Identification of genomic regions associated with resistance to gastrointestinal parasites in an indigenous sheep by single- and multiple-locus methods

We investigated the association between 157 SNPs located in 75 candidate genes involved in the immune system and proxy traits for resistance to gastrointestinal nematodes in sheep. A total of 211 lambs from eight flocks were sampled. Nematode eggs per gram were counted and classified as: (i) Strongyles, (ii) Nematodirus spp., (iii) Trichuris spp. and (iv) Marshallagia marshalli. Single- and multiple-locus models were used to test the marker-trait associations. Seven significant SNPs were identified on chromosomes OAR6, 15, 16, and 19. These findings provide insights for breeding nemarode-resistant traits in low-input production systems. General linear model, fixed and random model circulating probability unification, and Bayesian-information and linkage-disequilibrium iteratively nested keyway analyses identified a significant association between the eggs per gram of Strongyles nematodes and a specific variant of the PRLR gene.

18F-Fluoroethyl-L Tyrosine Positron Emission Tomography Radiomics in the Differentiation of Treatment-Related Changes from Disease Progression in Patients with Glioblastoma

The follow-up of glioma patients after therapeutic intervention remains a challenging topic, as therapy-related changes can emulate true progression in contrast-enhanced magnetic resonance imaging. 18F-fluoroethyl-tyrosine (18F-FET) is a radiopharmaceutical that accumulates in glioma cells due to an increased expression of L-amino acid transporters and, contrary to gadolinium, does not depend on blood-brain barrier disruption to reach tumoral cells. It has demonstrated a high diagnostic value in the differentiation of tumoral viability and pseudoprogression or any other therapy-related changes, especially when combining traditional visual analysis with modern radiomics. In this review, we aim to cover the potential role of 18F-FET positron emission tomography in everyday clinical practice when applied to the follow-up of patients after the first therapeutical intervention, early response evaluation, and the differential diagnosis between therapy-related changes and progression.

Multiparametric Analysis Combining DSC-MR Perfusion and [18F]FET-PET is Superior to a Single Parameter Approach for Differentiation of Progressive Glioma from Radiation Necrosis

PURPOSE

Perfusion-weighted (PWI) magnetic resonance imaging (MRI) and O‑(2-[18F]fluoroethyl-)-l-tyrosine ([18F]FET) positron emission tomography (PET) are both useful for discrimination of progressive disease (PD) from radiation necrosis (RN) in patients with gliomas. Previous literature showed that the combined use of FET-PET and MRI-PWI is advantageous; hhowever the increased diagnostic performances were only modest compared to the use of a single modality. Hence, the goal of this study was to further explore the benefit of combining MRI-PWI and [18F]FET-PET for differentiation of PD from RN. Secondarily, we evaluated the usefulness of cerebral blood flow (CBF), mean transit time (MTT) and time to peak (TTP) as previous studies mainly examined cerebral blood volume (CBV).

METHODS

In this single center study, we retrospectively identified patients with WHO grades II-IV gliomas with suspected tumor recurrence, presenting with ambiguous findings on structural MRI. For differentiation of PD from RN we used both MRI-PWI and [18F]FET-PET. Dynamic susceptibility contrast MRI-PWI provided normalized parameters derived from perfusion maps (r(relative)CBV, rCBF, rMTT, rTTP). Static [18F]FET-PET parameters including mean and maximum tumor to brain ratios (TBRmean, TBRmax) were calculated. Based on histopathology and radioclinical follow-up we diagnosed PD in 27 and RN in 10 cases. Using the receiver operating characteristic (ROC) analysis, area under the curve (AUC) values were calculated for single and multiparametric models. The performances of single and multiparametric approaches were assessed with analysis of variance and cross-validation.

RESULTS

After application of inclusion and exclusion criteria, we included 37 patients in this study. Regarding the in-sample based approach, in single parameter analysis rTBRmean (AUC = 0.91, p < 0.001), rTBRmax (AUC = 0.89, p < 0.001), rTTP (AUC = 0.87, p < 0.001) and rCBVmean (AUC = 0.84, p < 0.001) were efficacious for discrimination of PD from RN. The rCBFmean and rMTT did not reach statistical significance. A classification model consisting of TBRmean, rCBVmean and rTTP achieved an AUC of 0.98 (p < 0.001), outperforming the use of rTBRmean alone, which was the single parametric approach with the highest AUC. Analysis of variance confirmed the superiority of the multiparametric approach over the single parameter one (p = 0.002). While cross-validation attributed the highest AUC value to the model consisting of TBRmean and rCBVmean, it also suggested that the addition of rTTP resulted in the highest accuracy. Overall, multiparametric models performed better than single parameter ones.

