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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography which shows &#40;A&#41; thickening of the mitral valve&#44; and &#40;B&#41; normal function of the aortic prosthesis&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infective endocarditis &#40;IE&#41; is a serious endovascular infection that requires early diagnosis because of its high initial mortality and morbidity rates and high risk of complications during follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> It has an estimated incidence of 3&#46;1 to 3&#46;7 episodes per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants per year&#44; and is especially common in the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical presentation of IE can be acute or subacute&#44; and it can develop with cardiac or noncardiac involvement&#46; The most common symptom is fever&#44; followed by anorexia&#44; weight loss&#44; weakness and night sweats&#46; Heart murmurs are detected in 85&#37; of patients and up to 25&#37; suffer embolic complications at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> This wide clinical spectrum makes it difficult to detect&#44; requiring a multidisciplinary approach formed by cardiologists&#44; cardiac surgeons&#44; microbiologists&#44; neurologists and specialists in infectious diseases and imaging&#46; By using newer&#44; recently introduced diagnostic imaging techniques&#44; 18F-fluorodeoxyglucose positron emission tomography&#47;computed tomography &#40;18F-FDG PET&#47;CT&#41; in particular&#44; a more accurate diagnosis is now possible&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a patient with suspected IE&#44; where this new image fusion technique was key to his management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a 54-year-old man with a mechanical aortic prosthetic valve implanted in 1998 following severe aortic regurgitation of rheumatic etiology who came to the emergency department reporting pain&#44; erythema and edema in the left leg&#44; without history of trauma and no fever or dyspnea&#46; He denied recent interventions or dental extractions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">He had hemorrhagic skin lesions on his palms and both soles&#44; most numerous on the left foot&#44; consistent with Janeway lesions&#46; No mobility abnormalities were found&#44; and there was no data to suggest any abdominal infectious process&#46; Auscultation revealed regular heart tones&#44; click of prosthetic aortic valve closure and pansystolic murmur&#44; predominantly in left parasternal border&#44; along with bibasilar crackles&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Blood tests in the emergency department showed an increase in inflammatory parameters &#40;procalcitonin 12&#46;45 ng&#47;ml&#44; C-reactive protein 17&#46;9 mg&#47;dl with neutrophilia&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Portable transthoracic echocardiography &#40;TTE&#41; &#40;Philips CX50&#44; with broadband sector array transducer S5-1 with frequency range 5-1 MHz&#44; Amsterdam&#44; the Netherlands&#41; showed no dysfunction of the mechanical aortic prostheses&#44; but did reveal thickening of the anterior mitral valve above A2 with a nodular image with irregular edges and a maximum diameter of 5 mm&#44; suggesting a mild double mitral lesion&#44; without other relevant changes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Consecutive blood cultures were positive for multi-drug-susceptible <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was admitted to the cardiology department with the diagnosis of mitral native valve endocarditis &#40;NVE&#41; secondary to <span class="elsevierStyleItalic">Staphylococcus aureus</span> in a patient with an aortic prosthesis&#44; with probable peripheral embolization&#46; By consensus with the infectious diseases department&#44; the patient was started on antibiotic therapy with cloxacillin&#44; intravenous daptomycin and rifampin&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After developing abdominal and neurological manifestations&#44; abdominal computed tomography &#40;CT&#41; and brain magnetic resonance imaging were performed&#44; showing several foci of splenic and lacunar infarction&#44; with resolution of the symptoms in less than 24 hours&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Infectious parameters began to decrease over the initial days of antibiotic treatment&#46; Two-dimensional &#40;2D&#41; and three-dimensional &#40;3D&#41; TTE and transesophageal echocardiography &#40;TEE&#41; showed absence of endocarditis progression and an apparently unaffected&#44; normal-functioning aortic prosthesis&#44; with similar findings as in the initial echocardiography &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Given the high suspicion of aortic prosthetic valve endocarditis &#40;PVE&#41; despite the negative echocardiogram&#44; an 18F-FDG PET&#47;CT was requested because of the high sensitivity and specificity of this technique for diagnosing PVE&#46; To reduce the myocardium physiological uptake of 18F-fluorodeoxyglucose &#40;18F-FDG&#41;&#44; the patient was prepared with a high-fat&#44; low-carbohydrate meal and fasted for 18 hours&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The images revealed an intense hyper-metabolism confined to the aortic annulus&#44; above the