Circulation. 2005;111:e375-e376
doi: 10.1161/CIRCULATIONAHA.104.477703
(Circulation. 2005;111:e375-e376.)
© 2005 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Fluorine-18–Labeled Deoxyglucose Positron Emission Tomography in the Diagnosis and Management of Aortitis With Pulmonary Artery Involvement
Lisa Mielniczuk, MD;
Robert A. deKemp, PhD;
Carole Dennie, MD;
Keiichiro Yoshinaga, MD;
Ian G. Burwash, MD;
Francois Bénard, MD;
Haissam Haddad, MD;
Donald S. Beanlands, MD;
Rob S.B. Beanlands, MD
From the Division of Cardiology (L.M., R.A.d.K., K.Y., I.G.B., H.H., D.S.B., R.S.B.B.), University of Ottawa Heart Institute, Ottawa, Ontario, Canada; Department of Radiology (C.D.), Ottawa Hospital, Ottawa, Ontario, Canada; and Department of Nuclear Medicine (F.B.), Université de Sherbrooke, Sherbrooke, Quebec, Canada.
Correspondence to Rob S.B. Beanlands, MD, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada 40, rue Ruskin, Ottawa, Ontario, Canada, K1Y4W7. E-mail rbeanlands{at}ottawaheart.ca
A 58-year-old woman presented with a complex history of constitutional symptoms, heart block requiring pacemaker, and subsequent heart failure. Initial echocardiograms reported some periaortic thickening but no definite vegetations. The patient had received antibiotic therapy before initial presentation. She had multiple negative serial blood cultures and was treated for culture-negative endocarditis. Over the ensuing months, however, her condition progressively worsened. At the time of her presentation to our facility, she had persistent elevations of her C-reactive protein (CRP; 66 mg/dL), an accelerated erythrocyte sedimentation rate (ESR; 60 mm/h), and a P-antineutrophil cytoplasmic antibody (ANCA) immunofluorescence assay that was positive. She had negative serology for bartonella, coxiella, and brucella, as well as nonreactive syphilis and human immunodeficiency virus tests. C-ANCA, rheumatoid factor, anticardiolipin antibodies, and complement levels were also negative. Contrast-enhanced CT scan of her chest demonstrated significant inflammatory tissue at the root of the aorta extending into the interventricular septum but no other large-vessel involvement (Figures 1A and 2
A). An 18F-labeled deoxyglucose (FDG) positron emission tomography (PET) scan of the thorax was performed after a 12-hour fast. Increased FDG uptake was noted in the proximal aorta over the site of inflammatory tissue (Figures 1B and 2B). Fusion of the CT and FDG PET images confirmed the location and extent of the inflammatory area but also identified an area of inflammation in the pulmonary artery not previously appreciated on the CT scan (Figures 1C and 2C). The patient was diagnosed with aortitis and began high-dose prednisolone, with clinical improvement and subsequent normalization of CRP and ESR to 1 mg/dL and 4 mm/h, respectively. Follow-up echocardiograms showed improvement in aortic root thickening, and repeat FDG PET demonstrated resolution of the abnormal FDG uptake seen on the previous PET study (Figure 3B). The case demonstrates the utility of FDG PET (particularly when fused with CT imaging) to detect and monitor active aortitis. In this case, the FDG PET scan identified unsuspected active inflammation in the pulmonary artery that also responded to therapy.
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Figure 1. Baseline sagittal images. A, Sagittal oblique slice of a contrast-enhanced multidetector helical CT of the heart demonstrates thickening of the wall of the aortic root and adjacent interventricular septum. B, Corresponding FDG PET scan demonstrates increased activity over the same site in the proximal aorta. FDG uptake is also seen in the region of the pulmonary artery. C, Fusion of sagittal CT and FDG PET images shows that FDG uptake corresponds to the aortic root and pulmonary artery.
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Figure 2. Baseline coronal images. A, Coronal slice of the same contrast-enhanced CT confirms aortic root wall thickening in another imaging plane. B, Coronal PET image also demonstrates increased activity over the proximal aorta and in the region of the pulmonary artery. C, Fusion of coronal oblique images taken from CT and FDG PET. Fused images confirm increased FDG uptake in the aortic root and over the pulmonary artery.
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Figure 3. Follow-up FDG PET. A, Coronal oblique slice of contrast-enhanced CT of the heart at baseline, as seen in Figure 2A. B, Follow-up FDG PET scan done 4 weeks after steroid therapy was begun for aortitis. Increased uptake in the proximal aorta noted at baseline has now resolved. C, Fusion of baseline CT image and follow-up FDG PET scan confirms that the inflammatory activity seen at the aortic root and pulmonary artery has resolved with steroid therapy.
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Acknowledgments
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Dr Beanlands is a research scientist supported by the Canadian
Institutes of Health Research and the Premier’s Research
Excellence Award.
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