Detection of an Infected N-butyl-2-cyanoacrylate Plug by F-18 FDG PET/CT Scan in a Patient Who Received Endoscopic Intervention for Gastric Variceal Bleeding
A 63 year-old male with a history of hepatitis B associated liver cirrhosis (Child-Pugh Class A) was admitted to the emergency room with upper gastrointestinal bleeding. The hemoglobin level was 11.8 g/dL. Emergency upper endoscopy showed active bleeding from the cardiac varix (Gastro-esophageal varices-2 according to the Sarin classification). Hemostasis was achieved by injection of 2 mL of N-butyl-2-cyanoacrylate and he was discharged without complications.\nThe patient was readmitted one month later because of fever and myalgia, which started 10 days after discharge. The patient's vital signs at admission were as follows: temperature of 38.2℃, blood pressure of 126/70 mmHg, pulse rate of 124 beats/min, and a respiratory rate of 20 breaths/min. Physical examination showed no abnormalities. Results of laboratory tests were as follows: white blood cell 6,500/mm3 (neutrophil 84.9%), hemoglobin 10.4 g/dL, and platelet count 70,000/mm3. Erythrocyte sedimentation rate and C-reactive protein were elevated at 31 mm/hr and 3.89 mg/dL. Albumin was slightly decreased to 2.9 g/dL, aspartate aminotransferase (AST) was slightly increased to 42 IU/L, and other blood chemistry results were within the normal range: alanine aminotransferase (ALT) 28 IU/L, blood urea nitrogen (BUN) 8.4 mg/dL, and creatinine 0.80 mg/dL. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) were prolonged at INR 1.38 and 45 seconds. Because the patient had a history of of N-butyl-2-cyanoacrylate injection for gastic variceal bleeding control, infection through the N-butyl-2-cyanoacrylate plug was suspected and piperacillin/tazobactam and amikacin were started empirically. Abdominal CT () and follow up gastroscopy () showed an N-butyl-2-cyanoacrylate plug. Leukocyte scintigraphy showed only hypersplenism. Both TTE and TEE were performed in order to exclude infective endocarditis; both findings were negative. F-18 FDG (FDG) PET/CT performed on a Siemens/Biography Duo PET/CT scanner 60 minutes after intravenous injection of 12 mCi (444 MBq) of FDG showed focal FDG uptake (maximum SUV = 3.41) around the N-butyl-2-cyanoacrylate plug in the stomach cardia on fusion transverse images of FDG PET/CT (). Viridans streptococcus was isolated from three separate blood cultures on the same day. It was suspected that the infected N-butyl-2-cyanoacrylate plug in the gastric varices was the source of bacteremia and antibiotics were changed to penicillin G and gentamicin. Follow up blood culture after one week of intravenous antibiotic treatment was negative for Viridans streptococcus. Follow up FDG PET/CT performed after two weeks of treatment with intravenous antibiotics showed a marked decrease in FDG uptake around the N-butyl-2-cyanoacrylate plug (). Treatment consisted of only intravenous antibiotics, without surgery or endoscopic intervention. The patient was discharged without fever or any sign of infection after four weeks of intravenous antibiotics. The patient visited the outpatient department five days after discharge without any sign of relapse.