The search was made for outpatient in vivo nuclear medicine procedures, per State, and subsequently grouped for the entire country. Such services are licensed for operations and can currently purchase radiopharmaceuticals for nuclear medicine. According to the investigation regarding apparatuses, there would be gamma cameras in Brazil, of those currently in operation.
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Such a figure does not match reality, as a finer analysis shows that only The other Such an analysis is possible as Datasus provides access to data regarding each one of the listed health services. Among the entities that operate their own nuclear medicine service, and therefore certainly have gamma cameras, In , , outpatient nuclear medicine procedures were performed by SUS.
Amongst the 50 types of procedures covered by SUS, 7 correspond to Figure 1 shows the regional distribution of such procedures throughout the national territory. There is a noticeable concentration in the most developed and more densely populated Southeastern region, followed by the Northeastern and Southern regions. In the investigated period, from to , the number of outpatient procedures performed by SUS increased by However such a growth was not uniform, with The growth was not constant either along those years.
Between and , a growth of 8. It is interesting to observe that between and the growth was 1. Such a distribution is similar to the distribution of other high complexity imaging diagnosis procedures, such as magnetic resonance imaging and x-ray computed tomography.
However in those two specific cases, according to the data from Datasus, private services are responsible for Table 2 shows that private services are responsible for practically all the procedures performed in the Northern region, closely followed by the Northeastern region. It is important to highlight that the Mid-western region presents with However, a more careful analysis reveals that the Federal District, where only public services perform diagnostic procedures for SUS, is accountable for such a value.
According to Table 3 , there is a great variation among the regions as regards types of services providers responsible for such diagnostic procedures. In the Midwestern region, practically all the patients requiring diagnostic procedures The Southeastern region is the region that gets closer to the intent to prioritize non-profit services. The Southern and Northeastern regions present a more balanced division between for profit and non-profit services.
As the contribution of the different types of services providers between and is analyzed, it is observed that the only modality that consistently grew was that of private for profit services Figure 3. The contribution of private nonprofit services in should be highlighted. According to the CNES databank, there are services performing specialized in vivo nuclear medicine procedures, The private entities have their own services in The others utilize outsourced services.
In total, As the number of entities offering their own nuclear medicine services with the list of services accredited by CNEN, one observes a discrepancy of Table 5 shows the situation per State and per region. The CNEN authorization is given to services to purchase half-life radioactive materials for studies such as in vivo 99m Tc imaging, for therapies utilizing Sm, for example, and for positron emitters PET imaging, the latter not being supported by SUS.
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However, the cases where the opposite occurs - a number of services authorized by CNEN smaller than that listed by SUS -, deserve attention. Such is the case in the Northeastern, Southeastern and Southern regions, led by the latter. Datasus does not provide fields to be filled out neither with the name of the technical manager nor the name of the radiological protection supervisor.
Although the filling-out of the SUS forms is mandatory for acknowledgement and payment of the procedures performed by the public network and by the partnering private network, not all fields are filled-out with reliable information. Such is the case of the information on number of gamma cameras that is important to depict the current scenario with reliable prospects on the reality of nuclear medicine procedures available to the Brazilian population by means of SUS. Such information was previously utilized by Freitas et al. However the limitations found by the present study had not been identified.
The present study demonstrates that it is possible to generate estimates based on other data provided by CNES. According to a market investigation carried out in by BizAcumen 8 , in there were approximately 1, gamma cameras in The United States of America, a number 4. A way to verify such values would be comparing them with those at the CNEN database, since the installation and use of nuclear medicine imaging equipment must be notified to CNEN by the health service. The present study demonstrates that, actually, the public nuclear medicine is practiced at private services.
It is a high complexity specialty which involves multidisciplinary personnel and knowledge, differently from other modalities so classified by SUS, such as magnetic resonance imaging and radiology. Additionally, due to the fact that such services utilize unsealed radiation sources, they should report to CNEN in order to obtain their operation licenses.
Because of such characteristics, the cost to maintain a nuclear medicine service is higher than that of a radiology service equipped with computed tomography and magnetic resonance imaging apparatuses. Perhaps for such a reason, the portion of procedures performed at private services is even greater than those two other specialties. The proportion in-creases in determined States such as Mato Grosso do Sul, where all nuclear medicine diagnostic procedures are carried out at private services.
