Vasculitis of ascending aorta detected on FDG PET/CT in a patient with fever of unknown origin
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Vasculitis of ascending aorta detected on FDG PET/CT in a patient with fever of unknown origin A 59-year-old man was admitted for fever of unknown origin.Fever was associated with chills.His medical record revealed the history of aortic valve replacement 11 years earlier, as well as enterococcal endocarditis 4 months prior to the current admission.The patient was found to have normal left ventricular size with borderline systolic function, left ventricular hypertrophy, right ventricle at the upper limit of normal size, mild systolic dysfunction and mild transvalvular aortic insufficiency on transthoracic echocardiography; while no vegetations were observed on transesophageal echocardiography.Sequential blood cultures were negative; however, a blood culture sample obtained 5 days prior to last admission was shown to be positive for enterococci.In addition, persistently increased levels of erythrocyte sedimentation rate and C reactive protein at 48 mm/hour and 39 mg/L were noted, respectively.Subsequently, the patient underwent fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG-PET/CT) in search for the origin of the fever, which depicted increased radiopharmaceutical uptake in the aortic root with upward extension to the ascending aorta (figure 1), without any abnormal uptake of the prosthetic aortic valve in the non-attenuation corrected images.Rest of the whole body scan was unremarkable.Based on scan pattern, compatible with aortitis, the patient underwent antibiotic treatment with ampicillin/sulbactam. Fever immediately disappeared, and the inflammatory parameters as we all as patient's clinical situation improved.The patient is currently receiving antibiotics to fulfil the 8 weeks duration.Multiple imaging modalities, providing different and often complementary findings among a wide array of aortitis presentations and potential complications, are used in the evaluation of both inflammatory and non-inflammatory aortic diseases.Inflammatory cell infiltration of different levels of aortic wall, caused by various immunological, infectious or traumatic factors, as the presenting cause of aortitis, is the rationale for nuclear imaging including F-18 FDG PET, which applies the metabolic accumulation of F-18 FDG in the inflammatory milieu, mainly in monocytes.Limited spatial resolution of PET and its inability to provide precise anatomic characterisation warrant coregistration of CT or MRI for anatomic localisation.Inconclusive CT findings in the early stages of aortitis indicate the need for a more sensitive modality. 1PET is known to be the most sensitive test for detection of the early vessel inflammation.Keywords:
Chills
Parasternal line
Transesophageal echocardiogram
A 35-year-old man was admitted to the hospital because of fever, bacteremia, and a mass in the left atrium. Two weeks before admission, fever and shaking chills developed. A transesophageal echocardiogram showed a mass that was attached to the nonseptal side of the left atrium.
Chills
Bacteremia
Transesophageal echocardiogram
Transthoracic echocardiogram
Atrium (architecture)
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With the ultrasound transducer positioned at the second or third right intercostal space, the ascending aorta was visualized in 8 patients in whom dilatation of the ascending aorta had been demonstrated radiographically. The diameter of the ascending aorta by right parasternal scan, with the transducer held perpendicular to the chest wall, measured 4.2-6 cm. The aortic root diameter (at aortic valve level) recorded by conventional left parasternal scan was normal or only slightly increased in 5 cases, but in 3 others it approached the value obtained by right parasternal scan. Aortography performed in 3 patients demonstrated marked dilatation of the ascending aorta.
Parasternal line
Intercostal space
Aortography
Descending aorta
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Fever of unknown origin (FUO) refers to fevers of ≥101° F that persist for ≥3 weeks and remain undiagnosed after a focused inpatient or outpatient workup. FUO may be due to infectious, malignant/neoplastic, rheumatic/inflammatory, or miscellaneous disorders. Recurrent FUOs are due to the same causes of classical FUOs. Recurrent FUOs may have continuous or intermittent fevers and are particularly difficult to diagnose. With intermittent fever, recurrent FUO diagnostic tests are best obtained during fever episodes. With recurrent FUOs, the periodicity of febrile episodes is unpredictable. We present a case of a 70-year-old male who presented with recurrent FUO. Multiple extensive FUO workups failed to determine the source of his fever. During his last two episodes of fever/chills, blood cultures were positive for Enterobacter cloacae. Episodic E. cloacae bacteremias suggested a device-related infection, and the patient had a penile implant and permanent pacemaker (PPM). Following febrile episodes, he was treated with multiple courses of appropriate antibiotics, but subsequently fever/chills recurred. Since a device-associated infection was suspected, indium and PET scans were done, but were negative. The source of his intermittent E. cloacae bacteremias was finally demonstrated by gallium scan showing enhanced uptake on a cardiac lead, but not the penile implant or PPM. Gallium scanning remains useful in workup of FUOs, particularly when false-negative indium or PET scans are suspected. The involved pacemaker lead was explanted, grew E. cloacae and the patient has since remained fever free.
