Gallium Scan Research Articles

8411 Ectopic ACTH-dependent Cyclical Cushing’s Syndrome- the Art of Hide-and-seek

Abstract Disclosure: H. Mon: None. A. Kapoor: None. S. Qureshi: None. M. Martineau: None. K. Meeran: None. Case report: A 72-years-old lady was admitted with hypokalaemia, hyperglycaemia with metabolic alkalosis with background hypertension, type2 diabetes, osteoporosis and right-sided breast cancer treated with chemotherapy and radiotherapy 3years ago. She was previously seen in Endocrinology Clinic for similar episode and deemed not having Cushing’s or Conn’s syndrome on workup. During this admission, although there was no obvious Cushingoid appearance, there was refractory hypokalaemia. On further exploration, there were previous admissions with similar episodes in UK and in her home country, within the same year, a few months apart. Therefore, endocrinology workup was conducted for suspected cyclical Cushing’s syndrome. It demonstrated raised 24-hour urinary free cortisol of 5643 nmol/24hour (reference range 0-164 nmol/24hours), unsuppressed low dose dexamethasone suppression test with cortisol level of 800 nmol/L and increased ACTH level of 429 ng/L. MRI (pituitary) showed no pituitary lesion with probable empty sella and CSF filled. However, CT (thorax) showed enlarging lesion (previously from 1cm to 1.6cm) in the left lower lobe, concerning lung metastasis or primary lung malignancy. PET scan showed left lower lobe nodule having low-grade activity with likelihood of indolent malignancy and appearances of physiologic adrenal hyperplasia. Management: Given persistently high cortisol levels during admission with ongoing hyperglycaemia and refractory hypokalaemia, metyrapone was started and titrated accordingly. Her clinical condition including potassium and cortisol levels effectively responded to metyrapone. Gallium scan was booked for detail localization with ongoing lung MDT (multidisciplinary team meeting) and neuroendocrine tumour MDT.However, after starting metyrapone, she had type 1 respiratory failure, not responding to initial antibiotics. After excluding other possible respiratory aetiologies, empirical treatment for Pneumocystosis pneumonia (PCP) was initiated, after which blood test for Beta-D-glucan was found out to be significantly raised, supporting the presumptive diagnosis. Conclusion: Our case highlighted the following interesting points 1. diagnostic challenges, due to the fluctuating nature of cyclical Cushing’s syndrome, presenting with recurrent hypokalaemia. 2. the interesting nature of likely ACTH-dependent cyclical Cushing’s syndrome, progressing into florid Cushing’s syndrome, with efficacy to metyrapone 3. rare and compelling combination of 3 conditions of Cyclical Cushing’s syndrome, being ectopic ACTH-dependent and complicated by Pneumocystosis pneumonia (PCP). Presentation: 6/1/2024

Successful use of platelet-rich plasma as a regeneration technique for a non-healing diabetic leg ulcer with chronic osteomyelitis: A case report

Chronic diabetic leg ulcers can be challenging to manage, particularly when osteomyelitis coexists resulting in serious or even life-threatening conditions if not managed appropriately. Such cases require very long periods of treatment with several debridements, antibiotic bead implants, skin grafts or even amputations in many unfortunate cases. Despite that, conventional management appears to be inadequate with poor outcomes and a higher relapse rate. We report a case of a 26-year-old type 1 diabetic female patient presented with a history of non-healing diabetic leg ulcer complicated by chronic osteomyelitis of the left leg. Several wound debridements were performed with the application of vacuum-assisted closure, and culture-guided antibiotics were given. However, only minimal improvements were observed. Eventually, the leg was labeled as an unsalvagable limb due to poor blood supply based on an ankle-brachial index. Platelet-rich plasma (PRP) was tried showing promising results and significant improvement as confirmed by a gallium scan, which showed evidence of osteomyelitis remission. Two months later, the patient improved significantly with the ulcer healed and the osteomyelitis resolved. Autologous PRP promotes wound healing by providing necessary growth factors, reducing inflammation, and showing bactericidal activity. All efforts must be taken to preserve any limb before labeling it non-salvageable. This case report aimed to draw attention to the method that can be implemented to manage non-healing diabetic leg ulcers complicated by chronic osteomyelitis.

Accelerated silicosis in sandblasters: Pathology, mineralogy, and clinical correlates.