As the partnering private network is not obliged to meet the entire demand from SUS, part of the population may not receive care, for the benefit of the privately supported patients. Thus, the offering of nuclear medicine procedures performed by public services should be increased, starting by the States where the private services perform higher percentages of the procedures. Despite the great number of procedures performed at philanthropic services, there is no consistence in their growth over the years.
In , that number was considerably reduced, while the number of procedures performed at nonprofit private organizations, which were decreasing since , actually presented a noticeable increase in that period. Such a fact should be further studied in other instances. It is expected that almost all such procedures be performed by means of single photon emission computed tomography SPECT , although SUS pays the same value both for tomographic and planar procedures.
Such a difference, which leads to different diagnostic quality, cannot be verified by data supplied by Datasus. A great part of such studies must be based on whole-body scans and not only on planar acquisitions. Such data cannot be retrieved from Datasus either. With those apparatuses, it is possible to simultaneously obtain functional data provided by nuclear medicine, and anatomical data provided by CT, so the approach to be adopted and the total cost of the treatment could be optimized.
The simultaneous acquisition of functional and anatomical data is not covered by SUS. That is an important point to be evaluated as one considers a unified public system, but that is not yet a reality for SUS. One should also consider the aging of the population, leading to ever increasing number of cases of heart disease and cancer in general. Brazil does not produce the required 99 Mo and imports such material from Argentina, South Africa and Canada.
Such a reactor will produce 1, Ci of 99 Mo per week. The Brazilian Ministry of Science, Technology and Innovation estimates a considerable development of nuclear medicine in the country. Such investment may be increased by joint efforts with the Ministry of Health towards stimulating the growth of the specialty in the public network, as the private sector demonstrates to be very efficient in meeting its own demand as well as part of the demand from SUS, as demonstrated by the present study. The discrepancy between the number of nuclear medicine services enrolled at SUS and those accredited and licensed by CNEN indicates the need for placing efforts to unify the data.
It is very important to remind that the CNEN's authorization is based upon principles of radiological protection which must be in force at the enrolled institutions, in order to guarantee the safe utilization of unsealed radiation sources in nuclear medicine. Thus, it would be interesting that institutions enrolled at SUS only receive the payment for their services provided that they are authorized by CNEN to utilize radioactive materials in the specified quantities.
Also, it is important that the mandatory SUS forms include fields to be filled out with the name of the professional in charge of radiological protection supervision at the institution and with the function of responsible technical manager. Finally, it is important to highlight that the inclusion of a given clinic or nuclear medicine service in the list of institutions authorized by CNEN depends upon the initiative of the managers of such clinics or services. CNEN is accountable for the licensing and enforcement of its standards. The input of data to Datasus is done by the health managers at municipal, State and federal levels.
Such managers are responsible for the accuracy in the presentation of those data. For that reason, a modification must be directly made in the forms in order to mandatorily reflect the data contained in the CNEN lists. Datasus provides a wealth of information for investigations on the reality of nuclear medicine in Brazil. The general precautions to be taken in cases of pregnancy, breastfeeding, breastfed infants and young children, for all the procedures in nuclear medicine, are indicated. This should be discussed on a case-by-case basis.
Application of nuclear medicine to the gastrointestinal GI system is very useful for investigating many diseases. This is a noninvasive and painless examination, with administration of low doses of radiation to patients. It is easy to perform and is indicated for diagnosing and following up gastrointestinal diseases. The long acquisition time for most examinations increases the sensitivity for detecting gastrointestinal abnormalities.
Scintigraphy is generally of use for assessing organ function and the kinetics of gastrointestinal transit or excretion. This assesses the function and excretion of the salivary glands, both in the initial diagnosis and in post-treatment follow-up. The radioisotope used is pertechnetate, an anion that is concentrated and secreted by the epithelial cells of the salivary glands in the same way as seen with the anions that make up the saliva.
Thus, this substance reflects the production and physiological secretion of the saliva. This radiotracer is administered intravenously, and sequential images of the head are acquired for 30 minutes. Over the first ten minutes, increasing concentration of radiotracer in the salivary glands is observed, which represents the function. After administration of citric stimulus, generally using lemon, the excretion phase begins.
