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Images in cardiology
FDG-PET/CT in the diagnosis of aortitis in fever of unknown origin with severe aortic incompetence
  1. Mohammed Shamim Rahman1,
  2. Neill Storrar1,
  3. Lisa J Anderson2
  1. 1Department of Cardiology and Cardiothoracic Surgery, St George's Healthcare NHS Trust, London, UK
  2. 2Department of Cardiovascular Sciences, St George's University of London, London, UK
  1. Correspondence to Dr Mohammed Shamim Rahman, Department of Cardiology and Cardiothoracic Surgery, St George's Healthcare NHS Trust, Blackshaw Road, London SW17 0QT, UK; shamimrahman{at}doctors.net.uk

https://doi.org/10.1136/heartjnl-2012-303143

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    Case

    A 53-year-old woman with a history of ventricular ectopic ablation was admitted with weight loss, sweats and low grade fever and was found to have severe aortic incompetence and a dilated left ventricular cavity (6.1 cm) on transthoracic echocardiography (figure 1). No vegetations were seen on transoesophageal echocardiography and sequential blood cultures were negative. Despite extensive investigation she continued to deteriorate clinically and had a persistently elevated C reactive protein and erythrocyte sedimentation rate at 300 mg/l and 108 mm/h respectively. A positron emission tomography (PET)-CT scan with 18F-fluorodeoxyglucose (FDG) showed a striking increase in FDG uptake throughout the whole aorta as well as the subclavian and iliac arteries (figure 2), confirming a large vessel arteritis. She was treated with high-dose methylprednisolone for three days with a dramatic response, followed by an oral tapering regime. The patient remained well under routine outpatient follow-up with both the Cardiology and Rheumatology specialist teams.

    Figure 1
    Figure 1

    (A, B) Transthoracic echocardiogram demonstrating severe aortic regurgitation in (A) the apical 3-chamber view showing thickening of both mitral and aortic leaflet tips with retraction of aortic leaflet tips, also seen with (B) colour flow mapping. (C, D) Transoesophageal echocardiogram demonstrating (C) the structure of the aortic valve and the origin of the aortic regurgitation (D) by colour-flow mapping. This figure is only reproduced in colour in the online version.

    Figure 2
    Figure 2

    FDG-PET/CT scan demonstrating the distribution of inflammation through active uptake of FDG in the (A) ascending and descending aorta and (B) the aortic arch in the transverse plane. FDG, fluorodeoxyglucose; PET, positron emission tomography. This figure is only reproduced in colour in the online version.

    Aortitis is an inflammatory process of one or more layers of the aortic wall with large vessel arteritis, the most common cause of non-infective aortitis. The presence of aortic incompetence is associated with a poorer prognosis.1 Multi-modality imaging is recommended while FDG-PET/CT has a role in the diagnosis of large vessel vasculitis affecting the aorta though caution must be exercised, as FDG-PET/CT will detect just over half of affected patients.2 Management consists of immunosuppression with high-dose corticosteroid therapy. Surgery and percutaneous intervention are best avoided due to the early complications associated with aortic wall fragility, prosthetic valve dehiscence and refractory inflammation despite optimal anti-inflammatory therapy.1

    Acknowledgments

    Dr Patrick Kiely, (Consultant Rheumatologist, St George's Healthcare NHS Trust) for his help with patient care.

    References

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      . Surgical management of aortic regurgitation associated with takayasu arteritis and other forms of aortitis. Ann Thorac Surg 2007;84:1950–3.
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      . Positron emission tomography in giant cell arteritis and polymyalgia rheumatica: evidence for inflammation of the aortic arch. Am J Med 2000;108:246–9.
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    Footnotes

    • Contributors MSR: patient care, prepared manuscript and images. NS: patient care, literature search. LJA: in charge of patient care, final editing of manuscript.

    • Competing interests None.

    • Patient consent Obtained.

    • Ethics approval Informed written consent was obtained from the patient and submitted with the manuscript.

    • Provenance and peer review Not commissioned; internally peer reviewed.