Pattern of Bone Marrow Hypometabolism on 18 F-FDG PET CT in Systemic Lupus Erythematous-Associated Aplastic Anemia.

ABSTRACT: We present the case of a 23-year-old woman with juvenile onset systemic lupus erythematous on a background of thrombotic thrombocytopenic purpura, who was referred for 18 F-FDG PET CT scan due to pyrexia of unknown origin with raised inflammatory markers, severe thrombocytopenia, and anemia. An interesting pattern of predominantly photopenic hypometabolic bone marrow activity was demonstrated on 18 F-FDG PET CT.

68 Ga-PSMA-Avid Intranasal Solitary Fibrous Tumor.

ABSTRACT: The utility of molecular imaging in solitary fibrous tumors has not been fully established. We present a rare case of recurrent intranasal solitary fibrous tumor incidentally localized on 68 Ga-PSMA PET/CT scan, which turned out to be metabolically inactive on 18 F-FDG PET/CT.

Alleviation of cadmium toxicity in Zea mays L. through up-regulation of growth, antioxidant defense system and organic osmolytes under calcium supplementation.

Calcium (Ca) is a macronutrient and works as a modulator to mitigate oxidative stress induced by heavy metals. In this study, we investigated the role of Ca to ameliorate the Cd toxicity in Zea mays L. by modulating the growth, physio-biochemical traits, and cellular antioxidant defense system. Maize genotype Sahiwal-2002 was grown under a controlled glasshouse environment with a day/night temperature of 24 ± 4°C/14 ± 2°C in a complete randomized design with three replications and two Cd levels as (0 and 150 µM) and six regimes of Ca (0, 0.5, 1, 2.5, 5, and 10 mM). Maize seedlings exposed to Cd at 150 µM concentration showed a notable decrease in growth, biomass, anthocyanins, chlorophylls, and antioxidant enzymes activities. A higher level of Cd (150 µM) also caused an upsurge in oxidative damage observed as higher electrolyte leakage (increased membrane permeability), H2O2 production, and MDA accumulation. Supplementation of Ca notably improved growth traits, photosynthetic pigments, cellular antioxidants (APX, POD, and ascorbic acid), anthocyanins, and levels of osmolytes. The significant improvement in the osmolytes (proteins and amino acids), and enzymatic antioxidative defense system enhanced the membrane stability and mitigated the damaging effects of Cd. The present results concluded that exogenously applied Ca potentially improve growth by regulating antioxidants and enabling maize plants to withstand the Cd toxicity.

Extraction and Optimization of Active Metabolites From Cluster Bean: An In Vitro Biological and Phytochemical Investigation.

The current study aimed to explore active metabolites of locally recognized and high yielding cultivar cluster bean (BR-99) with a wide range of adaptability having antioxidant, antidiabetic, antimicrobial, and cytotoxic potential. Six solvents were used (crude methanol, n-hexane, chloroform, ethyl acetate, butanol, and aqueous) with escalating polarity for colorimetric determination of antioxidants such as total phenolic contents (TPC), total flavonoid contents (TFC), and free radical scavenging activity (FRSA) by DPPH (2, 2-diphenyl-1-picrylhydrazyl) assay. Moreover, an antidiabetic and anticancer study was conducted by α-amylase inhibition and MTT (3-(4, 5-dimethyl-2-thiazolyl)-2, 5-diphenyl-tetrazolium bromide) assay. Biological investigations were carried out against the most commonly found infectious microbial strains. The significant results (P ≤ .001) of each activity were seen among six tested solvent extracts. The ethyl acetate and methanol extract have more antioxidant potential with the highest TPC (16.38 ± .13 mg GAE/g) and TFC (8.15 ± .24 mg CE/g), respectively. Similarly, methanol extract presented the highest free radical scavenging activity (46.31 ± .91%), followed by ethyl acetate, butanol, chloroform, aqueous, and n-hexane extract. However, the maximum α-amylase inhibition (62.54 ± 1.47%) and anticancer activity against human lung cancer cells were congregated (78.31 ± 1.46%) in butanol and chloroform, respectively. A positive correlation was seen between TPC with TFC (R 2= .8356), FRSA (R 2= .8381), and anti-diabetic activity (R 2= .8082), which highlights the phenolic contents as strong anti-oxidant agents especially flavonoids. Each extract of cluster bean (BR-99) showed significant antimicrobial activities for all tested bacterial strains except B. cereus and E. coli. The profound results of maximum antibacterial activity were witnessed by chloroform extract while ethyl acetate extracts showed great antifungal potential against all tested fungal strains. The HPLC quantitative analysis results of cluster bean (BR-99) revealed the presence of active phytochemicals such as gallic acid, HB acid, vanillic acid, kaempferol, sinapic acid, ferulic acid, salicylic acid, coumarins, quercetin, rutin, p-coumaric acid, and catechin, and the variation in both phytochemical and biological spectrums envisioned the cluster bean (BR-99) used in future as a cheap, safer, and potent source of bioactive drugs.