The uptake peak usually occurs five to ten minutes after starting to administer the radiotracer, and complete excretion begins immediately after the stimulation with lemon Figure 1. Normal salivary gland imaging. Dynamic images are performed during 30 minutes and citric stimulus is on first fifteen minutes.
Region of interest are placed on right and left parotid red and dark blue and submandibulary yellow and light blue glands and time activity curves are created showing quantitative uptake and excretion analyses.
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The scintigraphic abnormalities depend on the type and severity of disease. Acute inflammatory and infectious diseases present uptake increased because of the increased vascularization and diminished secretion. Abscesses and cysts do not show any uptake. Anormal salivary gland imaging. Absence uptake and non excretion in parotid glands confirmed by quantitative curves by region of interest red and dark blue.
Scintigraphy on the esophageal transit is a noninvasive examination with oral administration of radiotracer that supplies information on esophageal motility, in relation to the duration of esophageal transit and segmental motor abnormalities such as adynamia and lack of coordination. The radiopharmaceuticals indicated for these assessments are those that are not absorbed by the esophageal mucosa, such as colloids and chelates: technetium- 99m Tc-sulfur colloid and diethylenetriamine pentaacetic acid DPTA. The radiopharmaceuticals are administered orally, diluted in 10 ml of water, and deglutition is stimulated every 20 seconds with the patient in either a supine or an upright position.
The transit time for the entire esophagus and in its three segments upper, middle and lower is quantified and the motor abnormality pattern adynamia or lack of coordination is determined Figure 3. Scintigraphy on esophageal transit. Normal, adynamia and adynamia with incordination patterns, respectivelly. Scintigraphy is the most sensitive noninvasive method for detecting gastroesophageal reflux, especially in children.
Colloids with low absorption rates in the esophageal and gastric mucosa are used, thereby reflecting the kinetics of the tracer within the digestive system. After oral administration of 99m Tc colloid, and with a field of view covering the stomach and esophagus, episodes of gastroesophageal reflux are identified and information on the quantity and duration of the reflux and the point that it reaches are obtained Figure 4. It has the advantage of continuous and more prolonged acquisition, which increases the sensitivity of the method. Other additional information obtained includes assessment of pulmonary aspiration, in the event that the reflux of the ingested material reaches the pulmonary tree.
Gastroesophageal reflux scintigraphy. A single episode with a short time, reaching the upper esophageal segment black arrow and during a long time red arrow. This is a noninvasive examination performed after intake of solid foods, liquids or a mixture of these. The emptying time and kinetics of the radiotracer in the stomach depend on the composition of the food ingested. Several pharmacological materials can be labeled with the radioactive substance, and the composition of both the food and the radiotracer depends on the standard adopted by each laboratory as the reference value.
The main indications include diabetic gastroparesis, anorexia nervosa, gastroesophageal reflux, gastritis, gastric ulcer, duodenal ulcer, Zollinger-Ellison disease, connective tissue disorders and others, along with postsurgical evaluations, vagotomy and gastrectomy. Other imaging methods such as MRI, CT and ultrasound offers better information about the anatomic display of liver and spleen than does this exam. The radionuclide colloid imaging is capitalized by phagocitosis by Kupffer cells of liver and spleen. The uptake and distribution of 99m Tc-colloid in liver and spleen reflects perfusion and the distribution of functioning reticulendothelial cells.
Usually, the information of liver-spleen scan include the size, shape and position, the distribution aspect of activity within the organs, as homogeneity or non-homogeneity, presence of any or many focal defects in activity and relative distribution of colloid among the liver, spleen and bone marrow. These present with increased hepatic uptake and include: focal nodular hyperplasia Figure 5 , cirrhosis with regenerating nodule, Budd-Chiari syndrome and Superior vena caval obstruction.
Masses with decreased hepatic uptake can be benign or malignant. These include: hepatoma, metastasis, cyst, adenoma, hemangioma, abcess, and pseudotumor. The most common causes of focal defects in the spleen include: abcess, cyst, infarct, lymphoma, and hematoma. Liver-spleen scintigraphy. Focal nodular hyperplasia. Anterior and posterior images. Focal uptake increased in liver black arrow. Spleen increased too red arrow.