aortic-valve prosthesis&#44; with inhibition of the rest of the cardiac metabolism after the prescribed preparation&#46; This confirmed the diagnosis of aortic PVE&#44; with no evidence of pathological deposits of tracer in the mitral valve or other body territories &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Consequently&#44; repeat 2D and 3D TTE and TEE revealed a previously non-existent&#44; or not visible&#44; 5-6 mm vegetation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> and <a class="elsevierStyleCrossRef" href="#sec0025">Supplementary Video 1</a>&#41;&#46; The vegetation was observed on the posterior surface of the aortic prosthesis and was not causing regurgitation&#46; A nodule persisted on the anterior surface of the mitral valve&#44; but the positron emission tomography&#47;computed tomography &#40;PET&#47;CT&#41; images showed it to be only a simple degenerative finding&#46; No abscesses or other complications of IE were observed and the mechanical aortic prosthesis discs were opening normally&#44; with a mean gradient of 25 mmHg and no significant regurgitation&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Having confirmed the diagnosis of staphylococcal PVE with the aid of the above images&#44; surgery to replace the prosthesis was considered the most appropriate treatment&#46; The aortic prosthetic valve was replaced by an aortic valve homograft &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; due to lower risk of reinfection than with mechanical valves thanks to the absence of synthetic components&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">After surgery&#44; antibiotic therapy was maintained for 6 weeks&#46; Postoperative echocardiography showed normal function of the aortic homograft&#46; The patient progressed favorably with negative follow-up blood cultures&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Mechanical or biological PVE occurs in 1-6&#37; of patients with prosthetic valves&#44; causing 10-30&#37; of all cases of IE&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Diagnosis is more difficult than in NVE&#44; due to a more atypical clinical presentation and lower sensitivity of the Duke criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> As in NVE&#44; the diagnosis of PVE is based on clinical signs and symptoms&#44; blood cultures and imaging techniques&#46; A combination of TTE and TEE is still the main imaging technique used&#44; and it should be performed in all patients with suspicion of IE&#46; However&#44; almost 30&#37; of cases of PVE show normal or inconclusive echocardiographic images&#44; without being able to rule out the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> As delay in treatment worsens prognosis&#44; other imaging techniques are necessary in cases of high clinical suspicion in order to increase diagnostic sensitivity&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">While cardiac CT could be suitable&#44; it only offers anatomical information without providing functional data&#44; which is a major limitation&#44; especially in the case of doubtful structural lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Nuclear medicine techniques have recently emerged as a supplementary method in patients with suspected endocarditis and uncertain results in other investigations&#46; PET&#47;CT with 18F-FDG in particular has gained importance in recent years&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It measures metabolic tissue activity so it can locate metabolic or functional abnormalities and differentiate them from surrounding healthy tissues&#46; It also provides accurate information about the anatomy thanks to the spatial resolution of CT&#46; The most commonly used radiopharmaceutical&#44; 18F-FDG&#44; is actively incorporated by activated leukocytes&#44; which accumulate at the site of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Its uptake is proportional to the amount of glucose consumed in a tissue&#44; explaining why this technique is of great use in oncology and infectious diseases&#46; In order to reduce the physiological uptake of 18F-FDG by myocardial tissue&#44; previous preparation with a high-fat&#44; low-carbohydrate meal is required&#44; followed by fasting at least 6 hours&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">While in the case of NVE it does not seem to provide greater diagnostic power&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> several studies report that 18F-FDG PET&#47;CT has higher rates of internal and external validity than echocardiography for PVE<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a>&#59; it has demonstrated sensitivity values of 73-85&#37;&#44; with a specificity approaching 80&#37; and a positive predictive value of 85&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> Many authors have proposed adding the abnormal uptake of 18F-FDG in PVE to the modified Duke criteria and this combination has been found to significantly increase sensitivity with little loss of specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The combination of the modified Duke criteria and 18F-FDG PET&#47;CT would achieve a sensitivity of 97&#37; for early diagnosis of PVE compared to 70&#37; for the criteria alone&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In a 2015 study&#44; an increase in sensitivity from 52&#37; to 90&#46;7&#37; was