Computational study of therapeutic potential of phosphorene as a nano-carrier for drug delivery of nebivolol for the prohibition of cardiovascular diseases: a DFT study.

Density functional theory (DFT) calculations were utilized to assess the drug delivery efficiency of phosphorene carrier for nebivolol drug to treat cardiovascular diseases. The optimized structures, excited state, and electronic properties of nebivolol, phosphorene, and nebivolol-phosphorene (nebivolol-PH) complex were considered to determine the drug delivery ability of phosphorene at the target site. The increased dipole moment (6.08 D) results in the higher solubility of the complex in polar solvents (water). Weak interactive forces between nebivolol and phosphorene were demonstrated by the non-covalent interaction (NCI) plot that facilitated the offloading of nebivolol at the targeted area. The analysis of frontier molecular orbitals (FMOs) revealed that during excitation, the charge was transferred from nebivolol as a higher occupied molecular orbital (HOMO) to phosphorene as a lower unoccupied molecular orbital (LUMO). Thus, the charge-transfer process was further studied by charge decomposition analysis (CDA). The calculated results at the excited state for the nebivolol-PH complex exhibited that the maximum wavelength (λmax) was red-shifted by 6 nm in the gas phase. The electron-hole theory and photoinduced electron transfer (PET) processes were carried out for the exploration of different excited states of the complex. Additionally, phosphorene with + 1 and - 1 charge states indicated the minor structural changes and provide the stable nebivolol-PH complex. This theoretical study also investigated that phosphorene can be exploited as an effective carrier for the delivery of a therapeutic agent as nebivolol to treat cardiovascular diseases. This work will also encourage the researchers to investigate the other 2D nanoparticles as a nano-drug delivery system (NDDS).

Prevalence and associated risk factors among patients with overactive bladder syndrome in Pakistan.

OBJECTIVES: To determine the Prevalence and associated risk factors among patients with overactive bladder syndrome in Pakistan. METHODS: This was a community-based, face to face, cross sectional survey to calculate the prevalence and its associated risk factors. A sample of 1058 patients, women and men aged between 35 to 60 years having symptoms of overactive bladder was selected through convenience sampling from different cities of Pakistan during September to December 2020. Data was collected by using an Overactive Bladder Scoring System (OABSS) tool for prevalence and a developed questionnaire to rule out the risk factors. RESULTS: The prevalence was 27.4% (n=289) and it increased with age. The average ages for women and men were 44.60±7.88 and 46.14±7.69 years respectively. The OAB prevalence was the lowest among the participants aged 35-43 years 15.2% (n=55) while it was highest among those who were aged 53-60 years 49.6%, (n=127). The age, body mass index, diabetes mellitus, income, family history, parity and urinary tract infection were found to be significant associated risk factors for overactive bladder with p value <0.05. CONCLUSION: The overall prevalence of overactive bladder was 27.4% and it does not differ by gender, hypertension, pelvic surgery, smoking, constipation and sleep while it has significant association with age, body mass index, diabetes mellitus, income, parity and urinary tract infections.

Clinical Features and Treatment Outcomes of Children with Anaplastic Large Cell Lymphoma.