Chills
Enterobacter cloacae
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Objectives : Sosihotang is a typical prescription in Sang Han Lun. And the alternate chills and fever is a Sosihotang's typical symptom. Therefore I will study of how the syndrome of Sosihotang's alternate chills and fever caused. Methods : Examine the claims of the syndrome of Sosihotang's alternate chills and fever in Sang Han Lun. The scholar's claims are not all same. Thus, I analysis the claims of many scholars. Results : The syndrome of Sosihotang has two mechanisms. The move of defensive Gi(衛氣) can explain the occurrence of alternate chills and fever. If the defense Gi enter inside the body, it struggle with pathogenic Gi, the fever is occurred. On the contrary to this, if the defense Gi exits the body the chills occurs because of the lack of defense Gi. Conclusions : The syndrome of Sosihotang could be taken ill by tranmission or direct attack of exogenous pathogenic factors(直中). Symptoms chills and fever occurs due to the entrance and exit of defensive Gi.
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We report a case of an anomalous origin of the right pulmonary artery (RPA) from the ascending aorta diagnosed at echocardiography at 13 days of age. The diagnostic clue was relieved in the suprasternal and parasternal high short-axis views, showing aorto-RPA continuity with a systolic flow in the left pulmonary artery and a systo-diastolic flow in the RPA. At 34 days of age the infant was submitted to surgery during which a direct end-to-lateral anastomosis without conduit interposition was performed. During the short-term follow-up the patient developed RPA stenosis at the anastomosis site and underwent percutaneous stent implantation.
Parasternal line
Right pulmonary artery
Left pulmonary artery
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Right parasternal image is not a part of the routine echocardiographic examination and is seldom used. In cases of ascending aorta aneurysm and dissection, this view may help provide crucial information when the standard views are unable to visualize them adequately. Here, we reported a case of aortic dissection that was diagnosed early and easily using the right parasternal image.
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Mini‐Abstract A 72‐year‐old asymptomatic woman with history of ischemic heart disease and repeat coronary percutaneous interventions underwent a routine transthoracic echocardiogram ( TTE ). A 9‐mm long, fixed, echo dense mass was visualized in the proximal ascending aorta. We performed a two and three‐dimensional transesophageal echocardiogram and a cardiac multidetector‐row contrast‐enhanced computed tomography with ECG gating, which revealed the unexplained mass to be an ostial right coronary artery stent protruding 9 mm into the ascending aorta. Coronary stent protrusion is a very unusual finding observed during routine 2D TTE , but it has many potential clinical consequences. This case suggests that 2D TTE is feasible and useful for the identification and follow‐up of protruding ostial coronary stents.
Transesophageal echocardiogram
Transthoracic echocardiogram
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Objectives : Sosihotang is a typical prescription in Sang Han Lun. And the alternate chills and fever is a Sosihotang``s typical symptom. Therefore I will study of how the syndrome of Sosihotang``s alternate chills and fever caused. Methods : Examine the claims of the syndrome of Sosihotang``s alternate chills and fever in Sang Han Lun. The scholar``s claims are not all same. Thus, I analysis the claims of many scholars. Results : The syndrome of Sosihotang has two mechanisms. The move of defensive Gi(衛氣) can explain the occurrence of alternate chills and fever. If the defense Gi enter inside the body, it struggle with pathogenic Gi, the fever is occurred. On the contrary to this, if the defense Gi exits the body the chills occurs because of the lack of defense Gi. Conclusions : The syndrome of Sosihotang could be taken ill by tranmission or direct attack of exogenous pathogenic factors(直中). Symptoms chills and fever occurs due to the entrance and exit of defensive Gi
Chills
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Chills
Bacteremia
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Aortography
Transesophageal echocardiogram
Ventricular outflow tract
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