Accepted Manuscript Title: Candida Pyelonephritis on FDG PET/CT Author: Junwei Zhang Lih Kin Khor Arvind Sinha Hoi Yin Loi PII: DOI: Reference:
S1201-9712(16)31165-1 http://dx.doi.org/doi:10.1016/j.ijid.2016.09.008 IJID 2713
To appear in:
International Journal of Infectious Diseases
Received date: Revised date: Accepted date:
15-8-2016 3-9-2016 5-9-2016
Please cite this article as: Zhang J, Khor LK, Sinha A, Loi HY, Candida Pyelonephritis on FDG PET/CT, International Journal of Infectious Diseases (2016), http://dx.doi.org/10.1016/j.ijid.2016.09.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Highlights
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Renal lesions are rarely demonstrated on FDG PET/CT in candidiasis. Renal lesions are often overlooked due to physiological urinary tracer excretion. Careful review is needed in oncology cases due to risk of opportunistic infection. FDG PET/CT is a valuable problem-solving tool in cases of fever of unknown origin.
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TITLE PAGE Title of Article: Candida Pyelonephritis on FDG PET/CT Type of Manuscript: Medical Imagery Authors:
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1. Junwei Zhanga (corresponding author) 2. Lih Kin Khora
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3. Arvind Sinhaa
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4. Hoi Yin Loia Institutional Affiliation of the Authors:
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a. Department of Diagnostic Imaging, National University Hospital, Singapore Address for Correspondence:
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Department of Diagnostic Imaging, Level 2 Main Building, National University Hospital 5 Lower Kent Ridge Road, Singapore 119074
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Email:
[email protected] Tel: (65) 6779 5555 Fax: (65) 6779 5678
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Financial Disclosures and Conflicts of Interest: None
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Candida Pyelonephritis on FDG PET/CT A seven year-old boy with newly-diagnosed B-cell acute lymphoblastic leukaemia on chemotherapy presented with fever of unknown origin (FUO). 18F- fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) shows abnormal FDG
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uptake with decreased enhancement in the cortex of the left kidney upper pole (Fig. 1), which is distinct from the normal tracer activity in the medulla and collecting system. Urine cultures
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were positive for Candida tropicalis and Candida glabrata and consistent with fungal
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pyelonephritis. There is also increased FDG uptake in the lower oesophagus and lower lobes (Fig. 2). Cultures from esophagoscopy and bronchoalveolar lavage were positive for C.
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tropicalis and C. glabrata and anti-fungal treatment with intravenous caspofungin commenced. Follow-up ultrasound over one month shows resolution of the hyperechoic
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lesion in the left kidney upper pole (Fig. 3).
Candidiasis has been shown to cause FDG-avid lesions in multiple organs, although renal
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lesions are rarely demonstrated [1,2]. Due to physiological tracer excretion, metabolically active lesions in the kidneys are often obscured and overlooked on FDG PET/CT [3]. This
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case highlights the need to pay careful attention to the configuration of tracer excretion and
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correlate with CT, so that lesions are not missed. This is especially pertinent in oncology patients where opportunistic infection often involves the kidneys. In invasive candidiasis, blood cultures are often negative despite the presence of deep-seated tissue infections, such as in our patient [4]. In FUO cases, FDG PET/CT is valuable in highlighting potential tissue sampling sites with the highest yield for cultures, allowing both diagnosis and susceptibility testing [2,5]. While the finding of increased FDG uptake in the kidneys is not specific, there may occasionally be morphological features on CT that point towards a fungal aetiology, such as the soft tissue filling defect of a fungus ball in the collecting system [6,7]. Source of funding None.
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Conflict of interest None. Ethical approval Approval was not required. References 1.
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Figure Legend Fig. 1 (a) FDG PET/CT shows an FDG-avid lesion in the cortex of the left kidney upper pole (solid arrows), which is distinct from the normal tracer activity in the medulla and collecting system (dashed arrows). (b) FDG PET/CT also shows increased FDG uptake in the lower
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oesophagus and bilateral lower lobes (arrows). (c) Follow-up renal ultrasound over one month demonstrates resolution of the focal cortical swelling and increased echogenicity in the
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left kidney upper pole (arrow).
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