LAUSR

An 81-year-old male patient with chronic kidney failure and prior trans-catheter aortic valve and pacemaker (PM) implantation (Fig. 1a) presented to the emergency department of our hospital with a 1-day history of severe, discontinuous, movement-linked high thoracic back pain. Clinical examination and a native thoraco-abdominal computed tomography (CT) scan were non-contributive for the diagnosis (Fig. 1b). During evaluation, the patient shivered and became feverish. Sepsis of unknown origin was hypothesized; blood samples were taken and empiric broad-spectrum antibiotics administered. The day after the admission, five out of six blood cultures revealed growth of methicillin-sensitive Staphylococcus aureus. We narrowed the antibiotic spectrum and performed a transesophageal echocardiography study, which ruled out endocarditis. Fluorine-18-fluorodeoxygluocose positron emission tomography/computed tomography (18F-FDG PET/ CT) was performed for advanced source identification. Increased radiotracer uptake was noted around the second dorsal vertebra (Fig. 1c–d, arrowhead) and along the subclavian portion of the PM wires (Fig. 1d, arrow). These findings were consistent with a septic vegetation on the proximal portion of the PM leads and spondylodiscitis from a septic embolism. Based on these data, we continued antibiotic therapy and removed the PM with leads. This case shows the role of 18F-FDG PET/CT in the identification of difficult to find septic foci.