Diffuse Splenic uptake on F-18 FDG PET: assisting in rare diagnosis of Visceral Leishmaniasis Laura Renshaw Nuclear Medicine Technologist Hunter New England Health Nuclear Medicine and PET Department HNEHI – Nuclear Medicine & PET Department • • • • • Opened in 2009 4 days a week ~10 scans per day F18-FDG RPA GE Discovery 690 The Patient • • • • • 69 Yr old Female Rheumatoid pulmonary nodules Fever with night sweats Splenomegaly Small monoclonal band of lymphocytes • ? Lymphoma • ? Infection Patient History • Extensive infective workup • 3 weeks fever & malaise Patient History • • • • Hx of extensive tropical travel France, Portugal & Spain September 2010 China & Tibet May 2010 USA, Canada, Vietnam, Cambodia, Bali, New Zealand, Italy, Mexico and Zimbabwe Workup Overview (Pre – PET/CT) • Pathology – NEGATIVE • Bone Marrow Biopsy - Splenomegaly ? - Felty’s Syndrome ? • Referred for CT Workup Overview (Pre – PET/CT) • Chest/Abdo CT – Pulmonary nodules – Mediastinal lymph nodes – Splenomegaly Workup Overview (Pre – PET/CT) • Further pathology - NEGATIVE • Echo - NEGATIVE • Biopsy (Non-diagnostic) PET/CT Procedure • • • • • 248Mbq F18 FDG IVC Imaging 1Hr post injection Base of skull to mid thigh Arms raised Low Dose CT - anatomical localisation + attenuation correction purposes Interpretation • Intense enlarged spleen • Neck & Bowel – Physiological • No other FDG avid areas Images Interpretation • Splenic Lymphoma? • Acute Malaria? • PET/CT = Definitive area of interest PET/CT Biopsy Diagnosis Visceral Leishmaniasis • 3 Types: Visceral, Cutaneous and Mucosal. • Parasitic disease protozoa of the genous Leishmania • Incidental infection/contact with host • Bite from a female phelobotimine sandfly Visceral Leishmaniasis • Extremely rare • Bangladesh, India, Nepal, Sudan and Brazil Visceral Leishmaniasis • Splenomegaly, lymphadenopathy, weight loss, fatigue, fever, diarrhoea • Treatment essential • Untreated = fatal • Lipid formulation of Amphotericin B • Monitoring essential Relevant Literature • 2006 Clinical Nuclear Medicine – “Diffuse metabolic activation of reticuloendothelium on F-18 FDG PET imaging in a case of Visceral Leishmania” • 2009 Nuclear Medicine Communications – “Clinical significance of diffusely increased splenic uptake on FDG-PET” – No mention of Visceral Leishmaniasis as a differential Value to Nuclear Medicine • • • • Critical turning point of diagnosis PET/CT Fast tracked diagnosis Numerous invasive tests pre PET/CT Where might the patient be now? – more invasive tests ? – succumbed to the disease? Value to Nuclear Medicine • FDG PET invaluable/sensitive tool in infection imaging (+++PUO) • Major role in infection imaging future • FDG PET more than oncology, neurology and cardiac • Clinical value in rare cases of unknown infection Conclusion •Recommend that Visceral Leishmaniasis be included as a rare, potential cause of isolated splenic hypermetabolic activity •FDG PET localisation of PUO Thankyou • Questions? References • Braunwald, E et al. 2001. Principles of Internal Medicine, 15 th ed. McGraw Hill • Lui, Y. 2009. Clinical significance of diffusely increased splenic uptake on FDG-PET. Nuclear Medicine Communications; 30: 763-769. • Lupi A, Todeschini G, Zanco P. 2006. Diffuse metabolic activation of reticuloendothelium on F-18 FDG PET imaging in a case of Visceral Leishmania. Clinical Nuclear Medicine; 31: 34-36. • Tronco et all. 2005. FDG PET of infection and inflammation. RadioGraphics; 25: 1357-1368. • http://www.bdtravelandhealth.com/jsp/activity/index.jsp?activityObjectID=32 • http://www.dpi.nsw.gov.au/__data/assets/pdf_file/0003/388452/AHNewsJan-Mar2011.pdf • http://www.medicinenet.com/leishmaniasis/article.htm • http://www.stanford.edu/group/parasites/ParaSites2010/Zach_Wettstein/Development%20of%20Drugs%20for%20the%20Tr eatment%20of%20Visceral%20Leishmaniasis.html • http://www.who.int/leishmaniasis/disease_epidemiology/en/index.html
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