1
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Trivedi SJ, Bourque JM. Innovations in Imaging: 18F-Fluorodeoxyglucose PET/CT for Assessment of Cardiovascular Infection and Inflammation. Curr Cardiol Rep 2024:10.1007/s11886-024-02137-z. [PMID: 39316219 DOI: 10.1007/s11886-024-02137-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE OF REVIEW 18F-Fluorodeoxyglucose positron emission tomography (PET) combined with computed tomography (CT), referred to as 18F-FDG PET/CT, plays a significant role in the diagnosis and management of patients with systemic infectious and inflammatory conditions. This review provides an overview of 18F-FDG PET/CT in systemic infectious and inflammatory conditions, including infective endocarditis (IE), cardiac implantable electrical device (CIED)/left ventricular assist device (LVAD) infection, sarcoidosis, and large-vessel vasculitis (LVV). RECENT FINDINGS This review highlights the past and present literature in the increasing role of 18F-FDG PET/CT in cardiovascular inflammation and infection, including diagnostic and prognostic findings. They key aspects of this paper are to highlight the importance of 18F-FDG PET/CT in cardiovascular infection and inflammation, and to provide illustrations of how it can contribute to patient diagnosis and management.
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Affiliation(s)
- Siddharth J Trivedi
- Cardiovascular Division (Department of Medicine), Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jamieson M Bourque
- Division of Cardiovascular Medicine, Cardiac Imaging Center, Departments of Medicine and Radiology, University of Virginia, 1215 Lee Street, PO Box 800158, Charlottesville, VA, 22908, USA.
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2
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Sammartino AM, Bonfioli GB, Dondi F, Riccardi M, Bertagna F, Metra M, Vizzardi E. Contemporary Role of Positron Emission Tomography (PET) in Endocarditis: A Narrative Review. J Clin Med 2024; 13:4124. [PMID: 39064164 PMCID: PMC11277723 DOI: 10.3390/jcm13144124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/20/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Endocarditis, a serious infectious disease, remains a diagnostic challenge in contemporary clinical practice. The advent of advanced imaging modalities has contributed significantly to the improved understanding and management of this complex disease. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) imaging has shown remarkable potential in improving the diagnostic accuracy of endocarditis. In the update of the Modified Duke Criteria, in 2023, The International Society for Cardiovascular Infectious Diseases (ISCVID) Working Group recognized specific 18F-FDG PET/CT findings as a major diagnostic criterion, particularly in patient with prosthetic valve endocarditis. The ability of PET to visualize metabolic activity allows for the identification of infective foci and could differentiate between infective and non-infective processes. This review examines the clinical utility of PET in differentiating infective endocarditis from other cardiovascular pathologies, highlighting its sensitivity and specificity in detecting native and prosthetic valve infections, including patients with transcatheter aortic valve implantation (TAVI), cardiac implantable devices (CIEDs), and left ventricular assistance devices (LVAD). Also, practical aspects and indications are illustrated to optimize the quality of imaging and reduce potential false positive results. In conclusion, the current use of PET in endocarditis has become a valuable diagnostic tool; as technological advances continue, PET will play an increasingly important role in the multidisciplinary approach to the management of endocarditis.
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Affiliation(s)
- Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (G.B.B.)
| | - Giovanni Battista Bonfioli
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (G.B.B.)
| | - Francesco Dondi
- Nuclear Medicine, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy
| | - Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (G.B.B.)
| | - Francesco Bertagna
- Nuclear Medicine, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (G.B.B.)
| | - Enrico Vizzardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (G.B.B.)
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3
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context: ASNC Imaging Indications (ASNC I 2) Series Expert Consensus Recommendations From ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. JACC Cardiovasc Imaging 2024; 17:669-701. [PMID: 38466252 DOI: 10.1016/j.jcmg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multisocietal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multifocal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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4
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I 2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. Heart Rhythm 2024; 21:e1-e29. [PMID: 38466251 DOI: 10.1016/j.hrthm.2024.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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5
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I 2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. J Nucl Cardiol 2024; 34:101786. [PMID: 38472038 DOI: 10.1016/j.nuclcard.2023.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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6
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. Clin Infect Dis 2024:ciae046. [PMID: 38466039 DOI: 10.1093/cid/ciae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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7
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Filippi L, Lacanfora A, Garaci F. One Fell Swoop: Septic Muscle Embolism and Central Venous Catheter Infection Imaged with [ 18F] Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography. Diagnostics (Basel) 2024; 14:180. [PMID: 38248057 PMCID: PMC10814708 DOI: 10.3390/diagnostics14020180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/29/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
We describe the case of a 43-year-old female with hereditary hemochromatosis, previously without cardiac issues, who presented with a severe fever (>40 to 41 °C) to our hospital. Initial assessments, including transthoracic echocardiography, showed no typical signs of infective endocarditis. A contrast-enhanced CT scan revealed a hypodense area in the right subscapular muscle, alongside pleural thicknesses. Due to the critical condition, a central venous catheter (CVC) was implanted for immediate intravenous treatment. Subsequent blood cultures, positive for Staphylococcus aureus, and transesophageal echocardiography led to a diagnosis of multivalvular infective endocarditis (MIE). Subsequently, the patient underwent positron emission tomography/computed tomography (PET/CT) with [18F]Fluorodeoxyglucose ([18F]FDG), which detected increased tracer incorporation in the muscle lesion, CVC, and pleural thicknesses. The final diagnosis was CVC infection and septic embolism to the subscapular muscle in a patient with pleuritis. This case showcases the critical role of [18F]FDG PET/CT as whole-body imaging modality in diagnosing and managing complex infective cases.
