Diagnostic Imaging of Infections and Inflammatory Diseases by Signore Alberto;Quintero Ana Maria; & Ana María Quintero

Author:Signore, Alberto;Quintero, Ana Maria; & Ana María Quintero
Language: eng
Format: epub
Publisher: John Wiley & Sons, Incorporated
Published: 2013-06-20T00:00:00+00:00

Sternal wound infections

Median sternotomy wound complications vary from sterile wound dehiscence to suppurative mediastinitis. Mediastinal, or sternal, wound infections are characterized by clinical or microbiological evidence of infected presternal tissue and sternal osteomyelitis, with or without mediastinal sepsis and with or without unstable sternum. Superficial sternal wound infection is confined to the subcutaneous tissue. Deep wound infection, or mediastinitis, is associated with sternal osteomyelitis with or without retrosternal space infection [79].

Although the incidence of sternal wound infection in patients undergoing median sternotomy is less than 1%, its associated mortality rate varies from 14% to 47%. The classic symptoms and signs of acute infection are infrequently encountered and can be obscured by associated postoperative pain or concomitant infection. Wound discharge, the most common presentation, is present in up to 70–90% of cases; local symptoms include wound pain, tenderness and sternal instability. Daily clinical evaluation of patients in the immediate postoperative period and a high index of suspicion are the most important factors in ensuring early diagnosis. Blood cultures should be performed in patients with a temperature above 38 °C that persists for more than 48 hours after surgery. Chest radiographs rarely are helpful. CT with mediastinal aspiration provides useful information both for diagnosis and management [79].

Radionuclide imaging also contributes useful information in patients with suspected sternal wound infection [80–86]. Cooper et al. [82] studied 99mTc-labeled WBC imaging in 29 patients with suspected sternal wound infections. They found that the test was 100% sensitive and 89% specific for diagnosing deep sternal wound infection, and suggested that labeled WBC imaging is a useful adjunct when clinical examination fails to confirm the diagnosis or when deep sternal aspirates of a sternal wound infection are not diagnostic. Bessette et al. [83] compared CT and dual-isotope SPECT (99mTc-MDP/111In-labeled WBC) in 32 patients with possible postoperative sternal osteomyelitis following median sternotomy. These authors found that the radionuclide test was more accurate than CT for differentiating soft tissue inflammation from sternal osteomyelitis.

Quirce et al. [84] prospectively investigated planar scintigraphy and 99mTc-labeled WBC SPECT in 41 patients with clinically suspected deep sternal infection. Nine patients had deep sternal infection, ten had superficial sternal infection and 22 had no infection. Planar imaging failed to detect any of the deep sternal infections at either 4 or 20 hours. SPECT correctly identified eight of nine deep sternal infections at 4 hours and all of them at 20 hours, with no false-positive results. Planar imaging identified 16 of 18 superficial sternal infections at 4 hours and all of them at 20 hours. SPECT identified 17 of 18 infections at 4 hours and all of them at 20 hours. Other infections unrelated to the sternotomy were identified in seven patients. The authors concluded that labeled WBC imaging reliably diagnoses sternal infection after median sternotomy and SPECT facilitates the differentiation of superficial from deep sternal infection. The test also detects other sites of infection, providing alternative diagnoses.

Bitkover et al. [85] investigated the anti-G mAb, BW 250/183, for diagnosing sternal infection in 29 patients who had

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