OBJECTIVE: To describe clinical features and treatment options in pediatric patients with ALCL (Anaplastic large cell lymphoma) and their outcome over a span of 10 years. STUDY DESIGN: A retrospective-observational study. PLACE AND DURATION OF STUDY: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, from January 2005 to December 2015. METHODOLOGY: Medical records of pediatric patients with anaplastic large cell lymphoma was retrospectively collected after IRB approval. Data was reviewed for patients confirmed on histopathology and age less than 20 years at the time of diagnosis to see clinical features and treatment outcomes. Descriptive statistics were applied. RESULTS: A total of 40 children, 27 males (67.5%) and 13 females (32.5%) with ALCL (CD30 +), were reviewed. B symptoms were present in 32 (80%) patients, nodal involvement in 39 (97.5%), and mediastinum involvement was present in 8 (20%) patients. Visceral (lung, liver, spleen) and cutaneous involvement was seen in 16 (40%) and 6 (15%) patients, respectively. ALK was positive in 19 patients (48%) and Bone marrow was involved in 3 patients (7.5%). Stage III was seen in 29 (72.5%). All patients were treated on ALCL 99 protocol. Five-year EFS (event-free survival) and OS (overall survival) was 30 and 60%, respectively. There were 7 relapses, 2 progressive disease, 16 death and 3 refusal for treatment. CONCLUSION: This analysis shows poor outcomes in pediatric ALCL. The most common cause of mortality was hematological toxicity and febrile neutropenia associated with it. Supportive care needs to be improved. Key Words: Clinical features, Outcomes, Anaplastic large cell lymphoma (ALCL), Children.

Before and After Treatment Characterization of Cerebrospinal Disease in Bing-Neel Syndrome Using 18F FDG PET/MRI.

Bing-Neel syndrome is a rare neurological complication of Waldenström macroglobulinemia. We present the case of a 71-year-old man who underwent prechemotherapy and postchemotherapy FDG PET/MRI scan for the evaluation of cerebrospinal disease. In light of limited literature and lack of consensus guidelines on the role of metabolic imaging, we aim to highlight the utility of FDG PET/MRI in the diagnosis and response assessment in Bing-Neel syndrome.

Towards more accurate 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) imaging in active and latent tuberculosis.

Tuberculosis (TB) is one of the leading causes of death worldwide. Although the disease is curable and preventable, it is underdiagnosed in many parts of the world. Positron emission tomography (PET) imaging using 18 F-FDG in TB can localise disease sites and the extent of disease. 18F-FDG accumulates in the immune cells that participate in inflammation and granuloma formation, such as activated macrophages and lymphocytes. Therefore, FDG PET/CT scanning is now being evaluated for its usefulness in the diagnosis of extrapulmonary TB and in monitoring the response to treatment. FDG PET/CT imaging is positive and has high sensitivity in active TB, complementing conventional radiological imaging (X-ray, computed tomography, magnetic resonance imaging) in the diagnosis of primary pulmonary, extrapulmonary, and post-primary or miliary TB. FDG PET/CT has low specificity when it is used for solitary pulmonary nodule characterization, and its ability to differentiate TB from malignancy is limited in this setting. Dual point imaging has been proposed as a way to overcome this limitation. FDG PET/CT can reliably differentiate active from inactive disease, and there is promising evidence that it can contribute to the assessment of the response to treatment with an impact on patient management. FDG PET/CT has been found positive in cases of latent TB infection and its ability to identify activation early is currently being explored. More studies are needed to establish the utility of this method in recognizing multidrug-resistant TB cases. Furthermore, other PET radiotracers might prove useful in the functional imaging of TB infection in the future.

The value of 18F-FDG PET-CT and 131I-norcholesterol scintigraphy in the characterization of high-risk adrenal masses.

PURPOSE: To assess the value of F-FDG PET-computed tomography (CT) and I-norcholesterol scintigraphy in noninvasive characterization of high-risk adrenal lesions using surgical pathology as the gold standard. METHODS: We retrospectively reviewed clinical cases referred to the adrenal multidisciplinary team in a tertiary centre over the last 6 years. Inclusion criteria were the presence of indeterminate adrenal lesions and performance of combined imaging with 2-deoxy-2-[fluorine-18] fluoro- D-glucose Positron emission tomography/ computed tomography and I-norcholesterol scans. The accuracy of CT, PET-CT and I-norcholesterol findings was assessed by comparison with the postoperative histopathological outcome. RESULTS: Sixteen patients fulfilled the inclusion criteria. Ten underwent unilateral adrenalectomy, and six had clinical follow-up. The number of cases categorized as concerning on the basis of unenhanced CT, F-FDG PET-CT and I-norcholesterol was 11, 9 and 2, respectively. The mean diameter of adrenal lesions was 4.5 ± 1.9 cm. Average SUVmax of the FDG-avid adrenal lesions was 5.0 ± 2.0 (range 3.5-9.7). Fourteen adrenal masses showed I-norcholesterol uptake. All adrenal masses turned out to be benign lesions. CONCLUSION: Conventional CT and FDG PET parameters are not adequately specific for determination of a benign lesion in this selected cohort of high-risk patients. Use of I-norcholesterol in this patient cohort may provide additional value.