CONCLUSION

A multiparametric MRI-PWI and [18F]FET-PET model consisting of TBRmean, rCBVmean and PWI rTTP significantly outperformed the use of rTBRmean alone, which was the best single parameter approach. Secondarily, we firstly report the potential usefulness of PWI rTTP for discrimination of PD from RN in patients with glioma; however, for validation of our findings the prospective studies with larger patient samples are necessary.

Hepatic brucellosis detected by 18F-FDG PET/CT

A 52-year old woman with fever of unknown origin underwent fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) scan for further evaluation. A clinical history of cervical cancer (CIS) operated 20 years ago was documented. Two foci in the right lobe of the slightly enlarged liver presented increased ¹⁸F-FDG uptake. Visceral brucellosis was diagnosed via blood culture. The patient received anti-brucella therapy and recovered rapidly, the liver lesions diminished on control CT.

Quantitative trunk sway analysis under challenging gait conditions in early and untreated Parkinson's disease

INTRODUCTION

Even experienced clinicians may encounter difficulties in making a definitive diagnosis in the early motor stages of Parkinson's disease (PD). We investigated whether quantitative biomechanical trunk sway analysis could support the diagnosis of PD early on.

METHODS

We quantified trunk sway performance using body-worn sensors during a test battery of six challenging gait conditions in a cohort of 17 early and untreated PD patients (with evidence of reduced tracer uptake in the basal ganglia on dopamine transporter scans) and 17 age- and sex-matched healthy controls (HCs).

RESULTS

Compared to HC, the PD group (Hoehn & Yahr ≤ 2, Unified Parkinson's Disease Rating Scale motor score: mean 13.7 ± 3.5 points) showed significant trunk rigidity in five challenging gait tasks (decreased medio-lateral direction and sway angle area). Post hoc receiver operating characteristic analysis of the significant parameters revealed excellent discrimination with high sensitivity and specificity.

CONCLUSION

In the early and untreated motor stages of PD, patients exhibit significant trunk rigidity during challenging gait tasks. Trunk sway motion recorded with body-worn sensors might be a useful tool to disclose a sometimes hard-to-trace cardinal motor sign of PD and support an early clinical diagnosis.

Vinorelbine in bladder-preserving multimodality treatment for muscle-invasive bladder cancer-a valid option for cisplatin-unfit patients?

Purpose

Treatment of muscle-invasive bladder cancer (MIBC) remains challenging, especially for elderly and/or comorbid patients. Patients who are unfit for or refuse surgery should receive bladder-preserving multimodality treatment (BPMT), consisting of transurethral resection of the bladder tumor (TURB) followed by combined chemoradiotherapy (CRT). We aimed to investigate the effectiveness of vinorelbine, a chemotherapeutic agent not routinely used for MIBC, in patients referred to CRT who are unfit for standard chemotherapy and would thus rely solely on radiotherapy (RT).

Methods

We retrospectively analyzed 52 consecutive patients with MIBC who received standard CRT with cisplatin (n = 14), CRT with vinorelbine (n = 26), or RT alone (n = 12). Primary endpoints were median overall survival (OS) and median cancer-specific survival (CSS). Secondary endpoints were median local control (LC), median distant control (DC), and OS, CSS, LC, and DC after 1, 2, and 3 years, respectively.

Results

Median OS and CSS were significantly higher for patients who received vinorelbine as compared to RT alone (OS 8 vs. 22 months, p = 0.003; CSS 11 months vs. not reached, p = 0.001). Median LC and DC did not differ significantly between groups. Vinorelbine was well tolerated with no reported side effects >grade II.

Conclusion

Our results suggest that CRT with vinorelbine is well tolerated and superior to RT alone in terms of OS and CSS. Therefore, this treatment regime might constitute a new treatment option for patients with MIBC who are unfit for or refuse surgery or standard chemotherapy. This study encourages a randomized controlled trial to compare this new regime to current standard therapies.

Visceral hepatic leishmaniasis in a melanoma patient in FDG-PET

BACKGROUND

Leishmaniasis is caused by protozoans that depend on female phlebotomine sandflies as vectors. The natural habitat of these sandflies is changing due to climate change. More patients will get immunocompromised due to cancer therapy.

CASE REPORT

We report the case of a 72-year-old patient with melanoma in whom we found visceral leishmaniasis mimicking hepatic metastasis in routine FDG-PET/CT. The patient was hospitalized due to fever and pancytopenia in the general hospital Steyr. The diagnosis was made by biopsy of the iliac crest with cytological study and polymerase chain reaction. After treatment with amphotericin B, the patient recovered, and tests became negative, including FDG-PET/CT. Because of climate change and the increasing use of immunomodulatory medication, our awareness of such findings should grow.

CONCLUSION

New pitfalls in diagnosis and surveillance of cancer patients because of altered environmental conditions and immunocompromised patients have to be considered.