calculated&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">There are also other qualities provided by 18F-FDG PET&#47;CT&#44; such as a single acquisition time point of the image&#44; generally at one hour after administration of 18F-FDG&#46; In addition&#44; the utility of 18F-FDG PET&#47;CT in monitoring the response to antimicrobial treatment in patients not selected for cardiac surgery has been reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;10</span></a> showing an early reduction in the quantified metabolic activity in cases of appropriate antibiotic coverage&#46; However&#44; there is still not enough evidence to support generalized implementation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Another advantage of this technique is the ability to detect peripheral septic emboli secondary to IE &#40;intestinal&#44; splenic&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> although there are certain limitations in the detection of stroke emboli&#44; as the physiological uptake of glucose by the brain is considerable and emboli in this location are usually smaller than 5 mm&#44; which is at the spatial resolution threshold of the current PET&#47;CT scanners&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a> In our case we did not see any uptake in tissues where peripheral embolization was suspected&#44; probably because the patient was covered by antibiotics at the time the technique was performed&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Certainly&#44; this imaging technique has other limitations that should not be overlooked&#46; It is important to remember that the heart tissue has physiological uptake of 18F-FDG&#44; so proper preparation has to be ensured before the test&#46; In addition&#44; there are many situations that simulate increased accumulation of this radiopharmaceutical&#44; generating false positives&#44; such as postoperative inflammation in patients who have undergone cardiac surgery in the previous months or certain disorders&#44; like diabetes&#44; the presence of tumors or active thrombi&#44; soft atherosclerotic plaques or vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Following these studies&#44; in the 2015 European Society of Cardiology guidelines&#44; the abnormal uptake of 18F-FDG detected by PET&#47;CT around prostheses implanted for more than three months was considered as a new major criterion in patients with suspected PVE&#46; In this context&#44; an algorithm including echocardiography and 18F-FDG PET&#47;CT was proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Taking these studies into account&#44; we considered our patient an appropriate candidate for 18F-FDG PET&#47;CT&#44; as echocardiography could not distinguish whether the endocarditis was attributable to the mitral native valve or to the prosthetic aortic valve&#46; In the knowledge that the management of PVE is substantially different from that of NVE&#44; requiring early surgery in the case of <span class="elsevierStyleItalic">Staphylococcus</span> infection&#44; the correct diagnosis was vital to offer to the patient the best treatment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion&#44; this case report is a good example to demonstrate the utility of 18F-FDG PET&#47;CT in cases of high suspicion of PVE with negative echocardiogram&#46; This type of image is not a substitute for clinical information&#44; microbiology and echocardiography&#44; but it is a tool to be considered in such patients&#46; Further studies are needed in order to clarify the role of 18F-FDG PET&#47;CT in other contexts of IE and to confirm its value in monitoring antimicrobial treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2016-12-26"
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          "clase" => "keyword"
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            0 => "Prosthetic valve endocarditis"
            1 => "Cardiac imaging"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prosthetic valve endocarditis is a major diagnostic challenge in clinical practice&#44; due to the lower sensitivity of the modified Duke criteria and a higher percentage of cases with negative or inconclusive echocardiography results&#46; The delay in establishing medical and surgical treatment increases the morbidity&#47;mortality rate&#46; New imaging techniques and 18F-FDG PET&#47;CT in particular have meant a significant advance in cases of high clinical suspicion and negative or inconclusive echocardiography&#44; increasing the overall sensitivity of the modified Duke criteria&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a male patient with prosthetic valve endocarditis&#44; where 18F-FDG PET&#47;CT provided the diagnostic key&#44; determining the origin of the endocarditis and avoiding treatment delay&#46;</p></span>"
