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Positron emission tomography for the diagnosis of prosthetic heart valve endocarditis

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 52yearold woman diagnosed with Marfan syndrome had undergone surgeries for the correction of the aorta; Bentall procedure (32 years ago) and a thoracoabdominal aortic replacement (3 years ago). The patient was referred to the hospital with a history of prolonged fever (>40 days). On admission, she had a fever of 39.9°C without any particular manifestations. Laboratory tests revealed leucocytosis (10 .2×10/L) and elevated C reactive protein (12.1 mg/dL), and methicillinresistant Staphylococcus epidermidis was cultured from the blood. A total body CT scan without ECG synchronisation was inconclusive for the origin of fever and cardiac vegetation was not detected on the transthoracic echocardiogram. However, positron emission tomographyCT (PETCT) revealed abnormal fluorodeoxyglucose uptake around the replaced aortic valve (figure 1), highly suggesting prosthetic valve endocarditis (PVE). She underwent an emergency valve replacement surgery with the isolation of the bloodborne pathogen from the resected valve. Following the surgery, the patient was administered prolonged antibiotic therapy and discharged in a state of recovery. Infective endocarditis (IE) can be fatal, which can occur with nonspecific symptoms, such as fever alone. Although the standard for the diagnosis of IE is the modified Duke criteria, it has poor diagnostic accuracy and lower sensitivity of approximately 70% in cases of PVE than in native valve endocarditis, making it challenging to diagnose the case as presented. PETCT, which can identify inflammatory and infectious processes with a high accuracy, is recently reported to be effective in the diagnosis PVE as well; it elevates the diagnostic sensitivity up to 97% in combination with the Duke criteria. Other metaanalysis or editorial comments by specialists in nuclear medicine indicated the utility of PETCT to uncover undiagnosed PVE cases. 4 European Society of Cardiology guideline also included PETCT as one of the diagnostic methods. It is, however, necessary to be careful about false positive findings on PETCT due to surgical adhesives used in past cardiac surgeries. The present case highlighted that IE should be considered in patients with prolonged fever, for which PETCT is a useful tool for diagnosis, especially among those after prosthetic heart valve replacement.