This exam is indicated for evaluating hemangiomas. These lesions are clusters or large blood filled sinuses. The radiotracer used is 99m Tc-red blood cells RBC , injected intravenously. The typical appearance of 99m Tc-RBC scan is a focal area of decreased perfusion on the first study flow phase , and in the immediate images because the flow with 99m Tc-RBC is relatively low compared to the hemangioma. About 1 or 2 hours later, the radiolabelled cells reach the hemangioma vessels, and then these lesions present as a focal hot spot, with intensity similar to the heart.
This method is highly specific to confirm hemangioma. The common causes of lower GI bleeding in adults include neoplasms, inflammatory bowel disease, diverticular disease and angiodysplasia. The effective therapy for acute GI bleeding depends on accurate localization of the site of bleeding.
The first one is preferred in the investigation of GI hemorrhage, especially in cases of intermittent or slow bleeding, because the radiotracer remains in the intravascular space. Imaging may be performed over a period of 24 hours. The second one is high, specifically to identify the bleeding site, but the sensitivity is low, because it is performed for a short time and the bleeding needs to be present at the moment of scintigraphy. Nuclear medicine examinations play an important role in the noninvasive evaluation of cardiac physiology.
Myocardial perfusion imaging MPI has high sensitivity to evaluate perfusion in the left ventricular wall and thus indirectly assess coronary flow. The ischemic cascade is the basis and the best justification for the use of nuclear medicine examinations in the evaluation of coronary artery disease. Myocardial perfusion imaging can be performed with thallium chloride and Pharmaceuticals labelled with 99mTc sestamibi, tetrofosmim and teboroxime.
To use thallium chloride it is necessary to fast for at least 4 hours. Radiopharmaceuticals labelled with 99mTc have advantages and disadvantages when compared to thallium chloride, as best rate of counts and less sensitivity to assess viability, respectively. The stress phase can be accomplished by exercise or by the use of drugs such as dipyridamole, adenosine, and dobutamine. The sensitivity and specificity of these types of stress are similiar.
Clinical applications of the study with thallium chloride are: diagnosis of coronary artery disease, assessing the extent and severity of coronary stenosis, myocardial viability assessment and therapeutic efficacy CABG and angioplasty. Radiopharmaceutical labelled with 99mTc are usually associated with cardiac monitoring during image acquisition, thus allowing quantitative analysis with motility evaluation of the left ventricular wall and ejection fraction.
Clinical applications of the study using radiopharmaceuticals labelled with 99mTc are: a diagnosis of coronary artery disease, risk stratification post-myocardial infarction and therapeutic efficacy Figure 6.
Myocardial perfusion scintigraphy with 99mTc-sestamibi. A: Pre-angioplasty: ischemia of the apex and the middle and apical regions of the anteroseptal wall of the left ventricle. B: Post-angioplasty: a study without evidence of myocardial ischemia. The principle objective of myocardial viability assessment is to identify patients eligible for coronary artery bypass grafting CABG. Several criteria were used to determine the clinical impact of CABG: improvement in regional left ventricular function, in global left ventricular function ejection fraction , symptoms, functional capacity, in cardiac remodeling and long term prognosis [ 1 ].
Imaging with thallium chloride and home-redistribution protocol can be used to assess the presence of viable myocardium. Using the protocol stress-rest-reinjection, in addition to similar information, the presence of ischemia can be evaluated. Currently this study has been little used, due to advances in methods of enzymatic detection of acute myocardial infarction. The maximum uptake of 99mTc-pyrophosphate occurs 24 to 72 hours after the event.
Imaging of myocardial infarction with 99mTc-pyrophosphate. The objective is to assess the global and regional ventricular function. The parameters evaluated in this study are: motility of the ventricular wall, left ventricular ejection fraction, analysis of phase and amplitude. The clinical indications are: acute myocardial infarction, coronary artery disease, cardiomyopathy, valvular disease, congenital heart disease, therapeutic efficacy assessment and evaluation of cardiotoxic drugs. The sympathetic and parasympathetic innervation of the heart plays an important role in regulating the cardiac function [ 3 ].
The activation of sympathetic innervation causes increased heart rate chronotropic effect , contractility inotropic effect and conduction atrioventricular [ 4 ]. Norepinephrine is produced and stored in presynaptic vesicles in sympathetic nerve terminals [ 5 ]. Thus, the radionuclide used for cardiac adrenergic imaging is I-MIBG metaiodobenzylguanidine that is an guanethidine analogue which mimics norepinefrina [ 6 ].