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      "pt" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A endocardite das pr&#243;teses valvulares &#233; um desafio diagn&#243;stico real na pr&#225;tica cl&#237;nica devido &#224; menor sensibilidade dos crit&#233;rios de Duke modificados e a uma maior percentagem de casos em que o ecocardiograma &#233; negativo ou inconclusivo&#46; O atraso no in&#237;cio do tratamento m&#233;dico ou cir&#250;rgico aumenta a taxa de morbilidade e mortalidade&#44; de modo que o surgimento de novas t&#233;cnicas de imagem e&#44; em particular&#44; da 18F-FDG PET&#47;CT tem sido um grande avan&#231;o em casos de alta suspei&#231;&#227;o cl&#237;nica com ecocardiograma negativo ou duvidoso&#44; o que aumenta a sensibilidade global dos crit&#233;rios diagn&#243;sticos de endocardite&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso cl&#237;nico de um homem com endocardite da pr&#243;tese valvular em quem 18F-FDG PET&#47;CT foi a chave diagn&#243;stica que permitiu diferenciar a origem da endocardite e evitar o atraso do tratamento&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography which shows &#40;A&#41; thickening of the mitral valve&#44; and &#40;B&#41; normal function of the aortic prosthesis&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">18F-fluorodeoxyglucose positron emission tomography&#47;computed tomography reveals intense hyper-metabolism confined to the aortic annulus&#44; above the aortic valve prosthesis&#44; with inhibition of the rest of the cardiac metabolism&#44; with no evidence of pathological deposits of the tracer in other body territories&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; 2-dimensional and &#40;B&#41; 3-dimensional transesophageal echocardiography&#46; A 5-6 mm vegetation can be seen on the posterior surface of the aortic prosthesis&#44; with a nodule persisting on the anterior surface of the mitral valve&#46; No abscesses or other complications of infective endocarditis are observed and the mechanical aortic prosthesis discs are opening normally&#46;</p>"
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                            0 => "N&#46; Fern&#225;ndez-Hidalgo"
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                            0 => "M&#46; Bartoletti"
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Case report
18F-FDG PET/CT in the diagnosis of prosthetic valve endocarditis
18F-FDG PET/CT no diagnóstico da endocardite das próteses valvulares
Verónica Vidal
Autor para correspondência
verovidal91@gmail.com

Corresponding author.
, Cristina Albiach, Josep Gradolí, José Leandro Pérez, Vicente Montagud, Joaquina Belchí, Salvador Morell, Lorenzo Fácila
Departamento de Cardiología, Hospital General Universitario de Valencia, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Infective endocarditis &#40;IE&#41; is a serious endovascular infection that requires early diagnosis because of its high initial mortality and morbidity rates and high risk of complications during follow-up&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> It has an estimated incidence of 3&#46;1 to 3&#46;7 episodes per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants per year&#44; and is especially common in the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical presentation of IE can be acute or subacute&#44; and it can develop with cardiac or noncardiac involvement&#46; The most common symptom is fever&#44; followed by anorexia&#44; weight loss&#44; weakness and night sweats&#46; Heart murmurs are detected in 85&#37; of patients and up to 25&#37; suffer embolic complications at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> This wide clinical spectrum makes it difficult to detect&#44; requiring a multidisciplinary approach formed by cardiologists&#44; cardiac surgeons&#44; microbiologists&#44; neurologists and specialists in infectious diseases and imaging&#46; By using newer&#44; recently introduced diagnostic imaging techniques&#44; 18F-fluorodeoxyglucose positron emission tomography&#47;computed tomography &#40;18F-FDG PET&#47;CT&#41; in particular&#44; a more accurate diagnosis is now possible&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a patient with suspected IE&#44; where this new image fusion technique was key to his management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a 54-year-old man with a mechanical aortic prosthetic valve implanted in 1998 following severe aortic regurgitation of rheumatic etiology who came to the emergency department reporting pain&#44; erythema and edema in the left leg&#44; without history of trauma and no fever or dyspnea&#46; He denied recent interventions or dental extractions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">He had hemorrhagic skin lesions on his palms and both soles&#44; most numerous on the left foot&#44; consistent with Janeway lesions&#46; No mobility abnormalities were found&#44; and there was no data to suggest any abdominal infectious process&#46; Auscultation revealed regular heart tones&#44; click of prosthetic aortic valve closure and pansystolic murmur&#44; predominantly in left parasternal border&#44; along with bibasilar crackles&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Blood tests in the emergency department showed an increase in inflammatory parameters &#40;procalcitonin 12&#46;45 ng&#47;ml&#44; C-reactive protein 17&#46;9 mg&#47;dl with neutrophilia&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Portable transthoracic echocardiography &#40;TTE&#41; &#40;Philips CX50&#44; with broadband sector array transducer S5-1 with frequency range 5-1 MHz&#44; Amsterdam&#44; the Netherlands&#41; showed no dysfunction of the mechanical aortic prostheses&#44; but did reveal thickening of the anterior mitral valve above A2 with a nodular image with irregular edges and a maximum diameter of 5 mm&#44; suggesting a mild double mitral lesion&#44; without other relevant changes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Consecutive