Paediatric gastric and intestinal Crohn's disease detected by ...Original Case Report Figure 1.The...
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Original Case Report Paediatric gastric and intestinal Crohn's disease detected by 18 F-FDG PET/CT Abstract We present a case of gastric and intestinal Crohn's disease associated with extra-intestinal manifestations of fever, rash in the lower limbs, in a 12 years old boy. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) was performed for the diagnosis of the disease causing fever of unknown origin. Gastroscopy showed polypoid hyperplasia and ulcers in the stomach and their pathology suggested gastric Crohn's disease. Intestinal Crohn’s disease was also diagnosed. Cor- ticosteroids were temporarily effective. During 2 years of follow-up, there were clinical remissions and re- lapses confirmed by endoscopy in both the stomach and the small intestine. Hell J Nucl Med 2014; 17(3): 208-210 Published online: 22 December 2014 Introduction C rohn's disease can affect all gastrointestinal tract, but rarely the stomach. Gastric and intestinal endoscopy are first used for its diagnosis [1]. Fluorine-18-fluo- rodeoxyglucose ( 18 F-FDG) hybrid positron emission tomography and computed tomography scan (PET/CT) has often been used to diagnose mucosal inflammation in cases of gastrointestinal Crohn’s disease in adults and children [2-7]. To our knowledge, this is the first report published of 18 F-FDG uptake on a PET/CT scan in a pediatric patient with gastric and intestinal Crohn’s disease. Case report and Discussion A 12 years old boy presented with intermittent fever of unknown origin of 40 days dura- tion. The concurrent symptoms included sore throat, abdominal pain and nausea. These symptoms were relieved by antibiotics and gastric mucosal protective agents. The boy also had weight loss. His white blood cells were 11.7x10 9 /L, with neutrophils 83,4%, red blood cells 3,73×10 12 /L, hemoglobin 107g/L, platelets 220x10 9 /L, C-reactive protein 86mg/L and erythrocyte sedimentation rate 46mm/h. Blood culture was negative. Bone marrow biopsy showed inflammatory lesions. Abdominal ultrasound showed enlarged pancreas with uniform echo and peri-pancreatic and mesenteric lymph nodes (the largest lymph node was18mm x 8mm). The 18 F-FDG PET/CT scan demonstrated diffuse heterogeneous uptake of the gastric walls (Fig. 1A arrows). The corresponding CT images showed a slight thickening of the gastric walls (Fig. 1B). The fused PET and CT images with the yellow areas confirmed that the 18 F-FDG uptake was focal (Fig. 1C). The MIP image showed a similar pattern (Fig. 1D arrows). Gastroscopy was performed, and its images showed multiple gastric areas of polypoid hyperplasia and ulcers of the gastric wall (Fig. 2A arrows). Pathology films after biopsy during gastroscopy showed granuloma and multiple inflammatory cells (Fig. 2B). Subsequently, the patient received corticosteroid treatment. Ultrasound gastroscopy per- formed after a 10 days course of corticosteroids showed normal gastric wall (Fig. 2C and 2D). After two years, the patient had again intermediate fever, weight loss and shapeless stools positive for haemoglobin. Colonoscopy showed polypoid hyperplasia and ulcers with thickening of the small intestinal wall (Fig. 3A). Biopsy performed during colonoscopy showed granuloma and multiple inflammatory cells (Fig. 3B). Guangying Wang 1 BA, Yukun Ma 2 MD, Licheng Chen 3 MD, Chao Ma 4 MD 1. Department of Internal Medi- cine, 2. Department of Pediatric Surgery and 3. Internal Medicine, Linyi Peo- ple’s Hospital, Shandong, China, 4. Nuclear Medicine, Xinhua Hos- pital, Affiliated to School of Medi- cine Shanghai Jiaotong University, Shanghai, China Keywords: Gastric Crohn's dis- ease - Intestinal Crohn’s disease - In children - Diagnosis by 18 F-FDG-PET Correspondence address: Licheng Chen MD Jiefang Road 27 Internal Medicine, Linyi People’s Hospital, Shandong, China. Tel: +0539-86-82112918, E-mail:[email protected] Received: 18 November 2014 Accepted revised: 2 December 2014 208 Hellenic Journal of Nuclear Medicine • September - December 2014 www.nuclmed.gr
Transcript of Paediatric gastric and intestinal Crohn's disease detected by ...Original Case Report Figure 1.The...
