Perivalvular abscess complicating infective endocarditis: complementary role of echocardiography and indium-111-labeled leukocytes.

A 49-year-old black man with hypertension-induced chronic renal failure requiring hemodialysis and a history of arteriovenous access graft infection was admitted with Staphylococcus aureus sepsis, dyspnea, and peri-incisional erythema over his arteriovenous graft fistula. Results of a transthoracic echo demonstrated aortic sclerosis and concentric left ventricular hypertrophy. Results of a whole-body In-111 white cell (WBC) scan were negative over the arteriovenous graft site; however, an intense abnormal focus of labeled WBCs was evident to the left of the sternum. A subsequent transesophageal echocardiogram showed a mixed cystic-solid calcified mass adjacent the left aortic cusp. Surgery confirmed a perivalvular abscess. As a whole-body imaging modality, the In-111 WBC scintigram indicated the true location of the infectious process responsible for the patient's sepsis. The combination of echocardiography and radiolabeled WBC imaging increases sensitivity for detection of endocarditis/perivalvular abscess. Radiolabeled WBC imaging is more efficacious for monitoring therapy because the echocardiogram often does not change with treatment of endocarditis/perivalvular abscess.

Histopathological, lymphoscintigraphical, and immunological changes in the inguinal lymph nodes of rhesus monkeys during the early course of infection with Brugia malayi.

The relationship of the early lymphatic pathophysiological alterations with those of tissue inflammatory and cellular responses in the inguinal lymph nodes of Brugia malayi-infected rhesus monkeys was examined. Each of five animals was inoculated subcutaneously in the right calf with 200 third stage larvae (L3) and 5 weeks later, before the onset of patency [10 to 12 weeks postinoculation (PI)], their right inguinal nodes began to show signs of enlargement, becoming most prominent between weeks 10 to 16 PI. Histopathologically, the right nodes had eosinophilic lymphadenitis, lymphoid hyperplasia, and pronounced germinal centers. Lymphoscintigraphy using 99mTc-antimony trisulfide colloid showed pathophysiological alterations of the lymph flow rate in the right leg but not in the left leg at weeks 7 and 15 PI. In vitro blastogenesis to B. malayi antigens at week 10 PI showed the inguinal lymph node cells proliferated more vigorously than did peripheral blood cells early in infection. However, at week 24 PI both lymph node and peripheral blood cells proliferated to antigens. Flow cytometry showed an upregulation of HLA-DR+ lymphocytes in right lymph node cells from infected animals when compared to those from control animals. No changes in CD2, CD4, CD8, CD20, CD29, and CD45R cell numbers in lymph node of infected animals were seen when compared to control animals. Our results show that lymphatic pathology occurs early before the onset of patency, correlating with a marked tissue inflammatory and cellular responses of lymph node cells in B. malayi-infected rhesus monkeys. The rhesus could be an extremely useful model for understanding the evolution of pathology and pathogenesis of the disease.

Spontaneous coronary artery spasm documented in a young woman. A case report.

A 35-year-old woman with coronary risk factors presented with nonexertional atypical burning chest pain of 1 week's duration. A myocardial perfusion study with Tc-99m MIBI revealed a severe stress induced anteroseptal perfusion defect that completely reperfused on a subsequent resting Tc-99m MIBI study. Coronary angiography showed mild nonobstructive coronary artery disease. At the termination of the procedure, a spontaneous episode of burning chest pain occurred. Left main coronary artery reinjection of contrast revealed proximal diffuse left anterior descending coronary artery spasm. The patient was followed for 2 years with no further episodes of chest pain, while on calcium channel-blocker medication. The phenomenon of vasospastic angina and the role of myocardial perfusion scintigraphy is discussed.

Hypothesis: dietary management may improve survival from nutritionally linked cancers based on analysis of representative cases.

A limited number of case histories was analyzed and verified to examine the effect of a very low fat, moderately high fiber, and moderately reduced calorie diet on the survival and quality of life of patients with primary cancer of the pancreas, metastatic stage D2 prostate cancer, and other nutritionally linked cancers. The retrospective study of pancreatic cancer patients disclosed that 1-year survival was higher among those who modified their diets than in those for whom there was no evidence as to diet alteration. For patients with metastatic prostate cancer (stage D2), a case control study demonstrated a statistical association of dietary modification with longer survival and improved quality of life. A retrospective study utilizing questionnaires supported such dietary modifications as a useful tool in the management of nutritionally linked cancers.