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Affiliation(s)
- Luca Filippi
- Nuclear Medicine Unit, Department of Oncohaematology, Fondazione PTV, Policlinico Tor Vergata University Hospital, Viale Oxford 81, 00133 Rome, Italy;
| | - Annamaria Lacanfora
- Nuclear Medicine Unit, Department of Oncohaematology, Fondazione PTV, Policlinico Tor Vergata University Hospital, Viale Oxford 81, 00133 Rome, Italy;
| | - Francesco Garaci
- Department of Diagnostic Imaging, Molecular Imaging, University Hospital Tor Vergata, 00173 Rome, Italy;
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8
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Abstract
Septic pulmonary embolism (SPE) is a rare clinical entity that is distinct from the classic and more common non-septic thrombotic pulmonary embolism. SPE should be suspected in patients with a systemic acute inflammatory reaction or sepsis who develop signs and symptoms of pulmonary involvement. The diagnosis of SPE depends on the specific radiologic finding of multiple, peripheral, nodular, possibly cavitated lesions. SPE should prompt an immediate search for the primary source of infection; typically, right-sided infective endocarditis, cardiac implantable electronic devices, and septic thrombophlebitis as a complication of bone, skin, and soft tissue infection including Lemierre's syndrome, indwelling catheters, or direct inoculation via injection drug use. Invasive treatment of the infection source may be necessary; in thrombophlebitis, the efficacy and safety of anticoagulation remain undefined. Blood cultures may be negative, particularly among patients with recent antibiotic exposure, and broad-spectrum antimicrobial therapy should be considered. The in-hospital mortality of SPE ranges up to 20% in published case series. While trends in the incidence of SPE are unknown, the opioid epidemic, the growing use of cardiac implantable electronic devices worldwide, and the reported increase in cases of septic thrombophlebitis may be leading to an escalation in SPE cases. We provide a contemporary profile of SPE and propose a clinical management algorithm in patients with suspected or confirmed SPE.
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Affiliation(s)
- Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center at the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center at the Johannes Gutenberg University, Mainz, Germany
| | - Larry M Baddour
- Departments of Medicine and Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Division of Public Health, Infectious Diseases and Occupational Health, Rochester, Minnesota
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9
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 268] [Impact Index Per Article: 268.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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10
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Contemporary Review of Multi-Modality Cardiac Imaging Evaluation of Infective Endocarditis. Life (Basel) 2023; 13:life13030639. [PMID: 36983795 PMCID: PMC10052933 DOI: 10.3390/life13030639] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Infective endocarditis (IE) remains to be a heterogeneous disease with high morbidity and mortality rates, which can affect native valves, prosthetic valves, and intra-cardiac devices, in addition to causing systemic complications. The combination of clinical, laboratory, and cardiac imaging evaluation is critical for early diagnosis and risk stratification of IE. This can facilitate timely medical and surgical management to improve patient outcomes. Key imaging findings for IE include vegetations, valve perforation, prosthetic valve dehiscence, pseudoaneurysms, abscesses, and fistulae. Transthoracic echocardiography continues to be the first-line imaging modality of choice, while transesophageal echocardiography subsequently provides an improved structural assessment and characterization of lesions to facilitate management decision in IE. Recent advances in other imaging modalities, especially cardiac computed tomography and 18F-fluorodeox-yglucose positron emission tomography, and to a lesser extent cardiac magnetic resonance imaging and other nuclear imaging techniques, have demonstrated important roles in providing complementary IE diagnostic and prognostic information. This review aims to discuss the individual and integrated utilities of contemporary multi-modality cardiac imaging for the assessment and treatment guidance of IE.
