quite a time of it. It seems she had come in looking for directions. The problem was that she spoke absolutely no English, but was waving a piece of paper.

The front desk were having none of it. ‘Not here, ‘ they kept repeating, ‘try somewhere else’. Being an humanitarian at heart and, wanting to set an example, I intervened. The woman had one word written on the paper: ‘Liu’.

‘Is this your name? Are you trying to make an appointment?’ I asked with the greatest sympathy (think Mr Darcy – BBC adaption). This was greeted by incomprehension.

More waving of paper.

Now, at that time we had a relief wards-person who was a young, female, ABC (Australian Born Chinese). She just happened to be passing and seeing the problem, immediately offered her help. She was doing a degree at the university and was covering for two weeks as a holiday job. What luck.

‘Can I help?’ she asked me. ‘Great, of course you can. This woman seems lost.’

She turned to the woman, who also looked relieved.

‘WHAT DO YOU WANT ?’ she shouted at her.

‘Wait on,’ I said. ‘Don’t you speak Chinese?’

She turned to me with a look that said ‘Why would you think that?’.

‘No,’ she said quite reasonably. ‘I just thought you needed help’

Now, I’ve been yelling in English at non-English speaking patients for years, even before this young puppy was born. I’ve become quite accomplished at it. I didn’t need her help, thank you.

As it turned out a simple call to bed allocations found two Liu in the hospital. One in maternity just nearby. A simple miming of a pregnant belly and the old woman was on her way, hopefully right direction, with her ‘interpreter’.

Another triumph for multiculturalism.

Posted in Uncategorized

A day in the life*

One of the things’s that people, particularly other doctors, ask me, is: ‘What do you do all day?’.

For someone who has been in nuclear medicine for the last 35 years, and who has been told since he started, that nuclear medicine would not be around in a few years time, it is a victory of sorts that our practices still exist and are still busy.

And yes, we do PET scans. In fact I have two PET reporting days a week. But I’m talking about nuclear medicine. Old school ‘nucs’. Before PET. There is a tendency not only in medicine but in life to get excited by the ‘new thing’ and completely ignore the ‘old thing’.

This blog is strictly ‘old thing’. I have done that as a rearguard action because I don’t want the ‘old thing’ that has kept me happily entertained for 35 years to be ignored or forgotten. I still haven’t mastered it. There are still things that stump or intrigue me every week.

This entry is just a day where we had 14 bone scans. Slightly busier than the usual day in terms of bone scans – we didn’t do cardiac scans on that day because of a camera service – but it will give a partial answer to ‘What do you do all day?’

Case 1:

A 47-year-old man with a 4 year history of low back pain. Seen by a neurosurgeon. The question, as always ‘? facet joint arthritis’. No history of trauma

case 1


case 1 a

Bilateral L5 pars defects. No spondylolisthesis. No acute facet joint arthritis. Nothing else.

Case 2:

A 42-year-old woman with ‘widespread aches and pains’ from a rheumatologist. ‘Widespread aches and pains’ means ‘I think this patient has fibromyalgia but I want to make sure she doesn’t have an inflammatory arthritis, metastases or even widespread osteoarthritis before I send her back to her GP’.

case 2

Whole body blood pool: no inflammatory synovitis

case 2 a

Delayed whole body image: now this is interesting. There seems to be increased uptake at the end of the long bones – the knees, shoulders and ankles. It may be physiological but bone marrow expansion or, less likely, metabolic bone disease look like this.

case 2 b

Increased uptake in the proximal carpal rows bilaterally. This is either osteoarthritis or ‘old’ osteonecosis of the lunates. As she was asymptomatic there we didn’t chase it.

case 2 c

Lumbar spine SPECT. As a general rule, everyone with ‘WAAP’ has low back pain. But most importantly there is no evidence of sacroilitis.

So, no obvious cause for the whole body aches and pain, but the long bone uptake was mentioned along with the possibility of bone marrow expansion (as well as metabolic bone disease and physiologic). Of note, the patient was from the Mediterranean region so thalassemia should be considered.

Case 3:

A  63-year-old woman had a bone scan for skeletal metastases. A PET scan had demonstrated a metastasis in the distal left clavicle

case 3

Nothing much. We do two SPECT-CT to cover the whole spine on most patients, at least for their staging scan. You miss too much if you don’t. in this case there was a small focus in the distal left clavicle and not much else.