The clinical indications are: heart failure, cardiomyopathy, cardiac transplantation, ischemia and myocardial infarction and ventricular tachyarrhythmias. Pulmonary embolism PE is an important and treatable illness caused by migration of thrombus to the pulmonary circulation, commonly from the veins of the lower extremities. Untreated, PE can cause death [ 7 ]. The treatment includes oral anticoagulants, heparin and thrombolytic agents.
The clinical presentation of PE is variable, from asymptomatic to sudden death, including cough, hemoptysis, chest pain, breathlessness, syncope, palpitations, tachypnoea, cyanosis, tachycardia, pulmonary hypertension and right heart failure. But, these symptoms are not specific of PE, needing more tests to confirm or refuse the PE diagnostic.
Recently, Bajc et al, purposed a clinical algorithm for the investigation of patients with suspected PE. If the clinical likelihood of PE is low and the quantitative D-dimer is negative, a diagnosis of PE is unlikely and further investigations are not required. If the clinical likelihood of PE is low and the quantitative D-dimer is positive, further investigations for a range of diagnoses including PE may be required, particularly if the D-dimer level is markedly elevated.
If the clinical probability is other than low, it seems more appropriate to skip the D-dimer test and refer the patient directly to the appropriate imaging technique. A combined ventilation and perfusion study increases the specificity for PE diagnosis. A combined 1-day protocol is preferred. The scan can be with planar lung imaging anterior, posterior, left and right lateral and left and right posterior oblique or Spect imaging. In pregnancy only a perfusion scan is recommended. It is performed for mapping regional ventilation. Perfusion scintigraphy is accomplished by microembolization with radiolabelled particles injected into a peripheral vein.
The commercially used particles are MAA, which are labelled with 99m Tc. The particle distribution accurately defines regional lung perfusion. Each bronchopulmonary segment is supplied by a single end-artery. In principle, conical bronchopulmonary segments have their apex towards the hilum and base projecting onto the pleural surface. Occlusive thrombi, affecting individual pulmonary arteries, therefore produce characteristic lobar, segmental or subsegmental peripheral wedge-shaped defects with the base projecting to the lung periphery.
Follow-up of PE using imaging is essential to assess the effect of therapy, differentiate between new and old PE on suspicion of PE recurrence and investigate physical incapacity after PE [ 9 ]. Normal pulmonary scintigraphy. Inhalation and perfusion images are compared. Homogeneous uptake in lungs. Matched findings. In nuclear medicine the studies of genitourinary system can be divided into superior and inferior genitourinary tract. Studies evaluating the superior genitourinary tract include the kidneys, allowing evaluation of several characteristics such as blood flow, function, anatomy and integrity of the collection system, aiding in the diagnosis of different pathologies.
For the lower genitourinary tract studies are represented by radionuclide cystography and testicular scintigraphy. Dynamic renal scintigraphy renogram represents the study commonly used to evaluate the various pathologies associated with superior genitourinary tract. It is the main indication of renal dynamic studies. The exam is simple, painless, easy to perform and only prior hydration is necessary. It lasts 30 to 50 minutes, and such variation is associated with the use of diuretics Figures 9 and Dynamic renal scintigraphy with 99mTc-DTPA: flow, normal function and nonobstructive excretory pathways.
For this condition, the renal dynamic study is done in two phases: one utilizing a stimulus by angiotensin converting enzyme inhibitor, one hour before administration of the radiopharmaceutical and the other from the merely studying renal dynamic without stimulus considered study baseline. According to the pathophysiology of renovascular disease, the standard pattern of diagnosis is an abnormal study with stimulation of the angiotensin converting enzyme inhibitorassociated with a normal baseline study.
In renal transplant, renal dynamic study is mainly used for evaluation of its most common complications such as acute tubular necrosis and rejection. The scintigraphic pattern of acute tubular necrosis and acute rejection are very similar, with preserved or slightly reduced flow and reduced glomerular filtration rate.