Original Case Report
Paediatric gastric and intestinal Crohn's disease detected by 18F-FDG PET/CT
AbstractWe present a case of gastric and intestinal Crohn's disease associated with extra-intestinal manifestationsof fever, rash in the lower limbs, in a 12 years old boy. Fluorine-18 fluorodeoxyglucose positron emissiontomography/computed tomography (18F-FDG PET/CT) was performed for the diagnosis of the diseasecausing fever of unknown origin. Gastroscopy showed polypoid hyperplasia and ulcers in the stomachand their pathology suggested gastric Crohn's disease. Intestinal Crohn’s disease was also diagnosed. Cor-ticosteroids were temporarily effective. During 2 years of follow-up, there were clinical remissions and re-lapses confirmed by endoscopy in both the stomach and the small intestine.
Hell J Nucl Med 2014; 17(3): 208-210 Published online: 22 December 2014
Introduction
Crohn's disease can affect all gastrointestinal tract, but rarely the stomach. Gastricand intestinal endoscopy are first used for its diagnosis [1]. Fluorine-18-fluo-rodeoxyglucose (18F-FDG) hybrid positron emission tomography and computed
tomography scan (PET/CT) has often been used to diagnose mucosal inflammation incases of gastrointestinal Crohn’s disease in adults and children [2-7]. To our knowledge,this is the first report published of 18F-FDG uptake on a PET/CT scan in a pediatric patientwith gastric and intestinal Crohn’s disease.
Case report and Discussion
A 12 years old boy presented with intermittent fever of unknown origin of 40 days dura-tion. The concurrent symptoms included sore throat, abdominal pain and nausea. Thesesymptoms were relieved by antibiotics and gastric mucosal protective agents. The boyalso had weight loss. His white blood cells were 11.7x109/L, with neutrophils 83,4%, redblood cells 3,73×1012/L, hemoglobin 107g/L, platelets 220x109/L, C-reactive protein86mg/L and erythrocyte sedimentation rate 46mm/h. Blood culture was negative. Bonemarrow biopsy showed inflammatory lesions. Abdominal ultrasound showed enlargedpancreas with uniform echo and peri-pancreatic and mesenteric lymph nodes (the largestlymph node was18mm x 8mm).
The 18F-FDG PET/CT scan demonstrated diffuse heterogeneous uptake of the gastricwalls (Fig. 1A arrows). The corresponding CT images showed a slight thickening of thegastric walls (Fig. 1B). The fused PET and CT images with the yellow areas confirmed thatthe 18F-FDG uptake was focal (Fig. 1C). The MIP image showed a similar pattern (Fig. 1Darrows). Gastroscopy was performed, and its images showed multiple gastric areas ofpolypoid hyperplasia and ulcers of the gastric wall (Fig. 2A arrows). Pathology films afterbiopsy during gastroscopy showed granuloma and multiple inflammatory cells (Fig. 2B).Subsequently, the patient received corticosteroid treatment. Ultrasound gastroscopy per-formed after a 10 days course of corticosteroids showed normal gastric wall (Fig. 2C and2D). After two years, the patient had again intermediate fever, weight loss and shapelessstools positive for haemoglobin. Colonoscopy showed polypoid hyperplasia and ulcerswith thickening of the small intestinal wall (Fig. 3A). Biopsy performed during colonoscopyshowed granuloma and multiple inflammatory cells (Fig. 3B).