With increasing reports of accelerated and acute silicosis, PMF, and autoimmune disease among coal miners and silica-exposed countertop workers, we present previously incompletely-described pulmonary pathology of accelerated silicosis and correlations with mineralogy, radiography, and disease progression in 46 Texas oilfield pipe sandblasters who were biopsied between 1988 and 1995. Worker examinations included pulmonary function tests, chest X-ray (CXR), high-resolution computed tomography (HRCT), and Gallium-67 scans. Quantitative mineralogic analysis of pulmonary parenchymal burden of silica, silicates, and metal particles used scanning electron microscopy with energy dispersive x-ray spectroscopy (SEM EDS). Workers had clinical deterioration after <10 years exposure in dusty workplaces. Althoughinitial CXR was normal in 54%, Gallium-67 scans were positive in 68% of those with normal CXR, indicating pulmonary inflammation. The histology of accelerated silicosis is diffuse interstitial infiltration of macrophages filled with weakly birefringent particles with or without silicotic nodules or alveolar proteinosis. Lung silica concentrations were among the highest in our database, showing a dose-response relationship with CXR, HRCT, and pathologic changes (macrophages, fibrosis, and silicotic nodules). Radiographic scores and diffusing capacity worsened during observation. Silica exposure was intensified, patients presented younger, with shorter exposure, more severe clinical abnormalities, higher lung particle burdens, and more rapid progression in a subset of patients exposed to recycled blasting sand. Accelerated silicosis may present with a normal CXR despite significant histopathology. Multivariable analyses showed silica, and not other particles, is the driver of observed radiologic, physiologic, and histologic outcomes. Eliminating this preventable disease requires higher physician, public health, and societal awareness.

Acute Interstitial Nephritis and Colitis Secondary to Nivolumab Therapy for Melanoma Identified on Nuclear Gallium Scan

Acute Interstitial Nephritis and Colitis Secondary to Nivolumab Therapy for Melanoma Identified on Nuclear Gallium Scan

Laboratory and imaging findings of necrotizing otitis externa are associated with pathogen type and disease outcome: A retrospective analysis.

To examine associations of laboratory and imaging data with diagnostic parameters of necrotizing otitis externa (NOE) and its severity, and to compare between bacterial and fungal infections. Records of patients diagnosed with NOE during 2010-2018 at the Department of Otolaryngology, Head and Neck Surgery were reviewed retrospectively for demographics; disease characteristics; and laboratory, scintigraphy, and imaging results. Of 48 patients with NOE, the mean age is 73±11.6years; 32 (67%) were males; 83% had diabetes mellitus. Common pathogens were pseudomonas (49%) and fungi (33%). Sensitivities of the technetium-scan (SPECT ratio ≥1.5), temporal bone computed tomography (CT), and gallium-scan (SPECT ratio ≥1.3) were: 78.7%, 48.8%, and 31.4%, respectively. Gallium-scan results correlated positively with CT bone involvement (p=0.002) and hospital length of stay (p=0.0014). C-reactive protein (CRP) level correlated with hospital length of stay (p=0.028) and positive technetium-scan results (p=0.012). Fungal infection had a higher technetium SPECT ratio (2.16 vs. 1.77, p=0.04), gallium SPECT ratio (1.4 vs. 1.2, p=0.02), longer duration of systemic treatment (87.4 vs. 37.9days, p=0.014), and longer hospital length of stay (31.6 vs. 15.2days, p=0.004) compared to non-fungal infection. Eight (17%) patients had responded poorly to treatment. Fungal pathogens, facial nerve paresis, extra-auricular, and bilateral disease were more prevalent among the non-responders. The technetium scan has higher sensitivity than temporal bone CT for diagnosing NOE. The gallium scan and CRP correlated well with hospital length of stay. A high rate of fungal infection was found, with significantly higher technetium and gallium SPECT ratios and worse outcome compared to bacterial infection. Fungal NOE remains therapeutically challenging.

Change of Renal Gallium Uptake Correlated with Change of Inflammation Activity in Renal Pathology in Lupus Nephritis Patients.