blood cultures were positive for multi-drug-susceptible <span class="elsevierStyleItalic">Staphylococcus aureus</span>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The patient was admitted to the cardiology department with the diagnosis of mitral native valve endocarditis &#40;NVE&#41; secondary to <span class="elsevierStyleItalic">Staphylococcus aureus</span> in a patient with an aortic prosthesis&#44; with probable peripheral embolization&#46; By consensus with the infectious diseases department&#44; the patient was started on antibiotic therapy with cloxacillin&#44; intravenous daptomycin and rifampin&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After developing abdominal and neurological manifestations&#44; abdominal computed tomography &#40;CT&#41; and brain magnetic resonance imaging were performed&#44; showing several foci of splenic and lacunar infarction&#44; with resolution of the symptoms in less than 24 hours&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Infectious parameters began to decrease over the initial days of antibiotic treatment&#46; Two-dimensional &#40;2D&#41; and three-dimensional &#40;3D&#41; TTE and transesophageal echocardiography &#40;TEE&#41; showed absence of endocarditis progression and an apparently unaffected&#44; normal-functioning aortic prosthesis&#44; with similar findings as in the initial echocardiography &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Given the high suspicion of aortic prosthetic valve endocarditis &#40;PVE&#41; despite the negative echocardiogram&#44; an 18F-FDG PET&#47;CT was requested because of the high sensitivity and specificity of this technique for diagnosing PVE&#46; To reduce the myocardium physiological uptake of 18F-fluorodeoxyglucose &#40;18F-FDG&#41;&#44; the patient was prepared with a high-fat&#44; low-carbohydrate meal and fasted for 18 hours&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The images revealed an intense hyper-metabolism confined to the aortic annulus&#44; above the aortic-valve prosthesis&#44; with inhibition of the rest of the cardiac metabolism after the prescribed preparation&#46; This confirmed the diagnosis of aortic PVE&#44; with no evidence of pathological deposits of tracer in the mitral valve or other body territories &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Consequently&#44; repeat 2D and 3D TTE and TEE revealed a previously non-existent&#44; or not visible&#44; 5-6 mm vegetation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a> and <a class="elsevierStyleCrossRef" href="#sec0025">Supplementary Video 1</a>&#41;&#46; The vegetation was observed on the posterior surface of the aortic prosthesis and was not causing regurgitation&#46; A nodule persisted on the anterior surface of the mitral valve&#44; but the positron emission tomography&#47;computed tomography &#40;PET&#47;CT&#41; images showed it to be only a simple degenerative finding&#46; No abscesses or other complications of IE were observed and the mechanical aortic prosthesis discs were opening normally&#44; with a mean gradient of 25 mmHg and no significant regurgitation&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Having confirmed the diagnosis of staphylococcal PVE with the aid of the above images&#44; surgery to replace the prosthesis was considered the most appropriate treatment&#46; The aortic prosthetic valve was replaced by an aortic valve homograft &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; due to lower risk of reinfection than with mechanical valves thanks to the absence of synthetic components&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">After surgery&#44; antibiotic therapy was maintained for 6 weeks&#46; Postoperative echocardiography showed normal function of the aortic homograft&#46; The patient progressed favorably with negative follow-up blood cultures&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Mechanical or biological PVE occurs in 1-6&#37; of patients with prosthetic valves&#44; causing 10-30&#37; of all cases of IE&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Diagnosis is more difficult than in NVE&#44; due to a more atypical clinical presentation and lower sensitivity of the Duke criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;6</span></a> As in NVE&#44; the diagnosis of PVE is based on clinical signs and symptoms&#44; blood cultures and imaging techniques&#46; A combination of TTE and TEE is still the main imaging technique used&#44; and it should be performed in all patients with suspicion of IE&#46; However&#44; almost 30&#37; of cases of PVE show normal or inconclusive echocardiographic images&#44; without being able to rule out the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> As delay in treatment worsens prognosis&#44; other imaging techniques are necessary in cases of high clinical suspicion in order to increase diagnostic sensitivity&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">While cardiac CT could be suitable&#44; it only offers anatomical information without providing functional data&#44; which is a major limitation&#44; especially in the case of doubtful structural lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Nuclear medicine techniques have recently emerged as a supplementary method in patients with suspected endocarditis and uncertain results in other investigations&#46; PET&#47;CT with 18F-FDG in particular