Pembrolizumab-Induced Thyroiditis Shows PD-L1Expressing Histiocytes and Infiltrating T Cells in Thyroid Tissue - A Case Report

Context

Immune-related adverse events frequently take place after initiation of immune checkpoint inhibitors (ICI) therapy. The thyroid gland is the endocrine organ most commonly affected by ICI therapy, the pathological mechanism is still poorly understood.

Case Description

A 60-year old Upper Austrian male melanoma patient under pembrolizumab therapy received thyroidectomy because of a suspicious FDG avid thyroid nodule. Histopathology showed a pattern comparable with thyroiditis de Quervain. The inflammatory process consisted predominantly of T lymphocytes with a dominance of CD4+ T helper cells. In addition CD68+ histiocytes co-expressing PD-L1 were observed.

Conclusion

Clusters of perifollicular histiocytes expressing PD-L1 were observed in this case of pembrolizumab induced thyroiditis - probably induced by the former ICI therapy. This finding might indicate the initial target for the breakdown of self tolerance. In context with other data the immunological process seems to be driven by CD3+ lymphocytes infiltrating the thyroid.

Somatostatin Receptor Subtype Expression in Patients with Acromegaly and Complicated Clinical Course

Somatostatin analogues are considered to be the first line of treatment in acromegaly. Somatostatin analogues of the first generation mainly target the somatostatin receptor (SSTR) subtype 2 and have been proven efficient in the majority of patients with acromegaly. Pasireotide was the first somatostatin analogue also substantially targeting the SSTR subtype 5. An efficient drug for Cushing’s disease tailored to suboptimal-responding patients with acromegaly then became available. We immunohistochemically investigated SSTR subtypes expression in pituitary adenomas from operated acromegaly patients with clinical relapse and a complicated clinical course. Patients received pasireotide in the course of their disease. The predictive value of SSTR subtypes immunhistochemical analysis for the therapeutic response is discussed.

Giant silent corticotrope pituitary adenoma in a patient with complicated clinical course

Not required for Clinical Vignette.

68Ga/64Cu PSMA Bio-Distribution in Prostate Cancer Patients: Potential Pitfalls for Different Tracers

BACKGROUND

68Ga-PSMA is a widely useful PET/CT tracer for prostate cancer imaging. Being a transmembrane protein acting as a glutamate carboxypeptidase enzyme, PSMA is highly expressed in prostate cancer cells. PSMA can also be labeled with 64Cu, offering a longer half-life and different resolution imaging. Several studies documented bio-distribution and pitfalls of 68Ga-PSMA as well as of 64Cu- PSMA. No data are reported on differences between these two variants of PSMA. Our aim was to evaluate physiological distribution of these two tracers and to analyze false positive cases.

METHODS

We examined tracer bio-distribution in prostate cancer patients with negative 68Ga-PSMA PET/CT (n=20) and negative 64Ga-PSMA PET/CT (n=10). A diagnostic pitfall for each tracer was documented.

RESULT

Bio-distribution of both tracers was similar, with some differences due to renal excretion of 68Ga- PSMA and biliary excretion of 64Cu-PSMA. 68Ga-PSMA uptake was observed in sarcoidosis while 64Cu- PSMA uptake was recorded in pneumonitis.

DISCUSSION

Both tracers may present similar bio-distribution in the human body, with similar uptake in exocrine glands and high intestinal uptake. Similarly to other tracers, false positive cases cannot be excluded in clinical practice.

CONCLUSION

The knowledge of difference in bio-distribution between two tracers may help in interpretation of PET data. Diagnostic pitfalls can be documented, due to the possibility of PSMA uptake in inflammation. Our results are preliminary to future studies comparing diagnostic accuracies of 68Ga-PSMA and 64Cu-PSMA.

A rare case of a 123I-MIBG SPECT/CT positive, but 68Ga-DOTA-TOC PET/CT negative pheochromocytoma of the bladder

Pheochromocytoma (PHEO) is rare and belongs to the group of neuroendocrine tumours (NETs). These tumours can be found anywhere from the neck to the pelvis associated with sympathetic ganglia. Morphological imaging, for example CT, provides excellent anatomical detail and high sensitivity but lacks specificity as difficulties may occur when distinguishing between tumours derived from the sympathetic nervous system and other tumour entities. In contrast to anatomical imaging, functional imaging (¹²³I-MIBG, ⁶⁸Ga-DOTA-TOC PET) provides high sensitivity and specificity in detecting NETs. Early detection of PHEO is crucial and has a major effect on treatment and prognosis. This case report describes the important role of anatomical and functional imaging in a patient with a neuroendocrine tumour of unusual origin.