Background: Lupus nephritis (LN) often lead to end-stage renal disease in systemic lupus erythematosus patients. This study aimed to investigate the clinical application of renal gallium-67 scans for determining renal histological parameters in LN patients. Methods: Between 2006 and 2018, 237 biopsy-proven and 35 repeat biopsies LN patients who underwent renal gallium scans before or after biopsy were included for analysis. The classification and scoring of LN were assessed according to the International Society of Nephrology/Renal Pathology Society. A delayed 48-h gallium scan was performed and interpreted by semiquantitative methods using left kidney/spine (K/S) ratio. The renal histological results were compared with gallium uptake. Results: Out of 237 participants, 180 (76%) had proliferative LN. Baseline gallium left K/S ratio was significantly higher in class IV LN as compared to class III (median (interquartile range, IQR): 1.16 (1.0–1.3), 0.95 (0.9–1.1), respectively, p < 0.001). Furthermore, changes in gallium uptake between two biopsies were positively correlated with changes activity index (r = 0.357, p = 0.035), endocapillary hypercellularity (r = 0.385, p = 0.032), and neutrophils infiltration (r = 0.390, p = 0.030) in renal pathology. Conclusions: Renal gallium uptake is associated with active inflammation in LN. Changes in renal gallium uptake positively correlated with changes in activity index in renal pathology.

Gallium-67 Scan with Single Photon Emission Computed Tomography for the Evaluation and Monitoring of Infected Abdominal Aortic Aneurysms: A 10-Year Case Series.

PurposeThis study aimed to evaluate the role of gallium-67 single photon emission computed tomography (SPECT) with contrast computed tomography (CT) in the evaluation and monitoring of infected abdominal aortic aneurysms (IAAA).MethodsMaterials and A retrospective cohort analysis was performed using prospectively collected data of consecutive patients with IAAA in Princess Margaret Hospital in Hong Kong between January 2010 and December 2020. The patients were identified using the Radiology Information System.ResultsAll five patients had proven IAAA on CT and/or metabolic imaging. Among them, three were further supported by positive blood culture results. Gallium-67 SPECT with contrast CT was useful in the detection of residual disease, monitoring, and detection of recurrence.ConclusionGallium-67 SPECT with contrast CT is helpful for evaluating IAAA. It serves an important role in guiding management, especially during long-term follow-up.

Escalation from ABVD Following Positive Interim Functional Imaging Improves Progression Free Survival but Not Overall Survival in Advanced Classical Hodgkin Lymphoma - a Real World Analysis

Background: Interim functional imaging (IFI) is highly prognostic in advanced classical Hodgkin Lymphoma (cHL) and can guide therapeutic decisions. Patients with positive IFI whom were escalated to BEACOPP (Johnson et al, NEJM 2016, Press et al, JCO 2016) achieved higher progression free survival (PFS) compared with historical controls who received ABVD alone. However, the benefit of IFI guided intensification remains uncertain as no direct comparison was made in recent randomized reports. Furthermore, it is unclear whether there is any overall survival (OS) advantage to this risk adapted strategy given significant improvements in salvage options over the years. This is particularly relevant as therapy related adverse events are higher with BEACOPP than ABVD including greater incidence of infertility and secondary malignancies. At our center we adopted two treatment protocols for advanced cHL; hybrid ABVD / BEACOPP or ABVD alone. The aim of this analysis is to examine the role of risk adapted therapy escalation compared to completion of ABVD.Methods: After due IRB approval, patients with cHL whom were treated at our institution from 2008 - 2016 were identified. All records were retrospectively extracted. Inclusion criteria were newly diagnosed patients with stage IIB, III or IV who received first line curative intent therapy and with IFI scan evaluation. We excluded patients with nodular lymphocyte predominant (NLP) HL, early favorable disease, patient's not receiving curative therapy and those without IFI scan. Negative PET/CT was regarded as Deauville score of ≤ 3, whereas a negative gallium was defined as no evidence of 67Ga activity. Categorical and continuous variables were compared using Pearson's chi-squared and Wilcoxon / Kruskal-Wallis, respectively. OS and PFS were computed using Kaplan-Meir method with log ranks test.Results:A.Baseline characteristics: We identified a total of 216 cases during this time frame, we excluded patients due to lack of IFI (52), early favorable disease (19), NLP lymphoma (13) or palliative therapy (8). A total of 124 patients were included for further analysis. Median age was 26 years (14-83) with 64 (51.6%) males. Lymphoma subtype was nodular sclerosis (67.7%), mixed cellularity (5.5%) and cHL-NOS (26.6%). Thirty four (27.4%) were stage IIB, 43 (34.7%) were stage III while 47 (37.9%) were stage IV. Bulky disease was present in 36 (29%) and 32 (25.8%) received consolidative IFRT. Eighty five (68.5%) patients underwent PET/CT while the remaining underwent gallium scan as IFI. Median number of cycles at interim was 2 (2-4). All patients were from the middle east and north Africa (MENA) region. Median follow up was 40.9 (3-132) months.B.Risk adapted therapy stratified by IFI: Therapy administration was as follows; 84 (67.7%) received ABVD while the remaining 40 (32.3%) received ABVD followed by escalation to BEACOPP. A total of 36 (29%) patients had positive IFI and the cohort was subsequently stratified based on IFI results. Baseline features of the strata were non-significantly different as shown in table I. PFS at 2-years was significantly higher for ABVD with negative vs. positive IFI at 84.9% vs. 37.9%, respectively (p = 0.00015). Escalation to BEACOPP in cases of positive IFI also resulted in a significantly higher PFS compared to ABVD with at 64.7% vs. 37.9%, respectively. Escalation to BEACOPP compared to ABVD alone in cases of negative IFI resulted in similar PFS at 86.1% vs. 84.9% as shown in figure I. OS, was similar across the groups as shown in figure II (p=0.44). A total of 80% and 89% of relapsing patients on ABVD/BEACOPP and ABVD, respectively, received salvage followed by transplant.Conclusion: Escalation to BEACOPP resulted in significant improvement of PFS only in cases of positive IFI. However, it remained worse than those with a negative interim scan. The lack of OS difference may be due to effective salvage therapy as most relapsing patients proceed to transplant. Although retrospective, to our knowledge this is the first direct comparison between escalation vs. completion of ABVD. Given the toxicity associated with BEACOPP, its inability to completely overcome the adverse effects of positive IFI and efficacy of salvage therapy, there is clinical equipoise to warrant prospective randomization of escalated therapy in positive IFI cases. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

