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We present the case of a patient with an atypical course of frontotemporal lobar degeneration (FTLD) complicated by the use of an anticholinergic drug. A 70-year-old patient, followed by psychiatrists for depression and behavioral disorders, received a diagnosis of dementia with Lewy bodies (DLB) at another Center due to auditory hallucinations, gait impairment, and tendency to fall. He was then admitted to our Memory Clinic Unit for behavioral disturbances, such as delusional thinking, auditory hallucinations, and memory complaints. At that time, the patient's therapy included Lorazepam, Quetiapine, Promazine, and Biperiden. The latter was immediately suspended for the absence of extrapyramidal signs and to avoid the anticholinergic cognitive side effects. A 18F-FDG PET showed a derangement of cortical metabolism with diffusely reduced activity, and limited areas of hyperactivity involving lateral frontal and lateral temporal inferior regions bilaterally. The patient underwent a series of exams, including neuropsychological tests, 123I-MIBG scintigraphy, cerebrospinal fluid examination, and genetic analysis. A second 18F-FDG PET showed an extensive remodulation of metabolic activity: relative higher concentration of the tracer in the prefrontal and inferior temporal cortex was no more detectable. Similarly, the diffuse reduced metabolic activity could not be traced anymore. Nonetheless, the metabolic activity still appeared reduced in the frontal lobe, in the anterior cingulate bilaterally, and in the anterior part of the hemispheric fissure. Taken together, clinical and neuroimaging features would point to a FTLD-like form. Furthermore, the diagnostic work-up was likely confounded by the anticholinergic drug on 18F-FDG PET, highlighting the importance of carefully checking the patient's pharmacology during the diagnostic process.

Purpose To assess the presence and pattern of incidental interstitial lung alterations suspicious of COVID-19 on fluorine-18-fluorodeoxyglucose positron emission tomography (PET)/computed tomography (CT) ([18F]FDG PET/CT) in asymptomatic oncological patients during the period of active COVID-19 in a country with high prevalence of the virus. Methods This is a multi-center retrospective observational study involving 59 Italian centers. We retrospectively reviewed the prevalence of interstitial pneumonia detected during the COVID period (between March 16 and 27, 2020) and compared to a pre-COVID period (January–February 2020) and a control time (in 2019). The diagnosis of interstitial pneumonia was done considering lung alterations of CT of PET. Results Overall, [18F]FDG PET/CT was performed on 4008 patients in the COVID period, 19,267 in the pre-COVID period, and 5513 in the control period. The rate of interstitial pneumonia suspicious for COVID-19 was significantly higher during the COVID period (7.1%) compared with that found in the pre-COVID (5.35%) and control periods (5.15%) (p

In the present work, we report the case of a patient presenting signs of Lewy body dementia (DLB) and frontotemporal dementia (FTD) throughout different phases of the disease. In January 2017, a 79-year-old right-handed living man was admitted to our Memory Clinic for the presence of behavioral disturbances and progressive cognitive decline. For the previous six years, he was monitored by other Neurological Clinics for the onset of extrapyramidal features. Indeed, through the first phase of the disease (2011-2014), the patient predominantly showed: extrapyramidal features, initial cognitive decline, sleep disturbances, and visual hallucinations, together with a reduced dopamine transporter uptake in basal ganglia at the DATscan, suggesting a diagnosis of DLB. In a second phase (2015-2017), while his extrapyramidal features remained substantially stable, his cognitive profile deteriorated, with an additional development of severe behavioral and neuropsychiatric disturbances. Again, a subsequent DATscan study was positive and slightly worse than the preceding one; however, the 18F-FDG PET showed reduced metabolic activity in the frontal and temporal lobes, with the occipital regions left spared. Genetic analysis revealed a hexanucleotide expansion in C9ORF72 (6//38 repeats; ITALSGEN NV