has gained importance in recent years&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It measures metabolic tissue activity so it can locate metabolic or functional abnormalities and differentiate them from surrounding healthy tissues&#46; It also provides accurate information about the anatomy thanks to the spatial resolution of CT&#46; The most commonly used radiopharmaceutical&#44; 18F-FDG&#44; is actively incorporated by activated leukocytes&#44; which accumulate at the site of infection&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Its uptake is proportional to the amount of glucose consumed in a tissue&#44; explaining why this technique is of great use in oncology and infectious diseases&#46; In order to reduce the physiological uptake of 18F-FDG by myocardial tissue&#44; previous preparation with a high-fat&#44; low-carbohydrate meal is required&#44; followed by fasting at least 6 hours&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">While in the case of NVE it does not seem to provide greater diagnostic power&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> several studies report that 18F-FDG PET&#47;CT has higher rates of internal and external validity than echocardiography for PVE<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a>&#59; it has demonstrated sensitivity values of 73-85&#37;&#44; with a specificity approaching 80&#37; and a positive predictive value of 85&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> Many authors have proposed adding the abnormal uptake of 18F-FDG in PVE to the modified Duke criteria and this combination has been found to significantly increase sensitivity with little loss of specificity&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The combination of the modified Duke criteria and 18F-FDG PET&#47;CT would achieve a sensitivity of 97&#37; for early diagnosis of PVE compared to 70&#37; for the criteria alone&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In a 2015 study&#44; an increase in sensitivity from 52&#37; to 90&#46;7&#37; was calculated&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">There are also other qualities provided by 18F-FDG PET&#47;CT&#44; such as a single acquisition time point of the image&#44; generally at one hour after administration of 18F-FDG&#46; In addition&#44; the utility of 18F-FDG PET&#47;CT in monitoring the response to antimicrobial treatment in patients not selected for cardiac surgery has been reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;10</span></a> showing an early reduction in the quantified metabolic activity in cases of appropriate antibiotic coverage&#46; However&#44; there is still not enough evidence to support generalized implementation&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Another advantage of this technique is the ability to detect peripheral septic emboli secondary to IE &#40;intestinal&#44; splenic&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> although there are certain limitations in the detection of stroke emboli&#44; as the physiological uptake of glucose by the brain is considerable and emboli in this location are usually smaller than 5 mm&#44; which is at the spatial resolution threshold of the current PET&#47;CT scanners&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;5</span></a> In our case we did not see any uptake in tissues where peripheral embolization was suspected&#44; probably because the patient was covered by antibiotics at the time the technique was performed&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Certainly&#44; this imaging technique has other limitations that should not be overlooked&#46; It is important to remember that the heart tissue has physiological uptake of 18F-FDG&#44; so proper preparation has to be ensured before the test&#46; In addition&#44; there are many situations that simulate increased accumulation of this radiopharmaceutical&#44; generating false positives&#44; such as postoperative inflammation in patients who have undergone cardiac surgery in the previous months or certain disorders&#44; like diabetes&#44; the presence of tumors or active thrombi&#44; soft atherosclerotic plaques or vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Following these studies&#44; in the 2015 European Society of Cardiology guidelines&#44; the abnormal uptake of 18F-FDG detected by PET&#47;CT around prostheses implanted for more than three months was considered as a new major criterion in patients with suspected PVE&#46; In this context&#44; an algorithm including echocardiography and 18F-FDG PET&#47;CT was proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Taking these studies into account&#44; we considered our patient an appropriate candidate for 18F-FDG PET&#47;CT&#44; as echocardiography could not distinguish whether the endocarditis was attributable to the mitral native valve or to the prosthetic aortic valve&#46; In the knowledge that the management of PVE is substantially different from that of NVE&#44; requiring early surgery in the case of <span class="elsevierStyleItalic">Staphylococcus</span> infection&#44; the correct diagnosis was vital to offer to the patient the best treatment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion&#44; this case report is a good example to demonstrate the utility of 18F-FDG PET&#47;CT in cases of high suspicion of PVE with negative echocardiogram&#46; This type of image is not a substitute for clinical information&#44; microbiology and echocardiography&#44; but it is a tool to be considered in such patients&#46; Further studies are needed in order to clarify the role of 18F-FDG PET&#47;CT in other contexts of IE and to confirm its value in monitoring antimicrobial treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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    "fechaRecibido" => "2016-12-26"