Guangying Wang1 BA, Yukun Ma2 MD, Licheng Chen3 MD, Chao Ma4 MD
1. Department of Internal Medi-cine, 2. Department of Pediatric Surgery and 3. Internal Medicine, Linyi Peo-ple’s Hospital, Shandong, China, 4. Nuclear Medicine, Xinhua Hos-pital, Affiliated to School of Medi-cine Shanghai JiaotongUniversity, Shanghai, China
Keywords: Gastric Crohn's dis-ease - Intestinal Crohn’s disease- In children- Diagnosis by 18F-FDG-PET
Correspondence address:Licheng Chen MD Jiefang Road 27 InternalMedicine, Linyi People’s Hospital, Shandong, China. Tel: +0539-86-82112918, E-mail:[email protected]
Received:18 November 2014
Accepted revised:2 December 2014
208 Hellenic Journal of Nuclear Medicine • September - December 2014 www.nuclmed.gr
Original Case Report
Figure 1.The first column of images on the left, presents three representative trans-verse images through the stomach from the patient’s 18F-FDG PET/CT scan thatdemonstrate diffuse heterogeneous uptake (1A arrows). The images in the secondcolumn are the corresponding CT images (1B). The third column (1C) represents thefused PET and CT images with the yellow areas confirming that the 18F-FDG uptakeis localized in a large portion of the gastric wall. The far right image is the MIP image(1D see arrows) demonstrating the pattern of 18F-FDG uptake.
Figure 2. Gastroscopy demonstrated multiple gastric areas of polypoid hyperplasiaand ulcers of the gastric wall (2A arrows). Biopsy performed during gastroscopydemonstrated a granuloma and multiple inflammatory cells (2B arrows). All thesefindings are characteristic of gastric Crohn’s disease. An ultrasound gastroscopyperformed 10 days after treatment with corticosteroids showed normal gastricwalls (2C and 2D).
Figure 3. A, B: After two years of follow-up, colonoscopy showed polypoid hyperplasiaand ulcers and thickening of the small intestine wall (3A). Biopsy performed duringcolonoscopy demonstrated a granuloma and multiple inflammatory cells (3B).
The clinical presentation of Crohn’s disease is primarily de-termined by the location and extent of the disease. Withupper gastrointestinal tract involvement, nausea, vomiting,and abdominal pain prevail. Children and adolescents pre-senting with Crohn's disease usually have weight loss. Ourcase had all these symptoms and also fever. Crohn's diseasemay affect any part of the gastrointestinal tract, sometimesmore than one part, and can cause local inflammation [8]. Itsclinical course is characterized by a succession of periods ofclinical relapse and remission, as in our case in which lesionsin the intestine were also diagnosed 2 years later after diag-nosis of the gastric lesions.
Endoscopy has been considered the gold standard to diag-nose and assess Crohn’s disease [1]. However, endoscopy isunpleasant for the patient, sometimes incomplete because ofunreachable segments of the stomach, and can assess onlymucosal lesions, although the disease may sometimes affectdeeper parts of the gastrointestinal wall [5]. Focally enhancedgastritis (FEG) is typified by small collections of lymphocytesand histiocytes surrounding a small group of foveolae or gas-tric glands, often with infiltrates of neutrophils. Interestingly,the significance of FEG was commonly observed in youngerpatients, with the peak in the 5 to 10 years of age group (80%).Therefore, FEG may be associated with disease activity andthe presence of granulomas in pediatric Crohn’s disease [9].The 18F-FDG PET/CT scan is a noninvasive technique that canlocalize and semi-quantify inflammatory gastrointestinalareas [2-5].
However, CT and 18F-FDG PET/CT examinations are associ-ated with substantial exposure to ionising radiation. Even withchild-adapted low-dose protocols, patients undergoing a sin-gle 18F-FDG PET/CT examination are exposed to ionising radi-ation in the order of 10-20mSv, which is equivalent to roughly700-750 chest radiographs [10]. Therefore, 18F-FDG-PET hasto be discussed as a tool for the determination of extent anddegree of Crohn’s disease considering its additional radiationexposure. For pediatric patients 18F-FDG PET/CT can play a rolein the diagnosis and management of the underlying diseasein cases of fever of unknown origin.
In conclusion, to our knowledge this is the first reported 18F-FDG PET/CT examination of gastric and intestinal Crohn’s dis-ease. A pattern with diffuse heterogeneous uptake of 18F-FDGPET/CT in the gastric wall, may indicate among other diag-noses, the diagnosis of gastric Crohn’s disease.
The authors declare that they have no conflicts of interest.
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The second terrace with view to the third of the Asklepion, in Kos, the island where Hippocrates was born. Photo from Prof. Andreas Otte.
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