Serotonin 1A receptor density measured by F18-Mefway PET/CT in mesiotemporal cortex and raphe does not discriminate therapeutic response in patients with major depressive episode

BACKGROUND

More than 50% of patients with major depressive episode (MDE) fail to respond to initial treatment with first line pharmacological therapy. Altered receptor and serotonin transporter function are considered to be associated with mental disorders. Our investigation aimed on the density of the HT1A receptor in mesiotemporal cortex (MTC) and raphe measured by F18-Mefway in patients with MDD.

METHODS

Patients with untreated clinically suspected major depressive episode were recruited from June 2012 to May 2014. 49 patients were included into the study: 36 patients (73%) were identified as responders, whereas 13 (27%) were non-responders. Gender distribution was 26 men (56%) and 23 women (44%). For treatment, only a standard medication of a selective serotonin reuptake inhibitor (SSRI) with escitalopram in a range of 10-20 mg/day was permitted. Responders were defined by improvement of the MADRS>50%. Visually MTC had the highest uptake of F18-Mefway among all brain regions, an asymmetry could not be observed in any patient. An elliptical region was drawn over the amygdala and hippocampus area and a small circular region was drawn over the raphe nuclei. All data were calculated related to (unspecific) cerebellar uptake.

RESULTS

The quotient of the right MTC was 5.00 [4.33; 5.50] in all patients, in responders 5.00 [4.00; 5.75] and in non-responders 5.00 [4.50; 5.50] (P=0.56). The quotient of the left MTC presented with a median level of 4.50 [4.50; 5.50] in all persons. The responders had 4.50 [4.50; 5.75] which was not statistically significant to the data of the non-responders with 5.00 [4.50; 5.50] at P=0.64. The raphe had a median quotient of 2.50 [2.00; 3.00] in all and the cohort of responders, whereas non-responders had 2.50 [2.00; 2.50] (P=0.61). Also the absolute values of SUV in the three brain regions were not statistically different between the cohorts. Additionally, we did not find any sex-related differences in our patient group.

CONCLUSIONS

Serotonin 1A receptor density can be assessed efficiently by F18-Mefway and PET-CT in patients with MDE. The method can be estimated as a possible tool for clinical and academic investigation, marked tracer uptake can constantly be observed at MTC and the raphe. Anyhow, under conditions of real life in patient care, it is not possible to distinguish patients with a good prognosis who will respond to standard SSRI therapy from non-responders who would benefit from a different therapeutic approach starting earlier.

A hybrid, low-cost tissue-like epidural needle insertion simulator

Epidural and spinal anesthesia are mostly performed "blind" without any medical imaging. Currently, training of these procedures is performed on human specimens, virtual reality systems, manikins and mostly in clinical practice supervised by a professional. In this study a novel hybrid, low-cost patient simulator for the training of needle insertion into the epidural space was designed. The patient phantom provides a realistic force feedback comparable with biological tissue and enables sensing of the needle tip position during insertion. A display delivers the trainee a real-time feedback of the needle tip position.

The insufficiency fracture of the sacrum

Aim: The insufficiency fracture of the sacrum is often radiographically occult. Bone scintigraphy is a method of reference for the diagnosis; the results have been analysed retrospectively. Methods: Bone scintigraphy was done on patients who, predominantly after minor trauma, suffered from lower back pciin and whose radiographic findings were negative. Results: During a 24 month period, a sacral insufficiency fracture was diagnosed in 102 patients. H-shaped hyperfixation of the tracer - described as typical - was present in only 19.6% of the cases. Tracer accumulation was found as follows: located uni/bilateral in the sacral wings (32.4%/6.9%), horizontal (27.4%) and half H-shaped (13.7%). In 85% of the cases there were further fractures with main localisations in the pubic bone, in the spine and the ribs. Conclusion: The insufficiency fracture of the sacrum as cause of lower back pain is not uncommon, especially in postmenopausal women with risk factors. Bone scintigraphy is not only an adequate procedure for the detection of often radio-graphically occult sacral fractures, but also an easy method to reveal the often concomitand fractures.