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11
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Mikail N, Hyafil F. Turning the heart off: give it a second try? J Nucl Cardiol 2022; 29:3263-3266. [PMID: 35655114 DOI: 10.1007/s12350-022-03013-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, 8006, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, 8952, Schlieren, Switzerland
| | - Fabien Hyafil
- Department of Nuclear Medicine, Georges-Pompidou European Hospital, DMU IMAGINA, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, 20 Rue Leblanc, 75015, Paris, France.
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12
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Mikail N, Hyafil F. Nuclear Imaging in Infective Endocarditis. Pharmaceuticals (Basel) 2021; 15:ph15010014. [PMID: 35056069 PMCID: PMC8777992 DOI: 10.3390/ph15010014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 12/13/2022] Open
Abstract
Infective endocarditis (IE) is a life-threatening disease with stable prevalence despite prophylactic, diagnostic, and therapeutic advances. In parallel to the growing number of cardiac devices implanted, the number of patients developing IE on prosthetic valves and cardiac implanted electronic device (CIED) is increasing at a rapid pace. The diagnosis of IE is particularly challenging, and currently relies on the Duke-Li modified classification, which include clinical, microbiological, and imaging criteria. While echocardiography remains the first line imaging technique, especially in native valve endocarditis, the incremental value of two nuclear imaging techniques, 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG-PET/CT) and white blood cells single photon emission tomography with computed tomography (WBC-SPECT), has emerged for the management of prosthetic valve and CIED IE. In this review, we will summarize the procedures for image acquisition, discuss the role of 18F-FDG-PET/CT and WBC-SPECT imaging in different clinical situations of IE, and review the respective diagnostic performance of these nuclear imaging techniques and their integration into the diagnostic algorithm for patients with a suspicion of IE.
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Affiliation(s)
- Nidaa Mikail
- Department of Nuclear Medicine, Beaujon University Hospital, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du Général Leclerc, 92110 Clichy, France;
- Department of Nuclear Medicine, University Hospital Zurich, Rämistrasse 100, CH-8006 Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Wagistrasse 12, CH-8952 Schlieren, Switzerland
| | - Fabien Hyafil
- Department of Nuclear Medicine, Georges-Pompidou European Hospital, DMU IMAGINA, Assistance Publique-Hôpitaux de Paris, University of Paris, 20 Rue Leblanc, 75015 Paris, France
- Correspondence: ; Tel.: +33-01-56-09-56-24
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13
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Scholtens AM, Verberne HJ. FDG uptake in marrow and spleen: What does it mean? : Importance of clinical context in the interpretation of FDG uptake in marrow and spleen in infective endocarditis. J Nucl Cardiol 2021; 28:2543-2544. [PMID: 32170645 DOI: 10.1007/s12350-020-02095-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Asbjørn M Scholtens
- Department of Nuclear Medicine, Meander Medical Center, Amersfoort, The Netherlands.
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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14
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Husmann L, Huellner MW, Gruenig H, Eberhard N, Mestres CA, Rancic Z, Hasse B. Impact of PET/CT among patients with suspected mycotic aortic aneurysms. PLoS One 2021; 16:e0258702. [PMID: 34665830 PMCID: PMC8525767 DOI: 10.1371/journal.pone.0258702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/02/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose To determine the impact of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) on clinical management in patients with suspected mycotic aortic aneurysms (MAA). Materials and methods For this observational cohort study 101 PET/CT were acquired in 50 patients, thereof 50 for the initial diagnosis/baseline scan, 51 for follow-up. Impact on patient management was defined in three categories: PET/CT results were “confirmed” (by clinical follow-up), “suspected” (conclusive, not confirmed), or “misleading” (proven wrong by follow-up). For clinical follow-up patient data were recorded at the time of imaging, and at the latest recorded clinical visit. It included patient demographics, clinical information, laboratory data, results of microbiology and other diagnostic procedures, information about treatment, and patient’s general health condition. Results In four patients (8%) no clinical follow-up was feasible, the other 46 patients were clinically followed for a median of 898 days (IQR 320–4105). The combined evaluation of all 101 PET/CT demonstrated an impact on patient management in 78,5% of cases (48,5% confirmed, 30% suspected). Results of 21,5% of the PET/CT examinations were misleading. Respective values at baseline and at follow-up were: impact on patient management in 82% and 74,5% (70% and 27.5% confirmed, and 12% and 47% suspected), misleading cases in 18% and 25.5%. Conclusion In MAA, PET/CT has a high impact on patient management, which is more pronounced with baseline than with follow-up examinations. However, PET/CT results may be misleading in a smaller proportion of cases.