Case 4:

An 80-year-old man with low back pain. Gradually improving. A recent X-ray demonstrated a sclerotic lesion in the mid right iliac bone. ? Significance. case 4.png

Something in the region of the right SI joint. Something in the spine and left hip.

case 4 a

Multilevel degenerative disc disease and left L2/L3 facet arthritis.

case 4 b

The ‘something’ in the right SI was a ‘hot’ osteophyte ‘shining through’. I won’t show you every image just quote the conclusion of the report

The sclerotic lesion in the right iliac bone demonstrates no abnormal uptake on the bone scan and is therefore unlikely to be malignant.
Left L2/L3 facet joint arthritis.
Moderate L5/S1 degenerative disc disease with increased tracer uptake in the right side of the disc.
Partial transitional L5 vertebral body as described above.
Osteoarthritis of the superior femoral heads bilaterally.

Not unusual in an 80-year-old, and you may not want to treat any of them, but given that the real question was, ‘does he have a fracture or cancer?’, the answer is ‘no’ and everyone is happy.

Only a bone scan can do this and cover the whole body in one sitting.

Case 5:

A 18-year-old man with a 4 year history of non-specific low back pain. sent from a rheumatologist.

Blood pool:

case 5


case 5 b

Normalish…….mild increased tracer uptake in the SI joints, but that can be normal at 18 years.

case 5 c

Bilateral low grade sacroilitis, in keeping with sero-negative arthritis.

Case 6:

A 63-year-old woman with new diagnosis of breast cancer.

Bilateral L4/5 facet arthritis. No skeletal metastses.

Case 7:

A 23-year-old man with low back pain since a motorcycle accident 6 months previously.


Case 8:

A 24-year-old weight lifter. 10 week history of lower costo-chondral pain on the right.



Case 9:

A 72-year-old woman with right hip and flank pain after a recent fallcase9

No evidence for recent fracture.
Mild right L4/L5 facet joint arthritis.
Minor multilevel degenerative disc disease in the lumbar sacral spine.
Bilateral retro-patella arthritis.

Case 10:

A 48-year-old with back pain not radiating down the legs for 5 years. ? Focal disco-vertebral or facet joint arthritis.case10.png


So the radiating pain may be due a disc prolapse but, as has been said over many years, symptoms and disc prolapse seem to bear no relation to each other.

Our neurosurgeons like to make sure there are no other causes for the symptoms before they consider surgery. Wisely so, in my humble opinion.

Case 11:

A 39-year-old with a new diagnosis of carcinoma of the breast.


Case 12:

This is a 78-year-old man with moderate occipital pain of 6 months duration. No trauma, no precipitants. No history of anything.



case12 a
Avidly increased tracer uptake predominantly involving the dens in the midline which coupled with calcification of the transverse ligament of the atlas is most suggestive of crowned dens syndrome secondary to CPPD disease.

Case 13:

As we are attached to a hospital, the last cases of the day are usually geriatric inpatients who have ‘had a fall’ and are ‘unable to weight bear’. They usually arrive in their bed and it takes all the staff members (including the revered director) to transfer them.

The bone scan is used to see if they can be mobilized. The Xrays in A&E are usually normal (otherwise they would be in the orthopaedic ward) or the injury is not sufficent to explain why they basically can’t move.

Nuc Med to the rescue!

This is a 84-year-old woman whose request form read: ‘Recent fall with right shoulder pain also lower back pain. ? Recent fractures’.


Blood pool is okay. Note the right shoulder. Also note the position on the scanning bed and the size of the patient.


Okay, the back looks a mess. So does the shoulder. At least we can see fractures of the right 2nd and 3rd ribs.


Severe multilevel degenerative disc disease. Previous laminectomy and fusion and finally, a T8 vertebral fracture. Old T11 fracture.


The right shoulder is severe OA not a fracture. The right ‘shoulder pain is the fractures of the 2nd and 3rd ribs.


Recent fractures of the right 2nd and 3rd ribs anteriorly.
Severe osteoarthritis of the right shoulder.
Recent fracture of the T8 vertebral body.
Old fracture of T11.
Multilevel moderately severe degenerative disc disease in the thoracic and lumbar spine.

Case 14:

An 84-year-old man (from the geriatric ward via A&E – normal Xrays): recent fall in the backyard. Mid back pain. Also has pain in the lateral aspect of the right knee.


Increased uptake in L1 the right lateral femoral condyle and both hips.


Fracture superior end-plate of L1 and severe OA of the left hip joint.


Severe OA of the left hip joint.