The diagnosis of infective endocarditis (IE) is sometimes difficult when there are discrepancies between blood cultures, transesophageal echocardiography (TEE) and clinical judgment. The aim of this study was to assess the incremental diagnostic value of 18 F-FDG-PET/CT in 45 consecutive patients (73% male, mean age 61 ± 26 years) with suspected IE and inconclusive tests at admission. In 28 patients (19 with a cardiac valvular (15) or nonvalvular (4) device) with blood cultures positive for germs typically involved in IE the initial TEE was negative or inconclusive. In 10 patients presenting with fever TEE identified cardiac lesion possibly related to IE (ruptured mitral chordae, thickened valve leaflet, thickened prosthetic annulus), but blood cultures were persistently negative. Finally, 7 patients had metastatic or embolic lesions and a predisposing cardiac condition, but TEE was negative. When previous unknown lesions detected by PET/CT were confirmed by succeeding examinations, they were considered true positives. When PET/CT was negative, it was compared with the final diagnosis that was defined according to the modified Duke criteria determined during a 6-month follow-up. Thirty patients had definite IE at the end of the follow-up, 3 had possible IE, and in 12 patients the diagnosis was rejected. Twenty-seven patients (60%) exhibited abnormal FDG uptake around the cardiac valves, and 12 (27%) had extracardiac accumulation. In 5 patients the initial negative TEE became positive a mean 5 ±7 days after PET/CT had been performed The sensitivity, specificity, positive predictive value, and negative predictive value of PET/CT were as follows (95% confidence interval): 87% (68% to 95%), 67% (38% to 87%), 84% (65% to 94%), and 71% (42% to 92%), respectively. Adding abnormal FDG uptake as a new major criterion significantly increased the sensitivity of the modified Duke criteria at admission (68% [53% to 82%] vs. 96% [88% to 99%], p = 0.01). This result was due to a significant reduction (p < 0.001) in the number of possible IE cases. In conclusion PET/CT increases the diagnostic accuracy for IE in the subset of patients with possible IE and may help to manage a challenging situation.

A 76-year-old male with previous aortic valve replacement presented with intermittent fever. No apparent source of infection was found at clinical inspection. Blood cultures were positive for Streptococcus anginosus . Infective endocarditis was suspected and transoesophageal echocardiography (TOE) was performed. The exam showed a mildly degenerated bioprosthesis with thickened leaflets; there was an increased gradient (mean gradient 22 mmHg); neither valvular nor perivalvular regurgitation was identified. These findings were suspect for …

To compare some of the confirmatory investigations of brain death with clinical criteria in order to achieve the most sensitive and accurate diagnosis of brain death. All patients with isolated brain lesions and Glasgow Coma Scale (GCS)=3 were subjected to neurological examination after ruling out hypothermia, metabolic disorders and drug intoxications and diagnosed as clinically brain-dead when the brainstem reflexes were absent and the apnea test positive.Patients: 15 patients with clinical diagnosis of brain death entered this study. The patients were submitted to the following investigations: electroencephalogram (EEG), transcranial Doppler (TCD) of the middle cerebral arteries (MCA), cerebral blood flow measurements with the i.v. Xe-133 method (CBF) and selective cerebral angiography (CA). EEG was isoelectric in 8 patients while the remaining 7 patients showed persistence of electrical activity. TCD was compatible with intracranial circulatory arrest in 18 MCA districts, compatible with normal flow in 2 and undetectable in 10 out of 30 districts insonated. In CBF examinations, however, all the patients showed a characteristic “plateau” of the desaturation curves lasting through the whole investigation and suggestive of absent cortical flow. CA showed circulatory arrest in both carotid and vertebral arteries. Our study suggests that cerebral angiography and CBF studies are the most reliable investigations whereas the role of EEG and TCD remains to be determined because of the presence of false negatives and positives.

Sixty-eight severely head injured comatose patients were studied. Bit-colour-mapped SEPs to median nerve stimulation. BAEPs, CT and SPET regional values and ICP were assessed in relation to clinical information in evaluating cerebral function. All these variables were related to a 1-year outcome. Statistical tests confirmed the higher predictive reliability of both neurophysiological and perfusive (SPET) functional parameters compared to CT structural findings. Generally, SEPs appeared to be more reliable in predicting outcome than BAEPs. Modifications of frontal components could occur independently of post-central ones, being closely related to underlying cerebral lesions. The parameter showing the greatest correlation with outcome in the first recording session was the P25 latency, whereas this prognostic role was mainly assumed by the amplitude value of the frontal N30-P45 complex in a second recording session carried out during the third week following head trauma.