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Affiliation(s)
- Lars Husmann
- Department of Nuclear Medicine, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Martin W. Huellner
- Department of Nuclear Medicine, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Hannes Gruenig
- Department of Nuclear Medicine, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Nadia Eberhard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Carlos A. Mestres
- Clinic for Cardiac Surgery, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Zoran Rancic
- Clinic for Vascular Surgery, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Barbara Hasse
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
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15
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Impact of unknown incidental findings in PET/CT examinations of patients with proven or suspected vascular graft or endograft infections. Sci Rep 2021; 11:13747. [PMID: 34215835 PMCID: PMC8253756 DOI: 10.1038/s41598-021-93331-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022] Open
Abstract
Vascular graft or endograft Infections (VGEI) are rare but severe complications of vascular reconstructive surgery, and associated with significant mortality and morbidity risk. Positron emission tomography/computed tomography with 18F-fluorodeoxyglucose (PET/CT) has been shown to have a high diagnostic accuracy in the detection of VGEI. In this single-center prospective cohort study, we assessed the rate and the impact on patient management of relevant unknown incidental findings in PET/CT of patients with proven or suspected VGEI, and clinical follow-up of all patients was performed. Our study results show a comparably high rate of relevant unknown incidental findings (181 in 502 examinations), with documented direct impact on patient management in 80 of 181 (44%) of all findings. PET/CT scan- and patient-based evaluation revealed impact on patient management in 76 of 502 (17%) of all PET/CT scans, and in 59 of 162 (36%) of all patients, respectively. Furthermore, PET/CT correctly identified the final diagnosis in 20 of 36 (56%) patients without VGEI. In conclusion, in proven and suspected VGEI, PET/CT detects a high rate of relevant unknown incidental findings with high impact on patient management.
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16
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Kong E. F-18 fluorodeoxyglucose positron emission tomography/computed tomography in the infection of heart. Yeungnam Univ J Med 2020; 38:95-106. [PMID: 33053614 PMCID: PMC8016625 DOI: 10.12701/yujm.2020.00479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/10/2020] [Indexed: 02/05/2023] Open
Abstract
Infections involving the heart are becoming increasingly common, and a timely diagnosis of utmost importance, despite its challenges. F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a recently introduced diagnostic tool in cardiology. This review focuses on the current evidence for the use of FDG PET/CT in the diagnosis of infective endocarditis, cardiac implantable device infection, left ventricular assist device infection, and secondary complications. The author discusses considerations when using FDG PET/CT in routine clinical practice, patient preparation for reducing physiologic myocardial uptake, acquisition of images, and interpretation of PET/CT findings. This review also functions to highlight the need for a standardized acquisition protocol.
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Affiliation(s)
- Eunjung Kong
- Department of Nuclear Medicine, Yeungnam University College of Medicine, Daegu, Korea
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17
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Millar BC, de Camargo RA, Alavi A, Moore JE. PET/Computed Tomography Evaluation of Infection of the Heart. PET Clin 2019; 14:251-269. [PMID: 30826023 DOI: 10.1016/j.cpet.2018.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The 2015 European Society of Cardiology guidelines for the management of infective endocarditis included 18F-fluorodeoxyglucose (18F-FDG) PET/computed tomography (CT) in the diagnostic work-up of prosthetic valve endocarditis. This article examines the literature from the last 3 years to highlight the additional role 18F-FDG-PET/CT can contribute to an accurate diagnosis of cardiac infections and associated infectious complications. The challenges and pitfalls associated with 18F-FDG-PET/CT in such clinical settings must be recognized and these are discussed along with the suggested protocols that may be incorporated in an attempt to address these issues.
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Affiliation(s)
- Beverley Cherie Millar
- Northern Ireland Public Health Laboratory, Department of Bacteriology, Corry Building, Belfast City Hospital, Lisburn Road, Belfast, Co. Antrim BT9 7AD, Northern Ireland, UK.
| | - Raphael Abegão de Camargo
- Nuclear Medicine and Infectious Diseases, University of Sao Paulo Medical School (FMUSP), Sao Paulo, Sao Paulo, Brazil; Hospital Aristides Maltez, Avenida Dom João VI, n° 332, Serviço de Medicina Nuclear, 2° subssolo, Brotas, CEP: 40285-001, Salvador-BA, Brazil
| | - Abass Alavi
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, 110 Donner Building, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - John Edmund Moore
- Northern Ireland Public Health Laboratory, Department of Bacteriology, Corry Building, Belfast City Hospital, Lisburn Road, Belfast, Co. Antrim BT9 7AD, Northern Ireland, UK
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