LAUSR

An 83-year-old man with history of arterial hypertension, type-2 diabetes mellitus, a bioprosthetic aortic valve and a saphenous vein bypass graft to the left anterior descending coronary artery in 2012, presented with a 24-hour history of fever. Pertinent findings included fever, an aortic ejection murmur, pancytopenia and hyperglycemia. The electrocardiogram showed sinus rhythm and non-specific ST and T wave changes (Figure 1). Due to the suspicion of a possible IE, a transthoracic echocardiography was performed and did not show vegetations. The blood cultures were negative. A whole body computed tomography (CT) scan did not show remarkable positive findings at that time. He had persistently negative serial blood cultures but positive IgM and IgG serologies for Bartonella henselae. A F-fluorodeoxyglucose (F-FDG) PET/CT scan was performed after a 48-hour low-carbohydrate diet and the administration of a heparin bolus (50 IU/kg) 15 minutes before F-FDG injection. The PET revealed a focal peri-prosthetic uptake in the aortic valve with a maximum standardized uptake value (SUVmax = 8 g/ml) and a myocardial uptake at the apex (SUVmax = 8.3 g/ ml), which in the CT scan was suggestive of myocardial infarction (MI). The FGD uptake in the that area, suggests viable but ischemic myocardium likely representing stunning or hibernation (Figures 2, 3, and 4). A repeat 2-dimensional echocardiogram was performed showing akinesia of the apex, not present in in the earlier study. A cardiac MRI was performed which showed a thinned and akinetic apex with late subendocardial gadolinium enhancement [ 50% of thickness with an aneurysmal dilatation of the apex of the left ventricle in systole, suggestive of MI (Figure 5). The patient was treated with Doxycycline and Rifampicin and happily recovered and released from the hospital. Reprint requests: Estephany Abou-Jokh Casas, MD, Nuclear Medicine Department, Complejo Hospitalario Santiago de Compostela, Santiago de Compostela, Spain; [email protected] J Nucl Cardiol 2019;26:1057–60. 1071-3581/$34.00 Copyright 2019 American Society of Nuclear Cardiology.