Clinical value of FDG Hybrid-PET in staging and restaging of malignant lymphoma – compared with conventional diagnostic methods

Aim of the present retrospective study was to validate the clinical value of F-18-FDG PET imaging in lymphoma patients with a dual head camera modified for coincidence detection. Staging before and after oncological treatment was compared with a conservative diagnostic approach. Methods: 48 patients (28 non-Hodgkin lymphoma, 20 Hodgkin’s disease) received FDG-Hybrid-PET scans. Pretherapeutic staging was realized in 28 patients, 9 of them had control studies after they had completed therapy. Totally 29 persons were examined for posttherapeutic restaging. Computed tomography imaging and lymph node sonography was performed in all cases. Results were validated by clinical follow-up, in three cases a récidivé was proven by biopsy. Results: CT and ultrasound detected 77 lesions in 28 patients compared with 100 visualized by PET, but this difference in pretherapeutic staging did not reach significance at p >0.05 by Fisher’s t-test. Hybrid-PET obtained a sensitivity of 93%, a specifity of 79%, a positive of 82% and a negative predictive value of 92% for detection of residual disease. The values for CT + US were 87%, 64%, 72% and 88% respectively. Conclusion: FDG Hybrid-PET is as or even more accurate than standard morphologic diagnostic methods for prestaging in malignant lymphoma. Additionally, there is a substancial benefit for therapy monitoring of residual disease using coincidence detection PET with a ¾-inch crystal gamma camera.

Instant tough bonding of hydrogels for soft machines and electronics

Introducing methods for instant tough bonding between hydrogels and antagonistic materials-from soft to hard-allows us to demonstrate elastic yet tough biomimetic devices and machines with a high level of complexity. Tough hydrogels strongly attach, within seconds, to plastics, elastomers, leather, bone, and metals, reaching unprecedented interfacial toughness exceeding 2000 J/m2. Healing of severed ionic hydrogel conductors becomes feasible and restores function instantly. Soft, transparent multilayered hybrids of elastomers and ionic hydrogels endure biaxial strain with more than 2000% increase in area, facilitating soft transducers, generators, and adaptive lenses. We demonstrate soft electronic devices, from stretchable batteries, self-powered compliant circuits, and autonomous electronic skin for triggered drug delivery. Our approach is applicable in rapid prototyping and in delicate environments inaccessible for extended curing and cross-linking.

10-year-outcomes after rituximab for myasthenia gravis: Efficacy, safety, costs of inhospital care, and impact on childbearing potential

Rituximab (RTX) has emerged as an attractive off-label treatment option for patients with myasthenia gravis (MG) refractory to other immune therapies. However, data on long-term outcome after RTX for MG are still scarce. Here we present the 10-year outcomes [median (range) 10.1 (6.7-11.2) years] with respect to efficacy, safety, costs of inhospital care, and impact on childbearing potential in all four MG patients treated by one of the authors with RTX. In all patients, RTX led to sustained clinical improvement and eventual tapering of other immune therapies. RTX was well tolerated, and complications were not observed. After the start of RTX, annual costs for hospital admissions were markedly reduced compared to costs in the year preceding RTX. Under close clinical observation, two patients had uncomplicated pregnancies giving birth to a healthy child. With regard to its efficacy, excellent tolerance, lack of complications, low frequency of repeat infusions and pending patent expiry in many countries, RTX appears to compare favourably with other immune therapies used for MG. Multicentre trials and registries are urgently needed to further address long-term safety issues and clarify the efficacy and role of RTX in managing MG.

(18)F-fluorodeoxyglucose and (18)F-flumazenil positron emission tomography in patients with refractory epilepsy

Background

Epilepsy is a neurological disorder characterized by epileptic seizures as a result of excessive neuronal activity in the brain. Approximately 65 million people worldwide suffer from epilepsy; 20–40% of them are refractory to medication therapy. Early detection of disease is crucial in the management of patients with epilepsy. Correct localization of the ictal onset zone is associated with a better surgical outcome. The modern non-invasive techniques used for structural-functional localization of the seizure focus includes electroencephalography (EEG) monitoring, magnetic resonance imaging (MRI), single photon emission tomography/computed tomography (SPECT/CT) and positron emission tomography/computed tomography (PET/CT). PET/CT can predict surgical outcome in patients with refractory epilepsy. The aim of the article is to review the current role of routinely used tracer 2-deoxy-2-[¹⁸F]fluoro-D-glucose (¹⁸F-FDG) as well as non routinely used ¹⁸F-Flumazenil (¹⁸F-FMZ) tracers PET/CT in patients with refractory epilepsy.

Conclusions

Functional information delivered by PET and the morphologic information delivered by CT or MRI are essential in presurgical evaluation of epilepsy. Nowadays ¹⁸F-FDG PET/CT is a routinely performed imaging modality in localization of the ictal onset zone in patients with refractory epilepsy who are unresponsive to medication therapy. Unfortunately, ¹⁸F-FDG is not an ideal PET tracer regarding the management of patients with epilepsy: areas of glucose hypometabolism do not correlate precisely with the proven degree of change within hippocampal sclerosis, as observed by histopathology or MRI. Benzodiazepine-receptor imaging is a promising alternative in nuclear medicine imaging of epileptogenic focus. The use of ¹¹C-FMZ in clinical practice has been limited by its short half-life and necessitating an on-site cyclotron for production. Therefore, ¹⁸F-FMZ might be established as one of the tracers of choice for patients with refractory epilepsy because of better sensitivity and anatomical resolution.