Appearances of soft tissue calcification on Tc99m MDP bone scan.

Metastatic calcification relates to abnormal calcification resulting from hypercalcaemia in otherwise normal tissues. Hypercalcaemia can occur secondary to chronic renal failure, hyperparathyroidism, hypervitaminosis D, and metastatic neoplasms. Specific symptoms are often lacking, but calcification may be a marker of disease severity and its chronicity. We present cases with different patterns of soft tissue calcification on Tc99m MDP bone scan.

I-131 mIBG Scintigraphy Curie Versus SIOPEN Scoring: Prognostic Value in Stage 4 Neuroblastoma

Objective: I-131 mIBG scan semi-quantitative analysis with modified Curie and the International Society of Pediatric Oncology Europe Neuroblastoma (SIOPEN) scoring systems is helpful in the evaluation of disease extent and has prognostic impact in stage 4 neuroblastoma. Methods: Retrospective, cross-sectional analysis of baseline I-131 mIBG scans in 21 patients with stage 4 or 4S neuroblastoma diagnosed between January 2007 and December 2015. All scans were assessed for Curie and SIOPEN scores. Distribution of scores was evaluated for risk factors i.e. age at diagnosis (>18 months) and early relapse (within 12 months). A curie score <2 and SIOPEN score <4 at diagnosis were correlated with event-free survival (EFS) and overall survival (OS). Results: The data set comprised of 12 (57%) males and 9 (43%) females. Patients with age >18 months (n=9) at diagnosis or early relapse (n=9) had higher Curie [mean 5+7.5 standard deviation (SD), p=0.004] and SIOPEN (mean 5.2+10.8 SD, p=0.02) scores. Patients with a Curie score <2 and a SIOPEN score of <4 had better EFS and OS than patients with higher scores. Curie: 5-year EFS=Curie <2 (79%) versus Curie >2 (33%) (p=0.03); 5-year OS=Curie <2 (56%) versus Curie >2 (36%) (p=0.01). SIOPEN: 5-year EFS=SIOPEN <4 (70%) versus SIOPEN >4 (17%) (p=0.002); 5-year OS=SIOPEN <4 (58%) versus SIOPEN >4 (17%) (p=0.04). There was no statistically significant difference between the two scoring systems in terms of survival predictive value (Hazard ratio 2.38, 95% CI: 0.33-16.9, p=0.38). Conclusion: I-131 mIBG Curie and SIOPEN scores have prognostication value in stage 4 neuroblastoma and should be routinely applied. Higher scores predict unfavorable prognosis.

Hypermetabolic Hurthle Cell Adenoma on 18F-FDG PET/CT.

Thyroid incidentalomas are frequently reported on 18F-FDG PET/CT scan. High risk of malignancy is thought to be associated with increased metabolic activity and high standardized uptake value. Likewise, thyroid nodules with focal FDG avidity have a higher potential to be malignant. However, some benign nodules such as follicular and Hurthle cell adenomas can also present with focal hypermetabolic activity. We report a case of a 59-year-old lady diagnosed with gastric carcinoma, who had a hypermetabolic thyroid nodule on FDG PET/CT scan. Despite the complex texture of the nodule and intense focal avidity, the histopathology was consistent with Hurtle cell adenoma.

99mTc MDP SPECT-CT-Based Modified Mirels Classification for Evaluation of Risk of Fracture in Skeletal Metastasis: A Pilot Study.

Mirels' scoring system quantifies the risk of sustaining a pathologic fracture in osseous metastases of weight bearing long bones. Conventional Mirels' scoring is based on radiographs. Our pilot study proposes Tc MDP bone SPECT-CT based modified Mirels' scoring system and its comparison with conventional Mirels' scoring. Cortical lysis was noted in 8(24%) by SPECT-CT versus 2 (6.3%) on X-rays. Additional SPECT-CT parameters were; circumferential involvement [1/4 (31%), 1/2 (3%), 3/4 (37.5%), 4/4 (28%)] and extra-osseous soft tissue [3%]. Our pilot study suggests the potential role of SPECT-CT in predicting risk of fracture in osseous metastases.

