“String of pearls sign” on FDG PET imaging in two patients with PUO of diverse etiologies and rare associations

Abstract Background Pyrexia of unknown origin (PUO) may be related to several pathologies that need to be identified for proper treatment. PET is found to have highest diagnostic yield in identifying various causes of PUO. The aim of this study is to highlight and justify the use of 18F FDG PET (Fluorine Fluorodeoxyglucose Positron Emission Tomography) imaging as a whole body screening tool in two unique cases of febrile illness with lymphadenopathy but with diverse etiologies based on PET-guided biopsy. The unique arrangement of PET positive nodal disease as a “string of pearls sign” helps in easy identification of nodal disease. Case presentation The first case presented with fever and headache (past history of meningitis), high ferritin level, leukopenia, anemia, and raised inflammatory markers. CSF cell count was high, with mildly elevated protein and low glucose levels. PET positive nodes were biopsied; Kikuchi Fujimoto disease was confirmed with unexpected FDG avid pachymeningeal enhancements on PETMR indicating associated (active) meningitis which would have been missed if CT or MR was done as a standalone imaging. Lumbar puncture confirmed aseptic meningitis. The patient was treated with anti-inflammatory drugs, inj. methylprednisolone, and immunoglobulin together with hydroxychloroquine. The patient improved on follow-up. The second case presented with low-grade fever, pruritis, and nodular swellings in extremities, anemia, and pancytopenia. Based on PETCT findings, biopsy was attempted from FDG avid axillary nodes. Mantle cell lymphoma with rare nodular involvement of cutaneous and subcutaneous tissue was confirmed. Chemotherapy and tyrosine kinase inhibitor therapy was initiated, and the patient is doing well clinically. Conclusion The clinical impact of PET is twofold in both cases. It has accurately identified the nodal involvement even those subcentimetric in size by exhibiting a unique sign on PET resembling a “string of pearls” in the neck and chest with unrelated diverse etiologies. Secondly, additional findings of meningitis in the first case and cutaneous/subcutaneous nodular lymphomatous deposits in the second patient were possible only with whole body FDG PETMR/CT imaging. The rate of additional disease detection by PET is found to be greater than other conventional imaging modalities due to the functional basis of investigation.

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Phenobarbitone Induced Toxic Epidermal Necrosis in a Young Patient - A Rare Clinical Presentation: A Case Report and Brief Review of the Literatures

10.21203/rs.3.rs-458796/v1 ◽

2021 ◽

Author(s):

Biniyam A. Ayele ◽

Kemal Ali ◽

Eliyas Mulatu

Keyword(s):

Case Report ◽

Asthmatic Patient ◽

Wound Care ◽

Tube Feeding ◽

Whole Body ◽

Stevens Johnson Syndrome ◽

Low Grade ◽

First Case ◽

Epidermal Necrosis ◽

New Onset

Abstract Background: Toxic epidermal necrolysis (TEN)/ Stevens-Johnson syndrome (SJS) is the spectrum of severe, acute, mucocutaneous, Ig E mediated hypersensitivity reaction; universally related to different drugs. Phenobarbitone is known to cause hypersensitivity reactions with benign pattern; ranging from a mild to moderate rashes but not life-threatening reactions such as TEN/SJS. Little is known about TEN in asthmatic patient. To the best of our knowledge, this is the first case of Phenobarbitone-induced TEN in a young asthmatic patient from the sub Saharan African. Case report: We report a 14-year-old right handed asthmatic male patient who presented with extensive blister skin eruptions involving the whole body including mouth ear canal later followed by skin exfoliation associated with low grade fever, sore throat, and dysphagia. The hypersensitivity skin reaction developed two weeks after initiation of Phenobarbitone of 100mg twice daily for a new onset generalized tonic clonic seizure. The exfoliation also involved oral and Conjunctival mucosa; with estimated 65% body surface area involvement; hence the diagnosis of Toxic epidermal necrosis was made. The Laboratory investigations were relevant for mild leucocytosis, prolonged prothrombin time, and reduced albumin. Phenobarbitone was discontinued and replaced with clonazepam; and the patient was managed with fluids replacement, IV antibiotics, twice daily wound care, analgesics, and naso gastric tube feeding. On subsequent days in intensive care unit (ICU), the patients’ clinical condition started improving; the skin lesion also started to heal and exfoliate in most of the affected skin surface areas, and the patient was discharges improved after ten days of ICU care.Conclusion: In summary, the present case describes, a 14-years-old young child with history of allergy in a form of asthma and new onset seizure disorder; and developed toxic epidermal necrosis following exposure to Phenobarbitone. This case also highlighted the benign prognosis observed in paediatrics population with TEN.