The time and symptoms are the key to diagnosis. In serial renal studies, the renal graft dysfunction secondary to acute tubular necrosis should improve or remain unchanged, while the rejection demonstrates progressive deterioration. Currently, ultrasound is the method of choice for renal transplant dysfunction [ 10 ]. Dynamic renal scintigraphy with 99mTc-DTPA and use of diuretic: Deficit of flow and left renal function associated with obstructive hydronephrosis. The renal cortical scintigraphy with 99mTc-DMSA is the procedure of choice for evaluating acute pyelonephritis and renal scarring.
The image acquisition takes place 2 to 3 hours after intravenous administration of the radiopharmaceutical so that attachment occurs at the same cortical. The scintigraphic patterns in acute pyelonephritis are focal involvement of a single area or multiple areas and diffuse involvement of the kidney. Radionuclide cystography permits visualization of very small volumes of reflux, and is probably more sensitive than contrast cystography [ 13 ].
The procedure is performed by infusion of saline and radiopharmaceuticals within the bladder through the catheter, thereby evaluating the presence of reflux Figure Testicular torsion is considered a surgical emergency and the availability of this tissue is mainly related to ischemic time. The testicular ultrasound is a simple method and easily performed for evaluation of this condition, however, in children evaluating the flow can be difficult, testicular scintigraphy is indicated.
The scintigraphic findings depend on the stage of testicular torsion, in the early phase there is a normal flow, reduced or absent and the still image is a slight reduction in uptake of the radiotracer within the testicle, followed by an increase in flow and static image appearance of halo of mildly increased activity around a centrally cold testicle, ending with testicular infarction, in which there is an increased flow rate and persistent halo of increased activity around a cold center.
Bone scintigraphy identifies single or multiple focal or diffuse areas with increased osteoblastic activity, which reflects local bone remodeling. It is a highly sensitive examination for detecting such abnormalities, but its specificity is limited. It needs to be analyzed in conjunction with other imaging examinations. It is indicated for both adults and children, but should be interpreted differently for these two groups, given that the normal distribution of radiopharmaceutical in the skeleton differs between adults and children, particularly because of the presence of physiological osteoblastic activity in the growth cartilage of children.
These bone scans are based on the principle of phosphonate uptake in bone tissue, especially in blastic lesions. For example, from this principle, the presence of osteoblastic metastases from breast tumors or prostate tumors can be seen, among others. Likewise, changes typical of benign diseases such as bone infections, inflammatory activity of rheumatic diseases, and prosthesis complications like loosening, infection, etc. The radiopharmaceutical used most, which is called 99m Tc-methylene diphosphonate 99m Tc-MDP , binds to the amorphous phase of hydroxyapatite crystals by means of chemoadsorption.
It is administered intravenously as a bolus. Images can be acquired immediately afterwards when information on the blood supply and vascular permeability is important, like in cases of infectious or tumor growth processes. They may also only be acquired later on, after hours of injection, with acquisition of whole-body images in the anterior and posterior projections, in order to acquire information on osteoblastic activity.
It is worth emphasizing that this examination shows low sensitivity to predominantly lytic pathological conditions or to conditions with low bone remodeling, except in cases associated with significant osteoblastic abnormalities, such as in investigations of associated fractures, for example, in patients with multiple myeloma. The great advantage of this method is that it assesses the whole body in a single examination with high sensitivity, and it guides other examinations that are more specific.
Scintigraphies in children are showed in figure Bone scintigraphy in children. Acute phase of avascular necrosis in right femoral head. Vascular permeability decreased green arrow and photopenic area brown arrow in right femoral head. Three phase bone scan. Osteosarcoma in the right humerus. Flow, vascular permeability and osteoblastic activity increased in right humerus red arrows. Bone scintigraphies in adults.
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Normal scan: symmetric uptake on the sckeletal. Single bone metastasis on left rib.
Multiple bone metastasis. Multiple focal uptake on skull, scapulas, ribs, spine, pelvis and right femur. Monostotic Paget Disease on right humerus. Intense uptake on right humerus. Intense uptake on skull and focal uptake on ribs. Because of the characteristics of gallium uptake in tissues, this radiotracer can be used in relation to neoplastic diseases, especially lymphomas, and in cases of chronic inflammatory or infectious processes, such as those in fever of unknown origin or in patients with acquired immunodeficiency.
The radiotracer is administered intravenously 48 hours before producing whole-body initial images in the supine position, in the anterior and posterior projections.