False-positive Tc-99m sestamibi SPECT in a patient with left bundle branch block.

A 37-year-old man with atypical chest pain and complete left bundle branch block showed a marked exercise induced septal defect on Tc-99m sestamibi stress testing. A repeat examination at rest the next day revealed complete reversal of the previous septal defect. Coronary angiography two days later showed a normal coronary artery system. Left bundle branch block has been associated with false-positive results of exercise (and more recently, dipyridamole) TI-201 examinations for septal ischemia. The case presented here may be the first reported example of a false positive Tc-99m sestamibi examination for septal ischemia in the presence of left bundle block.

Concordant uptake of Tc-99m sestamibi and Tl-201 in unsuspected breast tumor.

An unsuspected breast tumor was discovered in a 65-year-old woman referred for evaluation of possible ischemic heart disease. Marked tumor uptake of Tl-201 and concordant but less intense uptake of Tc-99m sestamibi (Tc-99m MIBI) was observed after both planar and SPECT imaging post treadmill exercise. Although many reports in the literature document Tl-201 tumor uptake, this is much less frequently reported with Tc-99m MIBI at this time. To the authors' knowledge, Tc-99m MIBI breast tumor uptake has not been reported to date. Tc-99m MIBI might prove useful in the detection of primary and metastatic breast carcinoma, and warrants further investigation.

Extracorporeal shock-wave lithotripsy and ursodiol versus ursodiol alone in the treatment of gallstones.

The efficacy and occurrence of adverse effects after two forms of treatment were compared in 111 patients with biliary colic and radiolucent gallstones in this prospective, nonrandomized study. Fifty-four patients received extracorporeal shock-wave lithotripsy (ESL) plus ursodiol, and 57 patients received ursodiol alone. Among patients with a single stone (5-20 mm in size), no patient treated with ursodiol alone had a stone-free gallbladder at 6 or 12 months after treatment; of those treated with ESL plus ursodiol, 15 of 24 patients (63%) had a stone-free gallbladder at 6 months and 17 of 20 patients (85%) at 12 months. For patients with multiple stones (with an aggregate diameter of less than or equal to 30 mm), the incidence of a stone-free gallbladder was 2 of 43 patients (5%) at 6 months and 8 of 35 patients (23%) at 12 months in the ursodiol treatment group. In the ESL plus ursodiol group, the incidence of a stone-free gallbladder was 7 of 22 patients (32%) at 6 months and 9 of 20 patients (45%) at 12 months. Two patients in the ESL plus ursodiol group (4%) and 13 patients in the ursodiol group (24%) underwent cholecystectomy. Both patients in the ESL plus ursodiol therapy and 4 patients in the ursodiol group had emergency cholecystectomies because of acute cholecystitis. The remaining 9 patients in the ursodiol group had elective cholecystectomies. In this nonrandomized, prospective study, ESL plus ursodiol treatment produced stone-free gallbladders at a faster rate than ursodiol alone in patients with either single or multiple gallstones.

Pheochromocytoma: diagnosis by scintigraphy using iodine 131 metaiodobenzylguanidine.

We summarize our experience using iodine 131 metaiodobenzylguanidine (131I MIBG) imaging in 24 patients with suspected pheochromocytoma and compare 131I MIBG imaging with other imaging modalities such as computerized tomography and magnetic resonance imaging. Our results confirm the high sensitivity and excellent specificity reported from other centers experienced in 131I MIBG imaging. This radiopharmaceutical permits noninvasive, safe, accurate detection of pheochromocytomas of all types. Iodine 131 MIBG scintigraphy is especially efficacious in the detection of extra-adrenal, recurrent, and metastatic tumors. We review precautions in the screening of patients for 131I MIBG examination, imaging techniques, and drugs that interfere with tumor uptake of 131I MIBG. Though 131I MIBG imaging has some limitations, it deserves strong consideration whenever the diagnosis of pheochromocytoma is suspected.