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Primary Central Nervous System Lymphoma: Diagnostic Yield of Whole-Body CT and FDG PET/CT for Initial Systemic Imaging

Radiology ◽

10.1148/radiol.2019190133 ◽

2019 ◽

Vol 292 (2) ◽

pp. 440-446 ◽

Cited By ~ 5

Author(s):

Chong Hyun Suh ◽

Ho Sung Kim ◽

Ji Eun Park ◽

Seung Chai Jung ◽

Choong Gon Choi ◽

...

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Fdg Pet ◽

Diagnostic Yield ◽

Central Nervous System Lymphoma ◽

Whole Body ◽

Whole Body Ct ◽

Pet Ct ◽

Fdg Pet Ct ◽

Body Ct

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Comparison of diagnostic accuracy of 18F-FDG PET, 123I-IMT- and 99mTc-MIBI SPECT

Nuklearmedizin ◽

10.1055/s-0038-1623934 ◽

2006 ◽

Vol 45 (01) ◽

pp. 49-56 ◽

Cited By ~ 2

Author(s):

N. Özdemir-Sahin ◽

P. Hipp ◽

W. Mier ◽

M. Eisenhut ◽

J. Debus ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Fdg Pet ◽

Tumour Progression ◽

Roc Curves ◽

Low Grade ◽

Who Grade ◽

Pet Tracer ◽

Patient Groups ◽

99Mtc Mibi ◽

Mibi Spect

Summary Aim was to evaluates the diagnostic accuracy of the SPECTtracers 3-123I-α-methyl-L-tyrosine (IMT) and 99mTc(I)- hexakis(2-methoxyisobutylisonitrile) (MIBI) as well as the PET-tracer 2-18F-2-deoxyglucose (FDG) for detecting tumour progression in irradiated low grade astrocytomas (LGA). Patients, methods: We examined 91 patients (56 males; 35 females; 44.7 ± 11.5 years), initially suffering from histologically proven LGAs (mean WHO grade II) and treated by stereotactic radiotherapy (59.0 ± 4.6 Gy). On average 21.9 ± 11.2 months after radiotherapy, patients presented new Gd-DTPA enhancing lesions on MRI, which did not allow a differentiation between progressive tumour (PT) and non-PT (nPT) at this point of time. PET scans (n=82) were acquired 45 min after injection of 208 ± 32 MBq FDG. SPECT scans started 10 min after injection of 269 ± 73 MBq IMT (n=68) and 15 min after injection of 706 ± 63 MBq MIBI (n=34). Lesions were classified as PT and nPT based on prospective follow-up (clinically, MRI) for 17.2 ± 9.9 months after PET/SPECT. Lesion-to-normal ratios (L/N) were calculated using contra lateraly mirrored reference regions for the SPECT examinations and reference regions in the contra lateral grey (GM) and white matter (WM) for FDG PET. Ratios were evaluated by Receiver Operating Characteristic (ROC) analysis. Results: In the patient groups nPT and PT, L/N ratios for FDG (GS) were 0.6 ± 0.3 vs. 1.2 ± 0.5 (p = 0.003), for FDG (WS) 1.2 ± 0.4 vs. 2.6 ± 0.4 (p <0.001), for IMT 1.1 ± 0.1 vs. 1.8 ± 0.4 (p <0.001) and for MIBI 1.6 ± 0.7 vs. 2.6 ± 2.2 (p = 0.554). Areas under the non-parametric ROC-curves were: 0.738 ± 0.059 for FDG (GS), 0.790 ± 0.057 for FDG (WS), 0.937 ± 0.037 for IMT and 0.564 ± 0.105 for MIBI. Conclusion: MIBI-SPECT examinations resulted in a low accuracy and especially in a poor sensitivity even at modest specificity values. A satisfying diagnostic accuracy was reached with FDG PET. Using WM as reference region for FDG PET, a slightly higher AUC as compared to GM was calculated. IMT yielded the best ROC characteristics and the highest diagnostic accuracy for differentiating between PT and nPT in irradiated LGA.