1024 A Case-Controlled Series Examining the Utility of Nuclear Medicine Imaging in The Diagnosis and Management of Malignant Otitis Externa

Abstract Introduction This study aimed to assess whether combination modality imaging (CT, and/or Technetium/Gallium) had any additional benefits over single modality imaging (CT) in the management of malignant otitis externa (MOE). Method A six-year retrospective case-controlled series was performed including 73 patients presenting with a potential diagnosis of MOE. Results CT imaging was undertaken in 69/73 patients, and of these the CT confirmed the diagnosis in 58% (40/69). Of the 42% (29/69) of CT negative patients, 25 underwent Technetium scanning, revealing 40% (10/25) to be negative. These patients were discharged on a short course of topical and oral therapy with no disease recurrence. Gallium scan results, performed at the end of treatment, were more inconsistent, with 47% (25/53) of imaging still positive despite extended intravenous/oral/topical therapy. However,40% (10/25) of these had their therapy stopped without any further disease relapse. Conclusions Combination modality imaging, with CT and Technetium, did infer additional benefit over single modality imaging using CT. However, this was not the case for Gallium scanning, used to determine treatment end, which seemed to be poorly representative of residual disease presence. This study was utilised to provide a management algorithm to guide future practice.

Nuclear odontology: Pictorial essay

There is increased demand by the general dentist and oral surgeon’s for Nuclear Medicine (NM) imaging procedures both for initial diagnosis and follows up of patients with different dental and facial disorders. There are several procedures in NM including bone scan, gallium scan and PET scan which can offer important diagnostic information complementing the information obtained from other imaging modalities in particular a better understanding of the pathophysiology of the disease and therapy monitoring.

What's Your Diagnosis? Symptoms: Ear Pain and Chronic Ear Drainage

What's Your Diagnosis? Symptoms: Ear Pain and Chronic Ear Drainage

RetroSPECT: Gallium-67 as a Long-Lived Imaging Agent for Theranostics.

A limitation to the wider introduction of personalised dosimetry in theranostics is the relative paucity of imaging radionuclides with suitable physical and chemical properties to be paired with a long-lived therapeutic partner. As most of the beta-emitting therapeutic radionuclides emit gamma radiation as well they could potentially be used as the imaging radionuclide as well as the therapeutic radionuclide. However, the downsides are that the beta radiation will deliver a significant radiation dose as part of the treatment planning procedure, and the gamma radiation branching ratio is often quite low. Gallium-67 has been in use in nuclear medicine for over 50 years. However, the tremendous interest in gallium imaging in theranostics in recent times has focused on the PET radionuclide gallium-68. In this article it is suggested that the longer-lived gallium-67, which has desirable characteristics for imaging with the gamma camera and a suitably long half-life to match biological timescales for drug uptake and turnover, has been overlooked, in particular, for treatment planning with radionuclide therapy. Gallium-67 could also allow non-PET facilities to participate in theranostic imaging prior to treatment or for monitoring response after therapy. Gallium-67 could play a niche role in the future development of personalised medicine with theranostics.