[Bevacizumab as first-line therapy in metastatic renal cell carcinoma: Progression-free survival for 3 years]

We report the case of a 72-year-old woman who was diagnosed in 2006 with renal cell cancer (RCC) and had undergone consecutive tumor nephrectomy (clear-cell RCC, Fuhrmann grade II, stage pT3a, R0). Over the years, the patient underwent several surgical and radiological interventions due to various metastatic lesions. This case report describes the 3-year progression-free survival in a patient who underwent first-line therapy with the monoclonal antibody bevacizumab. Except for hypertension, the patient does not suffer currently from any other side effects of bevacizumab therapy.

Hereditary neuropathy with liability to pressure palsies presenting with sciatic neuropathy

Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal-dominant disorder associated with recurrent mononeuropathies following compression or trivial trauma. Reports on sciatic neuropathy as the presenting manifestation of HNPP are very scarce. We report on a 21-year-old previously healthy man who was admitted with sensorimotor deficits in his left leg. He had no history of preceding transient episodes of weakness or sensory loss. Clinical and electrophysiological examinations were consistent with sciatic neuropathy. Cerebrospinal fluid investigation and MRI of the nerve roots, plexus, and sciatic nerve did not indicate the underlying aetiology. When extended electrophysiological tests revealed multiple subclinical compression neuropathies in the upper limbs, HNPP was contemplated and eventually confirmed by genetic testing.

Mononeuritis multiplex: association with infectious condition and familial background in a tropical environment: a case report

Mononeuritis multiplex is characterized by an asymmetric pattern with affection of the peripheral nervous system; this form of polyneuropathy is often seen in non-systemic vasculitis. We present a case of multiplex neuropathy in a patient with histologicaly verified Hailey-Hailey disease. With the exception of this comorbidity--in its characteristic form presenting additionally with a superinfected subdermal node--we did not find any other possible etiologic factor possibly causative of multiplex neuritis. The diagnosis was confirmed by electrophysiological testing. To our knowledge, this is the first case report indicating a possible relationship between Hailey-Hailey disease and multiplex neuritis. There exists only one related study in the literature, which was conducted in Columbia--our patient's home country. This study delineates a clinically similar dermal disease (pemphigus foliaceus) in patients from rural Colombia (El Bagre). The authors detected anti-neuronal antibodies which were interpreted to be responsible for the pathognomonic burning sensations.

Rare clinical findings in a patient with sporadic hemiplegic migraine: FDG-PET provides diminished brain metabolism at 10-year follow-up

BACKGROUND

Sporadic hemiplegic migraine (SHM) is defined as migraine attacks associated with some degree of motor weakness during the aura phase and where no first-degree relative has identical attacks. SHM has a wide inter- and intraindividual clinical spectrum and, in case of prolonged aura symptoms and disturbed consciousness, can mimic several other acute neurological diseases.

CASE

In 1996, during his wedding night, a 28-year-old man developed left face, arm and leg weakness, nausea and a throbbing headache. Neurological examination on presentation revealed stupor, fever, meningism and left hemiplegia. There were no abnormalities on emergency magnetic resonance. Lumbar puncture showed mild lymphocytic pleocytosis and slightly elevated protein. He received symptomatic treatment. Subsequent genetic analysis revealed the T666M mutation in the CACNA1A gene of chromosome 19. He was diagnosed with SHM. In 2005, at the end of another episode of hemiplegic migraine (HM), he for the first time developed an episode of paranoid psychosis with anxiety and visual hallucinations. The psychiatric symptoms resolved within a week.

DISCUSSION

All perfusion SPECT and transcranial Doppler studies performed in the first days of HM attacks were consistent with hyperemia of the hemisphere contralateral to the neurological signs. FDG-PET/CT in January 2013 revealed a diffusely reduced glucose metabolism of the supratentorial cortex and marked asymmetric hypometabolism of the left cerebellum. The finding of progressive cortical metabolic dysfunction over years appears as a new finding. Glucose hypometabolism may indicate primary neuronal dysfunction as the cause of the prolonged deficits.

Pitfall in follow-up imaging of pancreatic neuroendocrine tumor by somatostatin receptor PET

56-year old woman was operated of a pancreatic NET in May 2011. Abdominal pain had led to imaging and consecutively the finding of cholecystolithiasis and the tumor. The gall bladder, left hemi-pancreas, regional lymph nodes and the (unintentional injured) spleen were resected. At routine control examination in October 2012 CT presented three contract enhancing intra-abdominal lesions with a diameter of 2-3.5 cm. Consecutively 68Ga-DOTA-NOC PET-CT showed high tracer uptake (SUV 10-12) at these lesions. Therefore a relapse of the neuro-endocrine tumor was suspected. After reoperation in December 2012 histology did not reveal any sign of neuroendocrine tumor but identified spleen tissue most probably caused by splenosis accidentally seeded at the first operation. Physiologically the spleen is highly avid at 68Ga-DOTATOC PET, but splenosis presents with less standard uptake value. In our case the described lesions presented with an SUV quite comparable to that of neuroendocrine tumor tissue.