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The therapeutic impact of 18F-FDG whole body PET

Nuklearmedizin ◽

10.1055/s-0038-1623920 ◽

2005 ◽

Vol 44 (01) ◽

pp. 8-14 ◽

Cited By ~ 7

Author(s):

B. Dietl ◽

J. Marienhagen

Keyword(s):

Fdg Pet ◽

Diagnostic Information ◽

Whole Body ◽

Therapeutic Concept ◽

Therapeutic Impact ◽

Additional Diagnostic Information ◽

Therapeutic Decisions ◽

Target Volumes ◽

18F Fdg ◽

Pet Scans

Summary Aims: An explorative analysis of the diagnostic as well as therapeutic impact of 18F-FDG whole body PET on patients with various tumours in the setting of an university hospital radiation therapy was performed. Patients and methods: 222 FDG PET investigations (148 initial stagings, 74 restagings) in 176 patients with diverse tumour entities (37 lung carcinoma, 15 gastrointestinal tumours, 38 head and neck cancer, 30 lymphoma, 37 breast cancer, 19 sarcoma and 16 other carcinomas) were done. All PET scans were evaluated in an interdisciplinary approach and consecutively confirmed by other imaging modalities or biopsy. Unconfirmed PET findings were ignored. Proportions of verified PET findings, additional diagnostic information (diagnostic impact) and changes of the therapeutic concept intended and documented before PET with special emphasis on radiooncological decisions (therapeutic impact) were analysed. Results: 195/222 (88%) FDG-PET findings were verified, 104/222 (47%) FDG-PET scans yielded additional diagnostic information (38 distant, 30 additional metastasis, 11 local recurrencies, 10 primary tumours and 15 residual tumours after chemoptherapy). The results of 75/222 (34%) scans induced changes in cancer therapy and those of 58/222 (26%) scans induced modifications of radiotherapeutic treatment plan (esp. target volumes). Conclusion: 18F-FDG whole body PET is a valuable diagnostic tool for therapy planning in radiooncology with a high impact on therapeutic decisions in initial staging as well as in restaging. Especially in a curative setting it should be used for definition of target volumes.

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Primary Gastrointestinal Stromal Tumor of the Liver with Cystic Changes

Case Reports in Gastroenterology ◽

10.1159/000495604 ◽

2019 ◽

Vol 13 (1) ◽

pp. 58-65

Author(s):

Takashi Tashiro ◽

Fumihiro Uwamori ◽

Yukiomi Nakade ◽

Tadahisa Inoue ◽

Yuji Kobayashi ◽

...

Keyword(s):

Liver Tumors ◽

Past History ◽

Brain Infarction ◽

Arterial Phase ◽

First Case ◽

Positron Emission ◽

Cystic Changes ◽

Multiple Bone Metastases ◽

The Right ◽

Cells Of Cajal

Gastrointestinal stromal tumors (GISTs) are known to originate specifically from the intestinal cells of Cajal located in the gastrointestinal mesenchyme. GISTs developing outside of the digestive tract have barely been reported. We encountered a first case of large primary GISTs in the liver with cystic changes. A 63-year-old man with a past history of brain infarction visited our hospital. The computed tomography (CT) revealed a 6-cm and a 10-cm mass in the right and the caudal lobe of the liver, respectively. These tumors have marginal enhancement in the arterial phase; however, they presented as hypodense in the internal tumor sites. Both liver tumors had cystic changes. Gastrointestinal examinations using endoscopy revealed no other gastrointestinal tumors, and [18F]-fluoro-2-deoxy-D-glucose positron emission tomography/CT revealed multiple bone metastases in addition to the liver tumors. The liver tumor specimens were composed of spindle cells, and the immunohistochemical staining for c-Kit and for DOG1, as discovered on GIST, was positive. The patient was diagnosed with primary hepatic GIST with cystic changes.

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Detection of EGFR Activating and Resistance Mutations by Droplet Digital PCR in Sputum of EGFR-Mutated NSCLC Patients

Clinical Medicine Insights Oncology ◽

10.1177/1179554921993072 ◽

2021 ◽

Vol 15 ◽

pp. 117955492199307

Author(s):

Klaus Hackner ◽

Anna Buder ◽

Maximilian J Hochmair ◽

Matthaeus Strieder ◽

Christina Grech ◽

...

