CASE REPORT
Vertebral “clover” scintigraphic image in a vertebral
metastasis misdiagnosed with Paget’s disease
Raquel Reyes
&
Pilar Peris
&
Ana Monegal
&
David Fuster
&
Nuria Guañabens
Received: 17 June 2008 / Revised: 30 July 2008 / Accepted: 15 August 2008 / Published online: 3 September 2008
#
Clinical Rheumatology 2008
Abstract The diagnosis of Paget’s bone disease (PD) is
often reached fortuitously with X-ray or scintigraphy. The
peculiar distribution of the bone tracer in some skeletal
locations, such as vertebra, may be highly suggestive of this
disorder. Indeed, there are two distinct vertebral images on
the bone scan highly specific of PD: the “clover” and the
“heart” images. It has been previously reported that the
specificity of these images for PD diagnosis is very high,
nearly 100%, then suggesting that these findings could be
patognomonic of this process. We have recently observed a
55-year-old male patient with back pain secondary to a
vertebral metastasis due to a hepatocellular carcinoma.
Initially, the bone scan showed the characteristic “clover”
image at T-12 level and he was misdiagnosed with PD.
Afterwards, the MRI suggested the diagnosis of a vertebral
metastasis, and a computed tomography-guided needle
biopsy further confirmed the diagnosis. In view of the
present data, this image cannot be considered as patogno-
monic of PD.
Keywords Bone scintigraphy
.
“Clover” image
.
“Heart” image
.
Paget’s bone disease
Introduction
The diagnosis of Paget’s bone disease (PD) is often reached
fortuitously with X-ray or scintigraphic examination. The
peculiar distribution of the bone tracer in some skeletal
locations, such as in vertebra, may be highly suggestive of
this disorder. Indeed, there are two distinct vertebral bone
scan images highly specific of PD [1]: the “clover” image,
affecting both vertebral pedicles and the spinous process,
and the “heart” image, affecting the vertebral body and the
spinous process. Previously reported specificity of these
images for PD diagnosis is 100%, suggesting that these
findings could be patognomonic of this process and
especially useful for vertebral monostotic forms, where
the diagnosis of the disease may be difficult.
We have recently observed a 55-year-old male patient
with back pain secondary to a vertebral metastasis due to a
hepatocellular carcinoma. Initially, the bone scan showed
the characteristic “clover” image at T-12 level and he was
misdiagnosed with PD. Afterwards, the MRI suggested the
diagnosis of a vertebral metastasis, and a computed
tomography (CT)-guided needle biopsy further confirmed
the diagnosis.
The patient was admitted to the Rheumatology depart-
ment because of a 3-month history of back pain. He
received an orthotopic liver transplantation 2 years ago
because of alcoholic liver cirrhosis associated with a
hepatocellular carcinoma. At physical examination, he
showed dorsal pain with spinal mobilization. The X-rays
did not show remarkable abnormalities and the bone
scintigraphy showed an increased tracer uptake with the
“clover” pattern at T-12, highly indicative of PD (Fig. 1).
Routine white and red blood cells counts, proteinogram,
calcium, phosphate, serum electrolytes, and renal function
test were all normal. Total alkaline phosphatase was slightly
Clin Rheumatol (2008) 27:1585–1586
DOI 10.1007/s10067-008-1001-2
R. Reyes
:
P. Peris (*)
:
A. Monegal
:
N. Guañabens
Service of Rheumatology, Metabolic Bone Diseases Unit,
IDIBAPS, Hospital Clínic, University of Barcelona,
Villarroel 170,
08037 Barcelona, Spain
e-mail: 22848ppb@comb.es
D. Fuster
Service of Nuclear Medicine, Metabolic Bone Diseases Unit,
IDIBAPS, Hospital Clínic, University of Barcelona,
Barcelona, Spain