Interference of Residual 99mTc-MIBI Activity in Syringe Needle on 99mTc-DMSA Scan Interpretation; Medical Error

A 4-month-old infant with a small right kidney underwent a 99mTc-DMSA scan showing unjustifiable findings including global cortical loss in the left kidney, increased liver and bowel uptake. Retrospective review revealed reuse of a sterile needle contaminated with residual 99mTc-MIBI, compromising scan quality and falsely elevating right kidney function. A repeat scan showed normal left kidney uptake and significantly reduced right kidney function. This case highlights the importance of employing safe techniques with disposable equipment, thorough workflow review, and transparent error reporting in nuclear medicine to ensure accurate diagnosis and patient safety.