Pheochromocytoma associated with prior carotid body tumors (chemodectomas). Detection with I-131 MIBG.

Chemodectomas (carotid body tumors) were surgically removed on two occasions, first 10 years and then 3 months prior to detection with I-131 MIBG of an adrenal pheochromocytoma in a 32-year-old man with a family history of chemodectoma. Recent reports suggest patients with multiple and/or familial instances of chemodectoma frequently have associated catecholamine-secreting tumors detectable with I-131 or I-123 MIBG. This case documents the above association and suggests that any patient with proven carotid body tumor(s) be screened for catecholamine-secreting tumors via urinary/plasma catecholamine determinations.

Incidental detection of hyperthyroidism during a perfusion lung scan for suspected pulmonary emboli.

Striking thyroidal uptake of Tc-99m pertechnetate was observed during the course of a perfusion lung scan performed with Tc-99m MAA to rule out pulmonary embolism in a 49-year-old man. There was no evidence of gastric pertechnetate activity. Radiochemical purity analysis of the Tc-MAA by chromatography in normal saline revealed 98.8% tagging, with 1.2% free pertechnetate. We estimate that a maximum of 60 microCi (2.2 MBq) of pertechnetate was available for thyroid trapping. This amount, given to a euthyroid volunteer studied with conventional gamma camera lung perfusion settings, failed to visualize the thyroid. A follow-up radioiodine thyroid uptake of the patient was markedly elevated, as was his thyroid function tests (T3,T7,T7). When diffuse intense thyroid gland radioactivity is seen during scintigraphy with a technetium radiopharmaceutical (e.g., bone and lung scans), consideration should be given to the possibility of hyperthyroidism. If gastric activity is not concomitantly seen, hyperthyroidism secondary to diffuse hyperplasia of the gland is probably present.

A model of Staphylococcus aureus bacteremia, septic arthritis, and osteomyelitis in chickens.

We studied the occurrence, magnitude, and kinetics of bacteremia and the resultant osteomyelitis and septic arthritis in an avian model of Staphylococcus aureus infection. Thirty-day-old male broiler chicks were inoculated i.v. with 10(5), 10(6), or 10(7) cfu of strain Duntravis, a beta-hemolytic, coagulase-producing, capsular type 8 isolate from the synovial fluid of a 2-year-old black boy. Bacteremia occurred in 80%, 90%, and 100% of animals inoculated with 10(5), 10(6), or 10(7) cfu, respectively. The magnitude of bacteremia in surviving, bacteremic animals increased for 96 hours after inoculation and then decreased after a plateau phase. Osteomyelitis and septic arthritis occurred only in chicks that were continuously bacteremic. The occurrence of osteomyelitis was uniform among continuously bacteremic animals and developed 1 to 23 hours after inoculation. Chickens are susceptible to systemic infections with S. aureus. Bacteremia, osteomyelitis, and septic arthritis may be induced in healthy chickens without prior manipulations that depress their resistance.

Pectoralis muscle uptake of thallium-201 after arm exercise ergometry. Possible confusion with lung thallium-201 activity.

Pectoralis muscle uptake of thallium-201 was noted in 8 (73%) out of 11 patients after exercise arm ergometry. Uptake varied from mild to marked and potentially could be confused with pulmonary Tl-201 activity with a resulting false-positive diagnosis of exercise-induced left ventricular dysfunction. The three patients exhibiting negative or trace Tl-201 uptake had suboptimal exercise efforts. The characteristics of pectoralis muscle Tl-201 uptake are illustrated, and differentiation from true lung Tl-201 activity is discussed.

Bone and liver imaging in regionally advanced melanoma.

The clinical records of 94 patients with regionally advanced melanoma (nodal disease or regional satellites) were reviewed to determine the value of preoperative bone and liver imaging. Of 68 bone scans obtained, none were suggestive of metastases. of 97 liver imaging studies (computed tomography, scintiscan, or sonography) in 88 patients, only two were found to have demonstrable metastases. Liver enzyme elevation was present in both of these patients. Bone and liver imaging in the absence of signs or symptoms of dissemination by history, physical examination, chest x-ray, and enzyme determination for regionally advanced melanoma appears to be of little value unless the patient is involved in a protocol study.