Keyword(s):

Stable Disease ◽

Progressive Disease ◽

Kinase Inhibitor ◽

Diagnostic Yield ◽

Resistance Mutation ◽

Egfr Mutations ◽

Plasma Samples ◽

Percent Agreement ◽

Nsclc Patients ◽

Egfr Mutated

Background: Proof of the T790M resistance mutation is mandatory if patients with EGFR-mutated non-small cell lung cancer (NSCLC) progress under first- or second-generation tyrosine kinase inhibitor therapy. In addition to rebiopsy, analysis of plasma circulating tumor DNA is used to detect T790M resistance mutation. We studied whether sputum is another feasible specimen for detection of EGFR mutations. Methods: Twenty-eight patients with advanced EGFR-mutated NSCLC were included during stable and/or progressive disease. The initial activating EGFR mutations (exon 19 deletions or L858R mutations) at stable disease and at progressive disease (together with T790M) were assessed in simultaneously collected plasma and sputum samples and detected by droplet digital polymerase chain reaction (ddPCR). Results: Activating EGFR mutations were detected in 47% of the plasma samples and 41% of sputum samples during stable disease, and in 57% of plasma samples and 64% of sputum samples during progressive disease. T790M was detected in 44% of the plasma samples and 66% of the sputum samples at progressive disease. In ddPCR T790M-negative results for both specimens (plasma and sputum), negativity was confirmed by rebiopsy in 5 samples. Concordance rate of plasma and sputum for T790M was 0.86, with a positive percent agreement of 1.0 and a negative percent agreement of 0.80. Conclusions: We demonstrated that EGFR mutation analysis with ddPCR is feasible in sputum samples. Combination of plasma and sputum analyses for detection of T790M in NSCLC patients with progressive disease increases the diagnostic yield compared with molecular plasma analysis alone.

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Microbiome and PCOS: State-of-Art and Future Aspects

International Journal of Molecular Sciences ◽

10.3390/ijms22042048 ◽

2021 ◽

Vol 22 (4) ◽

pp. 2048

Author(s):

Pierluigi Giampaolino ◽

Virginia Foreste ◽

Claudia Di Filippo ◽

Alessandra Gallo ◽

Antonio Mercorio ◽

...

Keyword(s):

Insulin Resistance ◽

Bile Acid ◽

Peptide Yy ◽

Fecal Microbiota Transplantation ◽

Polycystic Ovary ◽

Current Evidence ◽

Low Grade ◽

Fecal Transplant ◽

Secondary Bile Acid ◽

First Case

Polycystic ovary syndrome (PCOS) is a complex and heterogeneous endocrine disease. The hypothesis that alterations in the microbiome are involved in the genesis of PCOS has been postulated. Aim of this review is to summarize the available literature data about the relationship between microbiome and PCOS. A search on PubMed and Medline databases was performed from inception to November 20Most of evidence has focused on the connection of intestinal bacteria with sex hormones and insulin-resistance: while in the first case, a relationship with hyperandrogenism has been described, although it is still unclear, in the second one, chronic low-grade inflammation by activating the immune system, with increased production of proinflammatory cytokines which interfere with insulin receptor function, causing IR (Insulin Resistance)/hyperinsulinemia has been described, as well as the role of gastrointestinal hormones like Ghrelin and peptide YY (PYY), bile acids, interleukin-22 and Bacteroides vulgatus have been highlighted. The lower genital tract microbiome would be affected by changes in PCOS patients too. The therapeutic opportunities include probiotic, prebiotics and synbiotics, as well as fecal microbiota transplantation and the use of IL-22, to date only in animal models, as a possible future drug. Current evidence has shown the involvement of the gut microbiome in PCOS, seen how humanized mice receiving a fecal transplant from women with PCOS develop ovarian dysfunction, immune changes and insulin resistance and how it is capable of disrupting the secondary bile acid biosynthesis. A future therapeutic approach for PCOS may involve the human administration of IL-22 and bile acid glycodeoxycholic acid.

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Brain Metabolic Correlates of Persistent Olfactory Dysfunction after SARS-Cov2 Infection

Biomedicines ◽

10.3390/biomedicines9030287 ◽

2021 ◽

Vol 9 (3) ◽

pp. 287

Author(s):

Maria Isabella Donegani ◽

Alberto Miceli ◽

Matteo Pardini ◽

Matteo Bauckneht ◽

Silvia Chiola ◽

...

Keyword(s):

Fdg Pet ◽

Structural Connectivity ◽

Statistical Parametric Mapping ◽

Brain Regions ◽

Olfactory Dysfunction ◽

Whole Body ◽

Mapping Software ◽

18F Fdg ◽

Left Insula

We aimed to evaluate the brain hypometabolic signature of persistent isolated olfactory dysfunction after SARS-CoV-2 infection. Twenty-two patients underwent whole-body [18F]-FDG PET, including a dedicated brain acquisition at our institution between May and December 2020 following their recovery after SARS-Cov2 infection. Fourteen of these patients presented isolated persistent hyposmia (smell diskettes olfaction test was used). A voxel-wise analysis (using Statistical Parametric Mapping software version 8 (SPM8)) was performed to identify brain regions of relative hypometabolism in patients with hyposmia with respect to controls. Structural connectivity of these regions was assessed (BCB toolkit). Relative hypometabolism was demonstrated in bilateral parahippocampal and fusiform gyri and in left insula in patients with respect to controls. Structural connectivity maps highlighted the involvement of bilateral longitudinal fasciculi. This study provides evidence of cortical hypometabolism in patients with isolated persistent hyposmia after SARS-Cov2 infection. [18F]-FDG PET may play a role in the identification of long-term brain functional sequelae of COVID-19.