Medullary Thyroid Carcinoma: Prognostic Variables And Tumour Markers Affecting Survival.

BACKGROUND: Medullary thyroid carcinoma (MTC) is a relatively rare thyroid malignancy and its clinical course varies among patients due to its familial association. A number of prognostic factors have been studied, but the significance of these factors remains controversial. We evaluated the progression free survival (PFS) and overall survival (OS) of MTC and its association with tumour marker rising velocity and serum calcitonin (Ct) doubling time (DT). METHODS: Analysis of 83 (8.7%) consecutive MTC patients registered at a single centre between 1995 and 2015. The impact of tumour respectability, TNM stage, multiple endocrine neoplasia (MEN) syndrome, local recurrence, Ct DT and Ct rising velocity on PFS and OS was analysed. Median follow-up was 4.3 years (range: 1-18 years). RESULTS: Eighty-three (8.7%) of all thyroid cancers registered at our centre were MTC. Fifty-five males, 28 females. Mean age 39 years [range: 17-72 years]. Twenty-two were unresectable and 61 resectable. Five-year and 10-year OS was 84% and 77% respectively. Of 68 with follow up greater than a year; 20 (29.4%) were cured, 15 (22.1%) had biochemical evidence of disease, three (4.4%) had stable macroscopic disease and 30 (44.1%) had recurrent/progressive disease. Sixteen (23.5%) died. On multivariate analysis, T4 tumour, male gender, nodal and distant metastases, tumour resectibility, Ct DT less than two years and tumour marker rising velocity of greater than 0.05pg/ml/month were poor prognostic factors (pvalue <0.05). Age and association with MEN syndrome had no statistically significant survival impact. Radiotherapy reduced local relapse in patients with nodal disease. Total thyroidectomy with nodal clearance lessened relapses. CONCLUSION: Clinical stage and pathological aspects are predictors of disease progression. Persistent biochemical evidence of MTC does not affect OS, however, Ct DT < 2 years and rapid rate of tumour marker rise predict disease progression.

Impact and prognostic value of 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan in the evaluation of residual head and neck cancer: Single-center experience from Pakistan.

BACKGROUND: Overview of clinical impact of positron emission tomography-computed tomography (PET-CT) scans in patients with head and neck carcinomas at our center. METHODS: Retrospective review of posttreatment 18F-fluorodeoxyglucose (18F-FDG) PET-CT scans in patients with head and neck carcinomas with risk of residual disease. Clinical outcome served as the reference standard. RESULTS: This study included 93 patients (65.6% males, mean age: 48.8 years ± 17.2 standard deviation) with squamous cell carcinoma as most frequent histopathology (91.4%). PET-CT scans were performed on average 6 months posttreatment. Diagnostic accuracy, positive predictive value, and negative predictive value of PET-CT for disease were found to be 88%, 88%, and 92%, respectively. A median follow-up of 24 months was available for 91 patients. Kaplan-Meier curves showed significantly higher disease-free survival with negative PET-CT as compared to positive PET-CT (P = 0.01) and maximum standardized uptake values of <5.0 (P = 0.01). CONCLUSION: FDG PET-CT has diagnostic and prognostic implications in treated patient of head and neck cancers.

18F-FDG PET-CT imaging versus bone marrow biopsy in pediatric Hodgkin's lymphoma: a quantitative assessment of marrow uptake and novel insights into clinical implications of marrow involvement.