Place des explorations isotopiques dans les otites externes nécrosantes

BackgroundThe necrotizing otitis externa (NOE) is potentially lethal which mainly occurs on the most among the elderly and diabetic. The aim of our study was to evaluate the contribution of isotopic explorations in diagnosis, staging and monitoring of the NOE. MethodsOur retrospective study was about 50 patients with a strong suspicion of NOE who benefited a bone and/or gallium scintigraphy. ResultsOur population was composed of 38 men and 12 women with mean age of 68 years. All patients were diabetic. The most common complaint was otalgia (98% of cases). The sensitivity of computed tomography (CT) which was performed in 84% of cases was 66.6% of cases. Bone scintigraphy (BS) was performed in all patients showing increased uptake in the temporal region in 90% of cases. An extension to surrounding structures was objectified in 26% of cases. Follow-up Ga 67 SPECT was performed in 56% of cases, demonstrated increased uptake at the temporal region in 43% of cases. The statistical study showed that only the presence of an extended tympanic lysis on CT was statistically significant to the positivity of BS (P=0.036). No statistically significant correlation was found between all other CT abnormalities, clinical and biological signs and the positivity of bone scintigraphy. ConclusionIsotopic explorations were a great contribution in the management of the NOE. At the initial phase, the BS allowed to confirm very early an existence of osteomyelitis of the skull base. During the follow-up, the gallium-67 scan allowed the following of the evolution of infectious process.

High-Dose Chemotherapy (HDC) with Autologous Stem-Cell Transplant (ASCT) with Consolidative Radiation Therapy (RT) for Relapsed or Refractory (R/R) Primary Mediastinal B-Cell Lymphoma (PMBCL): 20-Year Experience at MD Anderson Cancer Center (MDACC)

Background Most PMBCL pts are cured with frontline chemoimmunotherapy ± RT. Data are scant regarding the role of HDC/ASCT for R/R PMBCL, and the benefit of RT administered peri-HDC/ASCT. Our institutional approach has focused on developing potentially more active HDC regimens, and on consideration of post-ASCT consolidation RT, especially for pts who had not achieved a CR at the time of HDC. Methods We retrospectively analyzed all patients (pts) with R/R PMBCL treated with HDC/ASCT at MDACC between 01/01/2000-12/31/2019. All pts underwent similar standard pre-SCT evaluation and met eligibility criteria as per our institutional guidelines. Response assessment differed over time and included CT and gallium scan (N=9) and PET/CT (N=49). Cox proportional hazards regression models evaluated the associations of the specific HDC regimen and clinical covariates of interest with EFS and OS. Results 58 pts received HDC/ASCT with BEAM-rituximab (N=36) or rituximab/gemcitabine/busulfan/melphalan ± vorinostat (R-GemBuMel) (n=22) (Table 1). The R-GemBuMel group included more pts pretreated with &amp;gt;2 lines of therapy than the R-BEAM group (55% vs. 28%, p=0.025), had fewer pts in CR (41% vs. 69%, P=0.01) and more pts in PD/SD at ASCT (32% vs. 3%, P=0.01). Prior RT at a median 44 (36-48) Gy was administered to 29 pts (20 R-BEAM, 9 R-GemBuMel, P=0.27). Nineteen pts (89% not in CR at SCT) who had not previously received full doses of RT received post-SCT RT (6 after BEAM, 13 after R-GemBuMel, P&amp;lt;0.001) at median 40 Gy (36-48). There were 2 treatment-related deaths in the R-BEAM arm, none in the R-GemBuMel arm. At median follow-up of 69.1 months (interquartile range, 36.5-85.2), the EFS rates were 57.6% (overall), 67.6% (R-GemBuMel) and 52.7% (R-BEAM) (Figure 1a). Their respective OS rates were 69.3%, 81.1% and 63.9% (Figure 1b). On multivariable Cox regression analyses, R-GemBuMel (vs. R-BEAM) (HR=0.29, p=0.05), and 1 organ involved (vs. &amp;gt;1) (HR 0.28, p=0.009) were associated with improved EFS, whereas older age (HR= 1.08 per year above median, p=0.005), refractory disease (SD/PD) at SCT (vs. CR/PR) (HR 5.44, p=0.01) correlated with worse EFS. Likewise, R-GemBuMel (HR= 0.16, p=0.03) and 1 organ involved (HR=0.17, p=0.004) significantly resulted in improved OS, whereas older age (HR= 1.11, p=0.002), and refractory (SD/PD) disease at SCT (HR= 21.27, p=0.001) correlated with worse OS. Neither sex nor disease status (primary refractory vs. relapse) nor No. prior lines (2 vs. &amp;gt;2) nor pre-SCT RT nor post-SCT RT correlated significantly with EFS or OS. Conclusions HDC/ASCT for R/R PMBCL pts, with post-SCT RT for pts with active disease at SCT, results in favorable long-term results. R-GemBuMel ± vorinostat seems to improve EFS and OS compared to R-BEAM. Disclosures Alousi: Incyte: Honoraria, Research Funding; Therakos: Research Funding; Alexion: Honoraria. Hosing:NKARTA Inc.: Consultancy. Kebriaei:Amgen: Other: Research Support; Ziopharm: Other: Research Support; Kite: Other: Served on advisory board; Pfizer: Other: Served on advisory board; Jazz: Consultancy; Novartis: Other: Served on advisory board. Popat:Bayer: Research Funding; Novartis: Research Funding. Qazilbash:Angiocrine: Research Funding; Bioline: Research Funding; Janssen: Research Funding; Bioclinica: Consultancy; Amgen: Research Funding. Shpall:Zelluna: Membership on an entity's Board of Directors or advisory committees; Adaptimmune: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Magenta: Membership on an entity's Board of Directors or advisory committees; Takeda: Other: Licensing Agreement. Champlin:Takeda: Patents &amp; Royalties; Genzyme: Speakers Bureau; Cytonus: Consultancy; Omeros: Consultancy; Actinium: Consultancy; Johnson and Johnson: Consultancy; DKMS America: Membership on an entity's Board of Directors or advisory committees. Nieto:Affimed: Consultancy, Other: Grant Support; Novartis: Other: Grant Support; Astra Zeneca: Other: Grant Support; Secura Bio: Other: Grant Support.