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          "clase" => "keyword"
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            0 => "Prosthetic valve endocarditis"
            1 => "Cardiac imaging"
            2 => "18F-FDG PET&#47;CT"
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            0 => "Endocardite das pr&#243;teses valvulares"
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            2 => "18F-FDG PET&#47;CT"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Prosthetic valve endocarditis is a major diagnostic challenge in clinical practice&#44; due to the lower sensitivity of the modified Duke criteria and a higher percentage of cases with negative or inconclusive echocardiography results&#46; The delay in establishing medical and surgical treatment increases the morbidity&#47;mortality rate&#46; New imaging techniques and 18F-FDG PET&#47;CT in particular have meant a significant advance in cases of high clinical suspicion and negative or inconclusive echocardiography&#44; increasing the overall sensitivity of the modified Duke criteria&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report the case of a male patient with prosthetic valve endocarditis&#44; where 18F-FDG PET&#47;CT provided the diagnostic key&#44; determining the origin of the endocarditis and avoiding treatment delay&#46;</p></span>"
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      "pt" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A endocardite das pr&#243;teses valvulares &#233; um desafio diagn&#243;stico real na pr&#225;tica cl&#237;nica devido &#224; menor sensibilidade dos crit&#233;rios de Duke modificados e a uma maior percentagem de casos em que o ecocardiograma &#233; negativo ou inconclusivo&#46; O atraso no in&#237;cio do tratamento m&#233;dico ou cir&#250;rgico aumenta a taxa de morbilidade e mortalidade&#44; de modo que o surgimento de novas t&#233;cnicas de imagem e&#44; em particular&#44; da 18F-FDG PET&#47;CT tem sido um grande avan&#231;o em casos de alta suspei&#231;&#227;o cl&#237;nica com ecocardiograma negativo ou duvidoso&#44; o que aumenta a sensibilidade global dos crit&#233;rios diagn&#243;sticos de endocardite&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso cl&#237;nico de um homem com endocardite da pr&#243;tese valvular em quem 18F-FDG PET&#47;CT foi a chave diagn&#243;stica que permitiu diferenciar a origem da endocardite e evitar o atraso do tratamento&#46;</p></span>"
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            "etiqueta" => "Appendix A"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography which shows &#40;A&#41; thickening of the mitral valve&#44; and &#40;B&#41; normal function of the aortic prosthesis&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">18F-fluorodeoxyglucose positron emission tomography&#47;computed tomography reveals intense hyper-metabolism confined to the aortic annulus&#44; above the aortic valve prosthesis&#44; with inhibition of the rest of the cardiac metabolism&#44; with no evidence of pathological deposits of the tracer in other body territories&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; 2-dimensional and &#40;B&#41; 3-dimensional transesophageal echocardiography&#46; A 5-6 mm vegetation can be seen on the posterior surface of the aortic prosthesis&#44; with a nodule persisting on the anterior surface of the mitral valve&#46; No abscesses or other complications of infective endocarditis are observed and the mechanical aortic prosthesis discs are opening normally&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Preparation of an aortic valve homograft prior to implantation during surgery&#46; &#40;B&#41; Visualization of the vegetation removed from the aortic prosthesis&#46;</p>"
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                    0 => array:2 [
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                      "titulo" => "Improving the diagnosis of infective endocarditis in prosthetic valves and intracardiac devices with 18F-fluordeoxyglucose positron emission tomography&#47;computed tomography angiography&#58; initial results at an infective endocarditis referral center"
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                          "etal" => true
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                      "titulo" => "Positron emission tomography&#47;computed tomography for diagnosis of prosthetic valve endocarditis&#58; increased valvular 18F-fluorodeoxyglucose uptake as a novel major criterion"
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                          "etal" => true
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                  "contribucion" => array:1 [
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46; Rouzet"
                            1 => "R&#46; Chequer"
                            2 => "K&#46; Benali"
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