OBJECTIVE: To evaluate whether positron emission tomography/computed tomography using fluorine-18 fluoro-deoxyglucose (18F-FDG PET-CT) predicts bone marrow involvement (BMI) in pediatric Hodgkin's lymphoma (pHL) with sufficient accuracy to supplant routine staging bone marrow biopsy (BMB), and to assess the clinical importance of marrow disease by comparing the prognosis of stage IV HL with BMI versus that without BMI. METHODS: Data were retrospectively analyzed for all cases of pHL between July 2010 and June 2015 referred for staging 18F-FDG PET-CT scan and BMB. The reference standard was BMB. Stage IV patients were divided into three groups to compare their progression-free and overall survival: PET+ BMB-, PET+ BMB+, and PET- BMB-. RESULTS: Of the 784 patients, 83.3% were male and 16.7% female, with age ranging from 2 to 18 years (mean 10.3 years). Among the total cases, 104 (13.3%) had BMI; of these, 100 were detected by PET imaging and 58 by BMB. BMB and 18F-FDG PET/CT scans were concordant for BMI detection in 728 patients (93%): positive concordance in 54 and negative in 674. Of the 56 discordant cases, four had a false-negative PET scans and were upstaged by BMB, 46 with focal uptake were PET/CT-positive and BMB-negative (not obtained from active sites), and six with diffuse uptake were false-positive on PET due to paraneoplastic marrow activation. The sensitivity, specificity, PPV, and NPV of PET for identifying BMI was 93.6, 94, 53, and 99.4% respectively. On quantitative assessment, mean iBM-SUVmax of bilateral iliac crests was significantly higher in those with BMI versus those without (p < 0.05). CONCLUSIONS: 18F-FDG PET-CT imaging is more sensitive than BMB for BMI detection in pHL staging. BMB should be limited to those with normal marrow uptake in the presence of poor risk factors or those with diffusely increased uptake to exclude marrow involvement in the background of reactive marrow.

Aggressive Disease Course of Papillary Thyroid Carcinoma with Focal Undifferentiated Component: A Case Report.

We report an aggressive papillary thyroid carcinoma (PTC) with focal undifferentiated component in a 32-year-old female. She had limited disease confined within the thyroid gland at diagnosis. Within 12 months of thyroidectomy and radioiodine ablation, thyroglobulin (Tg) levels were elevated. Second radioiodine ablative dose was given, however, stimulated Tg levels showed an upward trend with negative iodine scan within 12 months. An 18F fludeoxyglucose-avid solitary pulmonary nodule that was detected on positron emission tomography/computed tomography scan was resected followed by empiric radioiodine therapy. Within the next 10 months she developed multifocal bone metastases. The multifocal disease was rendered inoperable and treated with external beam radiation. The patient is on follow-up, and the Tg level continues to rise with local disease progression. In a small percentage of patients, PTC behaves as a very aggressive disease despite treatment. Focally undifferentiated thyroid carcinoma is an expression of the extreme end of the spectrum of differentiated thyroid carcinoma.

Fluorine-18 fluorodeoxyglucose avid thyroid incidentalomas on PET/CT scan in cancer patients: how sinister are they?

OBJECTIVE: To evaluate the prevalence of malignancy in incidental thyroidal uptake on PET with fluorine-18 deoxyglucose integrated with computed tomography (F-FDG PET/CT) in Pakistani cancer patients and to assess the role of standardized uptake value (SUV) in deciding which lesions to investigate further. METHOD: We retrospectively reviewed all patients who underwent F-FDG PET/CT scans over a period of 59 months and further analysed those with visually increased thyroidal uptake. Uptake was classified as focal or diffuse. RESULTS: Out of 10 012 F-FDG PET/CT scans done for evaluation of known, nonthyroid malignancies, 173 (1.7%) showed incidental thyroid uptake. Of these, 29 were malignant (33%; 24 focal, five diffuse) and 58 were benign (67%; 26 focal, 32 benign) cases. The prevalence of malignancy was significantly higher in cases of focal uptake (P=0.002). After controlling for sex, age, and SUV those with focal uptake were 6.5 times more likely to have malignancy compared with those with diffuse uptake. Odds ratio 6.5; 95% confidence interval 2.0-20.9; P less than 0.01. We found no correlation of SUV with the incidence or type of malignancy. CONCLUSION: Focal thyroid uptake on F-FDG PET/CT imaging should be sonographically correlated and if indicated with cytological analysis. Although diffuse uptake is usually benign, lymphoma is the leading malignant differential. Nonavid lesions have a low likelihood of malignancy.

"Bottle Brush Sign"-Spinal Meningeal Disease on 18F-FDG PET-CT Scan.

A 30-year-old man with a history of stage IV AE diffuse large cell lymphoma of left proximal humerus presented with new onset lower limb weakness at completion of chemotherapy. The F-FDG PET-CT scan showed increased intraspinal uptake from T12 to S1 vertebrae with unique "bottle brush" appearance in keeping with spinal meningeal disease. The leptomeningeal disease was further confirmed on correlative MRI scan.