Genoni, Michele

Schuler, Roland

Strobel, Klaus

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CLINICAL VIGNETTE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehm539Visualization of pericarditis with fluoro-deoxy-glucose-positron emissiontomography/computed tomographyKlaus Strobel1*, Roland Schuler2, and Michele Genoni31Division of Nuclear Medicine, Department of Medical Radiology, University Hospital Zurich, Raemistr. 100, 8091 Zurich, Switzerland; 2Institute of Clinical Pathology,Department of Pathology, University Hospital Zurich, Switzerland; and 3Department of Cardiovascular Surgery, University Hospital Zurich, Switzerland* Corresponding author. Tel: þ41 44 255 28 50, Fax:þ41 44 255 44 14. Email: klaus.strobel@usz.chA 38-year-old man presented with recurrent fever, night sweat,retrosternal pain, and vomiting. Laboratory test failed to identifya viral or bacterial agent. The patient did not respond to anti-biotics. Transoesophageal echocardiography showed pericardialeffusion and no valvular vegetations. The patient was referred tofluoro-deoxy-glucose-positron emission tomography/computedtomography (FDG-PET/CT) to identify an infectious focus.Whole-body FDG-PET/CT was performed after fasting and 1hour after intravenous administration of 350 MBq FDG. CoronalPET image (Panel D) demonstrates increased uptake in thewhole pericardium, pronounced on the right side (long arrows).PET/CT technique provides cross-sectional axial CT- (Panel A),PET- (Panel B), and fused PET/CT-(Panel C) images. The pericardiallayers were thickened and took up FDG. Between the pericardiallayers effusion was visible. Additionally, small pleural effusion wasdetected on the right side (short arrows). Pericardial biopsy wasperformed. The histopatholgical examination showed fibrosiswith chronic sclerosing and lymphoplasmacellular inflammationconsistent with chronic sclerosing pericarditis (Panel E). A specificaetiological lesion (e.g. granulomas, rheumatoid nodules) couldnot be identified. Furthermore, no causing agent could be ident-ified on specially stained histological sections, in microbiology orwith PCR. A therapy with corticosteroids was not successfuland 9 months after the biopsy, a pericardectomy was necessarybecause of the pericardial constriction.Although the majority of patients imaged with FDG-PET/CTsuffer from malignant diseases, this radionuclide is not tumour-specific. It has been proven experimentally that inflammatory cells also take up FDG. The most experience with FDG in infection andinflammation imaging exists in patients with fever of unknown origin and osteomyelitis. FDG-PET/(CT) has been used in the cardio-vascular area for imaging of large vessel vasculitis (Takayasu or giant cell arteriitis) and graft infections. Because there can be markedlyphysiological uptake of FDG in the heart, especially in the left ventricle myocardium, it is crucial to differentiate pathologicalFDG-uptake due to pericarditis from physiological uptake. That is why patient preparation for imaging of inflammatory or infectiousheart diseases with FDG differs from preparation for myocardial viability studies. In infection indications fasting for at least 4 h shouldguarantee energy supply of the myocardium by fatty acids. In FDG-viability studies, the combination of glucose and insulin adminis-tration before FDG-injection leads to FDG-uptake by switching the energy supply from fatty acids to glucose. Our case demonstratesthat it is possible to visualize a chronically active pericarditis with FDG-PET/CT. Of course, FDG-PET/CT should not be the firstimaging tool for patients with the suspicion for pericarditis but in unclear cases it may help prove the diagnosis, to show theextent of the disease, to exclude other infectious foci, to guide the biopsy, and it might be useful for therapy response assessment.Panel A. Axial low-dose CT image showing the thickened pericardial layers (long arrow) with pericardial effusion in-between andpleural effusion (short arrow).Panel B. Corresponding axial positron emission tomography image with increased FDG-uptake in the pericardium (arrow)Panel C. Fusion of corresponding CT and positron emission tomography image illustrating that the increased FDG-uptake matcheswith the pericardium.Panel D. Coronal MIP (maximum intensity projection) image with increased FDG-uptake in the pericardium (arrow).Panel E. Haematoxylin-eosin stained histologic section (200  ) showing fibrotic soft tissue with a chronic lympho-plasmacellularinflammatory infiltrate interspersed between thick collagenous bundles.Published on behalf of the European Society of Cardiology. All rights reserved.& The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org.1212 Clinical vignette

Visualization of pericarditis with fluoro-deoxy-glucose-positron emission tomography/computed tomography

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