Incidentally detected diaphragmatic hernia mimicking angina pectoris with Tc-99m MIBI myocardial perfusion imaging
A 74-year-old male patient with a history of hypertension, hypercholesterolemia, a mild transient chest pain, palpitation and severe dyspnea was referred to our Nuclear Medicine Department for Myocardial Imaging. Consists of a detailed medical history from the patient, characteristics of the chest pain was astringent, nonproductive, localized in the central part of the chest and occur after eating, and also cough and nausea accompanied by angina. The patient experienced severe dyspnea which was worse in supine position. All the laboratory blood biochemistry findings, complete blood count, the blood cardiac enzymes levels (troponin, creatinine phosphokinase, myocardial isoenzyme) electrocardiogram, echocardiography were in normal range. But, the chest X-ray was not performed before myocardial perfusion scan.\nAfter written informed consent was obtained from the patient, he underwent same day stress and rest 99mTc MIBI myocardial imaging with SPECT and stress test was performed with treadmill exercise. Target heart rate was 147 beat/min, achieved heart rate was 139 beat/min (94%) with 9.7 METS in 06.00 minutes. Stress images were acquired 45 minutes after intravenous administration of 296 MBq (8 mCi) at the peak heart rate on treadmill exercise test. Subsequently, the rest images were acquired 60 minutes after the second intravenous administration of 925 MBq (25 mCi). The images, provided after motion correction but not attenuation correction, show a moderate to severely reduced perfusion in the mid and inferolateral segments. In gated SPECT process, wall motion and thickening was normal. The ejection fraction was 60%. A review of the unprocessed data of rest imaging revealed, an extracardiac activity localized in the left hemitorax, behind the myocardium like a mirror vision of the left ventricle myocardium in rest images. The raw data of the rest images revealed a doughnut activity in the left chest, behind of the left ventricle. On the contrary, only minimal minimal activity was seen in the raw data of the stress at this localization []. Localization of 99mTc MIBI within that area likely considered as a herniation, which was not mentioned in the patients’ history.\nThe patient subsequently underwent the CT scan of the thorax and upper abdomen for the determination of the nature of the mass. Subsequent computed tomography (CT) of the thorax demonstrated that a part of the bowel, stomach and mesenteric fat tissue were herniated in the left hemithorax and because of these herniated tissues, the lungs were compressed at this localization []. Computed tomography (CT) of the thorax confirmed that the activity in the raw data of the MPS images corresponded to the left diaphragmatic hernia (Bochdalek type). Within the CT results; as the myocardial perfusion scintigraphy was normal, the patient's symptom of dyspnea, angina and vomiting was correlated with the herniation. The patient was referred to thoracic surgery clinic for the surgery.