Agreement between SPECT V/Q scan and CT angiography in patients with high clinical suspicion of PE.

OBJECTIVE: To track agreement between single positron emission computed tomography (SPECT) V/Q and CT angiography in patients with high clinical suspicion of pulmonary embolism (PE). If significant agreement occurs, a case could be made for more frequent use of chest radiography followed by SPECT V/Q scanning given its lower risk profile. INTRODUCTION: Diagnosis of PE can be difficult. CT pulmonary angiography (CTA) is the preferred initial test, but may be indeterminate, is a significant source of ionizing radiation, and is contraindicated in renal insufficiency. SPECT ventilation/perfusion imaging (V/Q) is therefore preferred in certain patients. METHODS: Two thousand nine hundred and twenty patients admitted to a tertiary care hospital in New York City were screened and 100 consecutive high-risk patients who required both CTA and V/Q for an initial indeterminate or negative imaging test despite a high pre-test probability were identified. The agreement between these tests was evaluated. RESULTS: There was no significant agreement between CTA and V/Q when positive, negative and indeterminate results were included (K = 0.18, SE = 0.09, p = 0.051). However, in the presence of a positive finding on either test, there was substantial agreement between the two (K = 0.62, SE = 0.27, p = 0.02). In 30 cases in which CTA was indeterminate, V/Q was diagnostic 93 % of the time. In 12 cases in which V/Q was indeterminate, CTA was diagnostic 83 % of the time and negative in 100 % of those cases. CONCLUSION: In the presence of an indeterminate CTA in patients with high clinical suspicion of PE, SPECT V/Q often provides a diagnosis.

Non-typhoid Salmonellae and prosthetic valve endocarditis: more than a rare coincidence? A review of the literature.

Non-typhoid Salmonellae (NTS) commonly cause gastroenteritis but are rarely found pathogens in prosthetic heart valve endocarditis. The details of two patients from the authors' institution and 15 published cases are reviewed in terms of their risk factors, clinical findings and outcomes. Only two of eight patients with paravalvular leakage or abscess--the most serious local complications--survived, both with surgery. It appears that NTS bacteremia in patients with prosthetic valves and concomitant risk factors should be treated early with high-dose antimicrobials for up to six weeks in order to minimize the risk of endocarditis.

A postoperative Gerbode defect in aortic prosthesis endocarditis with non-typhoid Salmonella.

The Gerbode defect is a congenital shunt from the left ventricle to the right atrium. The type I defect (2) results in a direct shunt through a portion of the membranous septum, while a type II (indirect) defect occurs if the membranous septal defect lies below the attachment of the septal leaflet of the tricuspid valve. The shunt is directed towards the right atrium through a cleft or perforations of the septal leaflet. Acquired Gerbode defects have been identified in endocarditis, after mitral or aortic valve surgery, or may be post-traumatic. The case is presented of a 69-year-old woman with a postoperative Gerbode defect in association with aortic prosthetic endocarditis caused by non-typhoid Salmonella.

Diffuse alveolar hemorrhage after infliximab treatment of Crohn's disease.

Infliximab (Remicade), a chimeric monoclonal antibody to tumor necrosis factor-alpha (anti-TNF-alpha), is being used with increasing frequency in the treatment of Crohn's disease. Infliximab's safety profile to date has been good with reported adverse events being mild to moderate. We report a case of diffuse alveolar hemorrhage after the second infliximab infusion in a patient with Crohn's disease. The mechanism by which infliximab may have caused the observed pulmonary insult remains unknown. Physicians should be aware of the possible association between infliximab treatment and the development of alveolar hemorrhage. Future cases should be reported.