[A biomechanical analysis of cyclical hand motor function: a pilot study in different Parkinsonian syndromes]

INTRODUCTION

Clinical assessment of hand bradykinesia in Parkinson's disease (PD) focuses mainly on the frequency, amplitude and rhythm of movements, thereby subjectively evaluating the correct performance of hand movements. The aim of the study was to quantify hand bradykinesia with kinematic data in different Parkinsonian syndromes.

PATIENTS AND METHODS

This retrospective study compared patients with idiopathic PD (IPD, n = 18), atypical Parkinson's syndrome (APS, n = 17), secondary Parkinson's syndrome (SPS, n = 18) and healthy controls (C, n = 18). All patients were receiving the best medical treatment. Hand movements were recorded using an ultrasound-system (Zebris®, Isny, Germany). Subjects were asked to perform pronation/supination of the forearm (diadochokinesis), flexion/extension of the hand (hand tapping) and tapping of the index finger. Mean amplitude, mean frequency and mean variability of movements were determined.

RESULTS

APS patients had significant complex hand movement disability with reduced amplitude and frequency in combination with increased motion variability in all movement tasks. The key disturbance in the IPD group concerned the rhythm in hand tapping and index finger tapping in combination with moderately reduced velocity and range of motion in all conditions. The cyclical hand movement characteristics in SPS patients showed movement slowness with normal amplitude and variability in all motor conditions.

CONCLUSION

Our results suggest that computerized quantitative analysis of cyclical hand movements can characterize and identify different representations of hand bradykinesia in different Parkinsonian disorders and hence may help clinicians to accurately assess therapeutic targets and outcome of interventions.

Serum leptin is correlated to high turnover in osteoporosis

OBJECTIVE

Clinical data have suggested that obesity protects against osteoporosis. Leptin, mainly secreted by white adipose tissue, might be involved by mediating an effect on bone metabolism. This study was conducted to investigate a possible relationship of leptin and bone turn-over in postmenopausal women with osteoporosis.

METHODS

We measured bone mineral density (BMD), serum leptin levels and markers of bone metabolism, including osteocalcin and cross-laps in 44 patients with osteoporosis. The main group consisted of 32 postmenopausal women.

RESULTS

Mean serum leptin was 13.1 microg/L and showed no statistically significant difference to the levels measured in a collective of normal persons adjusted for age and BMI. When related to serum cross-laps as markers of bone resorption, a positive correlation (p<0.05) was observed, whereas no correlation with osteocalcin could be seen.

CONCLUSIONS

A dual control of bone formation by leptin is assumed: This involves local mechanisms acting on osteoblasts and a central inhibitory effect on bone metabolism via a hypothalamic relay. Our data indicate that the net effect of circulating leptin may cause bone loss and is significantly related to high-turnover serum bone markers, at least in postmenopausal women with osteoporosis.

[SPECT and FDG-PET in diagnostics of neurolues]

Syphilis is a recurrent treponematosis of acute and chronic evolution. In general it is either sexually or congenitally transmitted. Primary syphilis appears as a single and painless lesion. Secondary syphilis may manifest years later, the secondary bacteremic stage is accompanied by generalized mucocutaneous lesions. Tertiary disease can be disseminated to bones and virtually any organ, involving principally the ascending aorta and the central nervous system. Nuclear medicine provides diagnostic methods in case of skeletal manifestations by bone scan - identifying periostitis and osteomyelitis. Hepatic gummas can be imaged by 99m-Tc-colloid liver scintigraphy. In neurosyphilis brain perfusion SPECT enables imaging of cerebral involvement by small vessel endarteritis resulting from syphilitic vascular disease. 18-FDG PET is also useful to evaluate neurosyphilis, a reduction of brain glucose consumption is observed. The technique adequately enables imaging of therapeutic response and might be superior to morphologic imaging. We present our experiences with these nuclear medicine methods in patients with neurolues. The incidence of neurolues is estimated at 2 per 100.000 inhabitants worldwide, migration processes might bring a re-emergence of this disease to Austria and other developed countries of the EU. Scintigraphic methods should be kept in mind for diagnostic evaluation of neurosyphilis.

