Granulomatosis with polyangiitis mimicking cardiac malignancy on 18 F-FDG PET/CT
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Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Sichuan, People’s Republic of China Sichuan Key Laboratory of Nuclear Medicine and Molecular Imaging, Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, People’s Republic of China
Received Aug 3, 2020; accepted Aug 4, 2020 doi:10.1007/s12350-020-02331-w
CASE PRESENTATION A 55-year-old man presented to our hospital with chest pain, chest congestion and shortness of breath for about 1 month. On auscultation, heart sounds were low with no murmur. Chest CT image showed the thickened pericardium and several pulmonary nodules in the upper lobe of lungs. A 18F-FDG PET/CT (Figure 1) was then performed to exclude the possibility of malignant lesions, which demonstrated multiple lesions in MIP (A). PET/CT detected the diffuse thickened pericardium with intense uptake (B-D, arrowhead; SUVmax of 23.0), a highly hypermetabolic area in the interatrial septum (E-G, coarse dotted arrow; SUVmax of 18.1), multiple mediastinal lymph nodes that exhibited elevated FDG activity (H-J, thin solid arrows; SUVmax of 9.6), as well as several pulmonary nodules with increased FDG activity (K-M, thin dotted arrows; SUVmax of 3.3). These findings were suggestive of cardiac malignancy, possibly lymphoma because of the infiltrative aspect. The patient then underwent video-assisted thoracoscopic surgery (VATS) biopsies of the pericardium, mediastinal lymph nodes and pulmonary nodule, pathologically revealing necrotizing granulomatous inflammation. Funding This study does not include any funding. Reprint requests: Chunyin Zhang, MD, Sichuan Key Laboratory of Nuclear Medicine and Molecular Imaging, Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, No. 25 TaiPing St., Jiangyang District, Luzhou 646000, Sichuan, People’s Republic of China; [email protected] J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2020 American Society of Nuclear Cardiology.
Additional analyses demonstrated a positive antineutrophil cytoplasmic antibody (ANCA) titer with elevated perinuclear ANCA and myeloperoxidase. The patient responded well to systemic steroids and cyclophosphamide. The final diagnosis was granulomatosis with polyangiitis (GPA). DISCUSSION Granulomatosis with polyangiitis is a multisystemic vasculitis of presumed autoimmune origin characterized by necrosis, granulomatous changes, and vasculitis, which predominantly involves the upper and lower airways, lungs and kidneys.1 Cardiac involvement is rare and the most common cardiac manifestation is pericarditis (6.35%), rarely conduction system granulomas.2 We present a case of GPA in which diffuse cardiac involvement was an initial symptom of the disease, which was extremely rare and to our knowledge no other similar case has been reported before. Although PET/CT findings are not specific for GPA,
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