PET-CT save a day in deep-seated infection

Abstract

A 60-year-old female had implantation of Ventriculoperitoneal (VP) shunt a year ago after suffering from subarachnoid hemorrhage with hydrocephalus. She presented this time with colicky abdominal pain and high swinging fever. Abdominal XRay (Panel A) was suggestive of intestinal obstruction due to paralytic ileus, which was treated conservatively. However, her fever persisted despite multiple broad-spectrum antibiotics. Whole body computed tomography with contrast was unremarkable. Lumbar puncture was done in view of intermittent confusion plus ongoing fever, it showed elevated cerebrospinal fluid total protein and high white cell count but the culture was negative. Eventually 2-[18F]-Fluoro-2-Deoxy-D-Glucose (2-[18F]-FDG) Positron Emission Tomography–Computed Tomography (PET-CT) revealed a 1.1 X 2.1 X 3.1 cm hypermetabolic (SUV max 9.1) rim enhancing collection around the tip of VP shunt, confirming the diagnosis of VP shunt infection (Panel B and C). Ventriculoperitoneal shunt infections may present with vague symptoms which make the diagnosis elusive. PETCT serves an important role given its enhanced diagnostic sensitivity. The patient completely recovered after removal of the infected shunt. From multiple case studies, PET-CT has been an emerging imaging tool in diagnosing shunt related infections in case of moderate clinical suspicion when first line of diagnostic modalities could not identify sources of infection [1,2].