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Multi-task weak supervision enables anatomically-resolved abnormality detection in whole-body FDG-PET/CT

Nature Communications ◽

10.1038/s41467-021-22018-1 ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

Sabri Eyuboglu ◽

Geoffrey Angus ◽

Bhavik N. Patel ◽

Anuj Pareek ◽

Guido Davidzon ◽

...

Keyword(s):

Fdg Pet ◽

Location Estimation ◽

Supervised Machine Learning ◽

Whole Body ◽

Free Text ◽

Abnormality Detection ◽

Weak Supervision ◽

Radiology Reports ◽

Pet Ct ◽

Fdg Pet Ct

AbstractComputational decision support systems could provide clinical value in whole-body FDG-PET/CT workflows. However, limited availability of labeled data combined with the large size of PET/CT imaging exams make it challenging to apply existing supervised machine learning systems. Leveraging recent advancements in natural language processing, we describe a weak supervision framework that extracts imperfect, yet highly granular, regional abnormality labels from free-text radiology reports. Our framework automatically labels each region in a custom ontology of anatomical regions, providing a structured profile of the pathologies in each imaging exam. Using these generated labels, we then train an attention-based, multi-task CNN architecture to detect and estimate the location of abnormalities in whole-body scans. We demonstrate empirically that our multi-task representation is critical for strong performance on rare abnormalities with limited training data. The representation also contributes to more accurate mortality prediction from imaging data, suggesting the potential utility of our framework beyond abnormality detection and location estimation.

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FDG-PET/CT in intensive care patients with bloodstream infection

Critical Care ◽

10.1186/s13054-021-03557-x ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Jordy P. Pijl ◽

Mark Londema ◽

Thomas C. Kwee ◽

Maarten W. N. Nijsten ◽

Riemer H. J. A. Slart ◽

...

Keyword(s):

Intensive Care ◽

Image Quality ◽

Fdg Pet ◽

Diagnostic Yield ◽

Unknown Origin ◽

Intensive Care Patients ◽

Pet Ct ◽

Infection Focus ◽

Focus Of Infection ◽

Fdg Pet Ct

Abstract Background 2-Deoxy-2-[18F]fluoro-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) is an advanced imaging technique that can be used to examine the whole body for an infection focus in a single examination in patients with bloodstream infection (BSI) of unknown origin. However, literature on the use of this technique in intensive care patients is scarce. The purpose of this study was to evaluate the diagnostic yield of FDG-PET/CT in intensive care patients with BSI. Methods In this retrospective cohort study, all intensive care patients from our Dutch university medical center who had culture-proven BSI between 2010 and 2020 and underwent FDG-PET/CT to find the focus of infection were included. Diagnostic performance was calculated and logistic regression analysis was performed to evaluate the association between FDG-PET/CT outcome and C-reactive protein level (CRP), leukocyte count, duration of antibiotic treatment, duration of ICU stay, quality of FDG-PET/CT, and dependency on mechanical ventilation. In addition, the impact of FDG-PET/CT on clinical treatment was evaluated. Results 30 intensive care patients with BSI were included. In 21 patients, an infection focus was found on FDG-PET/CT which led to changes in clinical management in 14 patients. FDG-PET/CT achieved a sensitivity of 90.9% and specificity of 87.5% for identifying the focus of infection. Poor quality of the FDG-PET images significantly decreased the likelihood of finding an infection focus as compared to reasonable or good image quality (OR 0.16, P = 0.034). No other variables were significantly associated with FDG-PET/CT outcome. No adverse events during the FDG-PET/CT procedure were reported. Conclusion FDG-PET/CT has a high diagnostic yield for detecting the infection focus in patients with BSI admitted to intensive care. Poor PET image quality was significantly associated with a decreased likelihood of finding the infection focus in patients with BSI. This could be improved by adequate dietary preparation and cessation of intravenous glucose and glucose-regulating drugs. Recent advances in PET/CT technology enable higher image quality with shorter imaging time and may contribute to routinely performing FDG-PET/CT in intensive care patients with BSI of unknown origin.

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