SEPTIC PULMOMARY EMBOLI SECONDARY TO UNREPORTED PARTIALLY TREATED DENTAL INFECTION

SESSION TITLE: Fellows Chest Infections Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Septic pulmonary emboli are usually caused by infected intravenous catheters and endocarditis. Dental infection is an extremely rare cause. We present a case of septic pulmonary emboli attributed to dental infection. Antibiotics, proper oral care and extraction of the causative teeth are key components of treatment. CASE PRESENTATION: Patient is a 60 year old male with no significant past medical history presented with complaints of fever, chills, myalgia. Patient states that about 2 weeks prior to presentation to the emergency department he had toothache and took antibiotics for two days with resolution of the pain. At the time of presentation, patient was afebrile, normotensive and was saturating 97 percent on room air. Patient underwent portable chest x-ray and Computerized tomography scan that revealed multiple bilateral patchy infiltrates with a lucent center suggestive of septic emboli. Physical examination was consistent with clear breath sounds bilaterally, no murmurs on cardiovascular examination. Oral examination revealed dental caries with no apparent gingivitis. Labs on admission showed hemoglobin of 13 gm/dL, white blood cell count of 12,000/mL, platelet count of 281,000/mm3, BUN of 13 mg/dL, creatinine of 0.58 mg/dL, sodium of 132 mEq/L, potassium of 3.8 mEq/L, sedimentation rate of 52 mm. TB Quantiferon test, HIV, ANCA panel were negative. Blood cultures were negative. Patient underwent a trans-esophageal echocardiogram that did not show endocarditis. He also underwent a whole body Gallium scan that showed increased uptake in the thorax and no other sites of infection. Consultation with oral maxillofacial surgery was sought due to the concern for dental source of infection. Patient underwent Orthopantogram that demonstrated lucency over the right maxillary suspicious for a fracture, partially edentulous oral cavity and extensive dental disease. Patient was started on broad spectrum antibiotic coverage with Vancomycin and Piperacillin- Tazobactam on which he developed acute interstitial nephritis presumed secondary to beta lactam antibiotics. Antibiotics were changed to Clindamycin and Doxycycline. Patient was subsequently discharged on oral antibiotics. He was followed in the pulmonary clinic with a repeat CAT scan that showed radiographic improvement in the septic emboli. DISCUSSION: Sustained Bacteremia and seeding in the lungs can occur in patients with periodontal infection. Indigenous oral florae include various Streptococci, Lactobacillus, Corynebacterium, and Actinomyces species. Antibiotics to cover oral flora is the main stay of treatment. Complications include pleural effusion and empyema. CONCLUSIONS: Dental infections are a rare cause of septic pulmonary emboli and are usually under reported by the patient. Antibiotics are the main stay of treatment. History and thorough physical examination are crucial in pointing towards the possible source of infection. Reference #1: Watanabe, Tsuyoshi et al. “Septic pulmonary embolism associated with periodontal disease: a case report and literature review.” BMC infectious diseases vol. 19,1 74. 21 Jan. 2019, doi:10.1186/s12879-019-3710-3 DISCLOSURES: No relevant relationships by Medhat Ismail, source=Web Response No relevant relationships by Rishitha Yelisetti, source=Web Response

