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Diagnostic challenges in infective endocarditis: is PET/CT the solution?

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Abstract

Purpose

Despite developments in both imaging and microbiological techniques, the final diagnosis of IE often remains challenging. In this single-center cohort study, we aimed to identify the specific indications for request of 18F-FDG-PET/CT in clinical practice and to evaluate the diagnostic benefit of this nuclear imaging technique.

Methods

A total of 235 patients with possible (n = 43) or definite (n = 192) IE according to the revised Duke criteria were prospectively studied from July 2013 until December 2016. Echocardiography was generally used as the primary cardiac imaging technique. All patients were treated by a multidisciplinary Endocarditis Team. Diagnostics with 18F-FDG-PET/CT were undertaken on request by at least one member of the multidisciplinary team when overall diagnostics were inconclusive.

Results

In 20 patients, 18F-FDG-PET/CT scan was performed for additional diagnostic evaluation. Hereof, 15 patients had a history of implanted cardiac prosthetic material. In six patients with definite IE, the use of 18F-FDG-PET/CT was helpful for further clarification of the diagnosis. In one patient with possible IE, the diagnosis could be reclassified to definite IE. In addition, one case of vertebral osteomyelitis as well as upper and lower leg abscesses and knee empyema were detectable as extracardiac foci. Furthermore, 18F-FDG-PET/CT leads to a modification of the management in five patients.

Conclusion

Our findings support the utility of 18F-FDG-PET/CT as an adjunctive diagnostic tool especially in the evaluation of prosthetic valve-/cardiac device-related IE and for the detection of extracardiac foci in some cases. However, due to remaining limitations also of this imaging technique, a multidisciplinary clinical evaluation still remains the essential basis for the diagnostic assessment.

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Acknowledgements

C.L. is supported by the German Centre for Infection Research (DZIF) and the Federal Joint Committee (G-BA, German Federal Ministry of Health). J.R. is supported by the German Centre for Infection Research (DZIF) and the German Research Foundation (DFG). G.F. has received research Grants from the German Federal Ministry of Education and Research (BMBF) 01KI1017 and 01KG0915 and is supported by the German Centre for Infection Research (DZIF).

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Authors and Affiliations

  1. Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany

    Christopher Hohmann, Guido Michels & Roman Pfister

  2. Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany

    Matthias Schmidt

  3. Department of Cardiac Surgery, University Hospital of Cologne, Cologne, Germany

    Navid Mader

  4. Department I of Internal Medicine, University of Cologne, KerpenerStraße 62, 50937, Cologne, Germany

    Myriam Ohler, Lara Blanke, Clara Lehmann, Jan Rybniker, Sarah M. Fünger, Gerd Fätkenheuer & Norma Jung

  5. Institute for Medical Microbiology, Immunology and Hygiene, University Hospital of Cologne, Cologne, Germany

    Nathalie Jazmati

  6. German Center for Infection Research (DZIF), Bonn-Cologne, Cologne, Germany

    Clara Lehmann, Jan Rybniker & Gerd Fätkenheuer

  7. Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany

    Clara Lehmann & Jan Rybniker

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  1. Christopher Hohmann
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  2. Guido Michels
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Correspondence to Norma Jung.

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Conflict of interest

C.H. reports personal fees from MSD Sharp & Dohme and Pfizer, lecture fees from Actelion and travel grants from Actelion, Bayer, Orion Pharma and MSD Sharp & Dohme. G.M. received lecture fees from Pfizer, Novartis, Servier, ZOLL, Getinge and Orion Pharma. In the past 3 years, N. Jazmati has received payment for lectures from MSD Sharp & Dohme. C.L. has received honoraria for lectures or travel grants from Abbott, ViiV, Gilead, MSD, and Janssen. In the past 2 years, G.F. has received lecture fees from Bristol Myers Squibb, Janssen Cilag, Merck Sharp & Dohme and Pfizer, travel grants from Gilead and Janssen Cilag, research grants from Gilead, Janssen Cilag, Merck Sharp & Dohme and Roche. G.F. served on advisory boards of Janssen Cilag, Merck Sharp & Dohme, Merck Serono, Pfizer, Roche and Shionogi. In the last 3 years, N. Jung has received lecture fees from Labor Stein, Novartis, Gilead, Infectopharm and MSD and travel grants from Gilead, Novartis and Basilea.

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Hohmann, C., Michels, G., Schmidt, M. et al. Diagnostic challenges in infective endocarditis: is PET/CT the solution?. Infection 47, 579–587 (2019). https://doi.org/10.1007/s15010-019-01278-6

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