Causes and Prognosis of Nontraumatic Acute Renal Failure Requiring Dialysis in Adult Patients with and without Diabetes

Despite advanced techniques of renal replacement therapy the overall mortality of patients with ARF is still high. The majority of patients with ARF requiring dialysis are those with nontraumatic ARF. In a retrospective study we compared the causes of nontraumatic ARF, the risk factors for the development of renal failure and the mortality rates in patients with and without diabetes mellitus who received dialysis therapy in the years 1991-2000. A total of 232 patients were included in the study, 34 (14.6%) of them with and 198 patients (85.4%) without diabetes. The predominant causes of nontraumatic ARF like congestive heart failure (26.4 vs. 13.6, p < 0.05) and hypotension/hypovolemia (20.6 vs. 7.6%, p < 0.05) occurred more frequently in diabetic patients. The prevalence of sepsis (8.8 vs. 10.1%, NS), malignancy/ hypercalcemia (5.8 vs. 11.6%, NS) and other causes of nontraumatic ARF were similar in both groups. The prevalence of hepato-renal syndrome (5.8 vs. 13.6%, p < 0.05) and acute kidney graft failure (2.9 vs. 15.1%, p < 0.05) was higher in the nondiabetic individuals. Patients with diabetes showed more often chronic predictors for the onset of ARF like pre-existing hypertension (93.6 vs. 51.0%, p < 0.05), congestive heart failure (44.1 vs. 14.6%, p < 0.005), pre-existing renal insufficiency (76.4 vs. 46.9%, p < 0.05) and ACE-inhibitor therapy (32.3 vs. 9.6%, p < 0.005). Additionally, the prevalence of multiple organ failure (MOF) as prognostic factor was significantly higher in the diabetic patients (47.0 vs. 21.7%, p < 0.05). The mean number of dialyses therapy was 4.7 vs. 4.5 per patient. The overall mortality was 41.1 vs. 44.% (NS). In conclusion, the prevalence of the most common causes of nontraumatic ARF was different between the patients with and without diabetes. The diabetic individuals had more frequently predictors for the onset of ARF. The overall mortality was approximately the same in both groups.

Multitracer study in Heidenhain variant of Creutzfeldt-Jakob disease: mismatch pattern of cerebral hypometabolism and perfusion imaging

Creutzfeldt-Jakob disease (CJD) is a subacute spongiform encephalopathy. This fatal prion disease is characterized by rapidly progressive dementia with a variety of neurological disorders. Diagnostic methods provided by nuclear medicine might be helpful for evaluation of patients with probable CJD as additional diagnostic tools to MRI and cerebro-spinal fluid evaluation. The experience with FDG-PET and brain perfusion SPECT is presented.

Somatostatin-receptor positive brain stem glioma visualized by octreoscan

In diffuse brainstem gliomas often surgical biopsies cannot be obtained. The diagnosis relies upon imaging criteria, first line being MRI. Gliomas generally express somatostatin receptors (SSTR), which might enable receptor imaging. We present the case of a female adolescent with acute onset of hallucinations, dysphagia and diplopia. MRI detected a suggestive large pontine glioma. This lesion presented with marked In-111-pentreotide tracer uptake. SSTR-scan provided information about SSTR-expression, tumour viability and extension. Radiopeptide therapy for selected patients might be discussed.

Hyperthyroidism affects arterial stiffness, plasma NT-pro-B-type natriuretic peptide levels, and subendocardial perfusion in patients with Graves' disease

BACKGROUND

Arterial stiffness is thought to play a critical role in the pathogenesis of cardiovascular events, and in hyperthyroidism increased cardiovascular event rates have been reported.

AIM

To investigate markers of systemic arterial stiffness, volume homeostasis, and subendocardial perfusion and its interrelationship in patients with Graves' disease (GD) in hyperthyroidism and euthyroidism.

METHOD

Aortic augmentation index (AIx@75) as a measure of systemic arterial stiffness and subendocardial viability ratio (SEVR) as a surrogate measure of subendocardial perfusion were assessed by applanation tonometry in 59 patients with GD in hyperthyroidism and euthyroidism, and measurements were compared to plasma levels of NT-pro-B-type natriuretic peptide (NT-ProBNP).

RESULTS

AIx@75 and NT-ProBNP levels were significantly increased in hyperthyroidism compared to euthyroidism and were positively correlated with each other. SEVR was significantly decreased in hyperthyroidism compared to euthyroidism, mainly due to increased heart rates as shown by the heart rate-corrected SEVR75.

CONCLUSIONS

In hyperthyroidism, patients with GD exhibited increased systemic arterial stiffness, paralleled by increased levels of NT-ProBNP, a marker of volume overload. The decreased subendocardial perfusion in hyperthyroidism seemed to be mainly due to increased heart rates. The observed unfavorable hemodynamic alterations in hyperthyroidism may serve to explain increased cardiovascular event rates in patients with GD.