S1804 Gut Friend or Foe: A Case of Lactobacillus Rhamnosus Endocarditis from Probiotic Use

INTRODUCTION: Probiotics are over-the-counter preparations of live bacterial cultures that confer a number of health benefits. Lactobacillus rhamnosus is an inhabitant of the gastrointestinal flora and a common ingredient in probiotics. In rare instances, it has proven to be pathogenic in humans, especially if immunocompromised. Here, we present a case of Lactobacillus infective endocarditis (IE) secondary to probiotic use. CASE DESCRIPTION/METHODS: A 60-year-old male with a history of Ross procedure and pulmonic valve replacement, history of infective endocarditis (IE) and adrenal insufficiency, atrial fibrillation/flutter, heart failure, diabetes, Erdheim-Chester disease on chemotherapy presented with worsening dyspnea for 2 weeks after a recent admission for pyelonephritis. His previous course was complicated by diarrhea associated with antibiotic use for which he started a probiotic three weeks prior. On day 2 of this admission, he became septic. Blood cultures grew Lactobacillus rhamnosus for which he was started on daptomycin and ampicillin. Trans-esophageal echocardiogram (TEE) revealed mild thickening of the aortic root with gallium scan confirming an infection involving the pulmonary outflow tract and aortic valve ring. Repeat TEE 10 days later revealed worsening pulmonic valve thickening and regurgitation at which time gentamicin was added for synergistic effect. The patient clinically improved and was discharged home on day 32 and completed 6 weeks of antibiotics. DISCUSSION: Probiotics are increasingly taken for their health benefits. However, using probiotics in an immunocompromised population may be harmful, resulting in extra-intestinal infections including lactobacillus endocarditis, which account for less than 0.5% of IE cases. The pathophysiology is not certain but likely arises from dysbiosis from an infection or recent antibiotic use, resulting in disrupted intestinal wall integrity and bacterial translocation. Properties of lactobacillus allow for its adherence to endovascular surfaces carrying an increased risk for endocarditis. While guidelines on treatment are limited, the literature frequently suggests a combination of a penicillin and an aminoglycoside, however culture sensitivities ultimately guide therapy. Mortality from this rare entity has been reported as high as 27%, necessitating prompt recognition and treatment. This case illustrates that probiotics should only be used when clinically indicated and caution should be exercised when used in an immunocompromised population.Figure 1.: Thickened pulmonic valve leaflet, concerning for small vegetation.Figure 2.: Aortic root thickening.

Clinical Value of Single-Photon Emission Computed Tomography Combined With Computed Tomography for Gallium-67 Scan