Recent L1 superior end plate fracture.
Possible fracture (non displaced) of the lateral aspect of the right lateral femoral condyle (arrowed).
Moderately severe osteoarthritis of both hips.
No evidence of a pelvic or hip fracture.

Home time homily:

We also did two thyroid scans and a renal scan for PUJ obstruction. I spoke to each of the patients individually in a language common to us both (English – loudly for those born overseas). All reports finished by 5:00pm.

Not digging ditches but and honest days work.

*tribute to the Beatles. If you listen to the song again you can see how closely my day corresponds to that of the protagonist of the song, except for the bit about smoking a joint and I don’t think an hour’s train trip home reading a Desmond Bagley novel was mentioned in the song either. 


Posted in Uncategorized

A blast from the past

Long ago, in the last century, we used to do testicular scans. Largely they were done to discriminate torsion from epididymo-orcitis. Then ultrasound became a routine means of diagnosis (yes, I know I’m giving my age away) and life became simpler.

Well, we recently got a request for a testicular scan.

This was done for a 17-year-old who previously had surgery for a left varicocoele. Symptoms of mild discomfort and swelling had recurred. A testicular scan was requested.

An anterior dynamic scan was performed using pertechnetate (we should have used labelled red blood cells, but anyway)..


This is the immediate blood pool image. There is evidence of venous incompetence on the left with increased uptake in the left scrotum.

Looks like this….

testicular venogram

That’s a testicular venogram showing similar changes.



Posted in Uncategorized | Tagged

It’s simple really…

Here’s a nice study that makes a case for the importance of nuclear medicine.

A 71-year-old man was referred for E coli bacteraemia. He had ongoing fevers despite antibiotics and a source for infection was sought. A white cell scan was requested.

Oh, and he had polycystic renal disease and was on dialysis.

His CT scan:


I will make it easy for you. One of his renal cysts is infected. Which one?

His fusion study – just the CT to make my point:

castle CT fusion

It’s that one (red arrow)

His white cell:castle nuc

A little hard to read, but the next image is the white cell component of the study – the red bits – projected (or fused) with the CT done at the same time i.e. SPECT-CT:

castle nuc fusion

All together it looks like this:castle all together

There it is.

Should be easy from here.

Posted in Infection | Tagged ,

Wrist pain

My working definition for ‘rare’ is something I haven’t seen before.

This is the case of a 35-year-old woman who fell on her right wrist one month before. She has pain over the radial aspect of her wrist and a ‘lump’ at the base of the thumb. A bone scan was requested. She had not had an X-ray.


black flow

Flow and blood pool are essentially normal to the right wrist (tourniquet on the left hence the asymmetry)

Delayed Planar:

black planar

Mild synovitis of the right wrist (maybe), but no focal uptake to suggest a fracture.


(Yes I did one despite the normal uptake)

black SP 1

Diffuse uptake but look at the proximal carpal row on the CT.

A bone is missing. Count them.

No trapezium. She has no previous surgery by the way.

black SP 2

The 3D reconstruction shows the trapezium rotated anteriorly to the volar (palmar) aspect of the trapezoid.

black SP 3

This is the lateral projection with the trapezium arrowed. Note the angle of the scaphoid.

This is a non-fracture volar dislocation of the trapezium.

As I have said, if I haven’t seen it – it’s rare! Google agrees with me.

Posted in Bone scan, Hand and wrist

Keep you eyes wide (the chance won’t come again)*

An 83-year-old woman was referred for a parathyroid scan for suspected parathyroid adenoma. She had a raised PTH and calcium level.


A nice focal area just potero-medial to the left upper pole. Now let’s look at the washout…



Good. It doesn’t washout. So she has a typical parathyroid adenoma. I tend to do a thyroid scan anyway. This shows us that the lesion is not a thyroid adenoma (see previous posts)


god thyroid.png


But wait….The focus on the thyroid scan is in the mid pole of the left lobe. The focus on the parathyroid scan is posterior to the upper pole.

So…a parathyroid adenoma and a thyroid adenoma.

*Come writers and critics
Who prophesize with your pen
And keep your eyes wide
The chance won't come again
And don't speak too soon
For the wheel's still in spin
And there's no tellin' who
That it's namin'.
For the loser now
Will be later to win
For the times they are a-changin'.

Bob Dylan
Posted in Endocrinology, Parathyroid scan

I’m back..again

No I haven’t been away. I’ve just been slack.

But I will be posting more frequently from now on.


Posted in Uncategorized