背景：鎵-67應用於腫瘤與發炎造影，但是鎵-67影像解析度較差且生理分布有時候變異性較大，因此單靠平面的全身掃描影像有時候不足以判斷疾病位置與範圍，而且有時難以區分是疾病造成的病理性攝取或是正常生理性分布。合併單光子斷層／電腦斷層影像可以增加平面影像的診斷效能，這項回顧性研究的目的在於評估單光子斷層／電腦斷層在鎵-67掃描判讀的額外貢獻。方法：從2016年2月到2017年4月，我們部門共進行了379人次的鎵-67腫瘤或發炎造影，核醫專科醫師選擇了61（16.1%）位患者進行單光子斷層／電腦斷層，選擇標準為單靠平面影像無法確定判讀的鎵-67放射活性，包括懷疑是病理性攝取但不太確定的病灶和可能是生理性但是不太尋常的分布。結果：在61位患者的平面影像上共有86處放射活性無法確定判讀，包括52處懷疑是病理性攝取和34處可能是生理性分布。在52處懷疑是病理性病灶中，單光子斷層／電腦斷層確認38處為病理性攝取的病灶，12處對於疾病的位置或範圍有不同的判讀，2處判讀由病理性攝取改為生理性分布。在34處可能是生理性分布中，單光子斷層／電腦斷層確認27處為正常生理性分布，7處判讀由生理性分布改為病理性攝取。單光子斷層／電腦斷層總共確認了65（75.6%）處的判讀結果，並改變了21（24.4%）處的判讀結果。結論：鎵-67掃描合併單光子斷層／電腦斷層與只靠平面圖像判讀相比，可以額外增加判讀結果的可信度與準確性。

Symptoms

Symptoms

Driveline Rerouting and Incision & Drainage for the Management of Chronic Driveline Infection in LVAD Recipients

Driveline infections (DLI) contribute significant morbidity to patients implanted with a left ventricular assist device (LVAD). Refractory infection despite appropriate antibiotic therapy warrants surgical intervention. We report the long-term results of patients undergoing surgical treatment for DLI. A single institutional retrospective chart review was performed for patients undergoing surgical treatment for DLIs from January 2017 to June 2019. Cohorts were defined by the index surgical procedure for a DLI; incision and drainage (I&D) or driveline rerouting(DR). DR included wide debridement of the infected tract, stripping of the velour, and re-tunneling of the driveline utilizing a sterile pieced of plastic tubing that was tunneled to a new exit site. (Figure 1) RESULTS: Fifteen patients underwent surgical therapy for DLIs. Mean age was 60 years. 13 (87%) patients were male. Average BMI was 26 kg/m2 and 5(33%) patients had DM. Implantation strategy was bridge to transplant (4) and destination therapy (11). Implanted devices included Heartmate III (9 pts), Heartmate II (5 pts) and HeartWare (1 pt). Median cardiopulmonary bypass time on index implantation was 76 (62-144) minutes. The most common presentation of DLI was driveline exit site drainage in 13(86%) pts. Gallium scan was performed in 12(80%) patients, 11 (92%) which showed increased uptake at driveline site. Average time to first DLI from LVAD implant was 552 days. Index surgical treatment for DLI included DR (8) and I&D (7). Recurrent infection was common (7(47%)pts), 3 DLI and 4 I&D pts. Mean time for reinfection after rerouting was 261 days and after I&D was 135 days. The difference in means was not statistically significant (p=0.86). Driveline rerouting is an acceptable treatment strategy for DLI. Compared to local drainage procedures, DR may result in an increased time free from recurrent infection. Reinfection rates are high in all cases of DLI and most occur less than 1 year after intervention.

A Study to Estimate the Variations in Management of Malignant Otitis Externa at Two Different Socio-Economic Hospitals: A Clinical Dilemma

Introduction: Malignant otitis externa is an aggressive and potentially fatal infection of ear and skull base. Few studies have attempted to frame a protocol for management of this condition. However, the applicability of protocols involving radionuclide investigations in rural areas with restricted access is a challenge. Also, treatment with oral quinolones has since been threatened as their use has become widespread and indiscriminate. Objective: Owing to lack of standardized diagnostic criterion and treatment regimes, and growing concerns regarding quinolone resistance, we reviewed cases of malignant otitis externa treated across two different socio-economic centres to identify diagnostic and management difficulties. Methods: A retrospective data analysis of patients with malignant otitis externa managed in a tertiary and primary care hospital was done between December 2017 and November 2018. All relevant data was retrieved for assessment. Results: 43 patients were identified, out of these 19 were at the private institute and 24 at the charitable institute. Otalgia was the predominant symptom among all. Pseudomonas aeruginosa was the most commonly isolated organism (81% of patients). Ciprofloxacin resistance reported was 38%. The tertiary care institute used CT and Gallium scans for diagnosis, whereas primary centre employed clinical parameters and CT only. Treatment included Meropenem, Ceftazidime, Amikacin at tertiary centre and Ciprofloxacin and Streptomycin at primary centre. Conclusions: Incidence of Ciprofloxacin resistance was high in our study confirming the growing concern documented in other studies. Access to higher antibiotics was restricted in rural areas where Streptomycin was used in combination with other drugs with promising results.