[en] The purpose of this study was to evaluate the diagnostic performance of '1⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) for chronic empyema-associated malignancy (CEAM). We retrospectively reviewed the ¹⁸F-FDG PET/CT images of 33 patients with chronic empyema, and analyzed the following findings: 1) shape of the empyema cavity, 2) presence of fistula, 3) maximum standardized uptake value (SUV) of the empyema cavity, 4) uptake pattern of the empyema cavity, 5) presence of a protruding soft tissue mass within the empyema cavity, and 6) involvement of adjacent structures. Final diagnosis was determined based on histopathology or clinical follow-up for at least 6 months. The abovementioned findings were compared between the ¹⁸F-FDG PET/CT images of CEAM and chronic empyema. A receiver operating characteristic (ROC) analysis was also performed. Six lesions were histopathologically proven as malignant; there were three cases of diffuse large B-cell lymphoma, two of squamous cell carcinoma, and one of poorly differentiated carcinoma. Maximum SUV within the empyema cavity (p < 0.001) presence of a protruding soft tissue mass (p = 0.002), and involvement of the adjacent structures (p < 0.001) were significantly different between the CEAM and chronic empyema images. The maximum SUV exhibited the highest diagnostic performance, with the highest specificity (96.3%, 26/27), positive predictive value (85.7%, 6/7), and accuracy (97.0%, 32/33) among all criteria. On ROC analysis, the area under the curve of maximum SUV was 0.994. ¹⁸F-FDG PET/CT can be useful for diagnosing CEAM in patients with chronic empyema. The maximum SUV within the empyema cavity is the most accurate ¹⁸F-FDG PET/CT diagnostic criterion for CEAM

[en] Metabolic Syndrome is strongly associated with Rheumatoid Arthritis, which significantly increases cardiovascular complications and hence morbidity and mortality. Treating Metabolic Syndrome decreases cardiovascular related disease flares and deaths. This study evaluates prevalence of metabolic syndrome in young Rheumatoid Arthritis patients. Methods: This Cross-sectional study was conducted in rheumatology department of a tertiary care hospital in Karachi. All diagnosed cases of rheumatoid arthritis from April to August 2018 were consecutively included. Disease activity of rheumatoid arthritis assessed by Clinical Disease Activity Index (CDAI). Associate determinants of rheumatoid arthritis were measured along with outcome variables. Results: Out of 104 rheumatoid arthritis patients, 34 (32.7%) found to have metabolic syndrome in whom 20 (58.8%) of patients were seropositive. A significant association of metabolic syndrome was found with age (p-value 0.023), BMI (p-value 0.006), waist circumference (p-value 0.002), FBS (p-value <0.001), SBP (p-value <0.001), DBP (p-value <0.001), TG (p-value <0.001), HDL (p-value 0.022), and Methotrexate drug history (p-value 0.030). Conclusion: We conclude that metabolic syndrome is highly prevalent in young rheumatoid patients with rheumatoid arthritis. Treating Metabolic Syndrome decreases cardiovascular related disease flares and deaths. This young population base study will help out to estimate the exact burden of Metabolic Syndrome to decrease overall morbidity and mortality. (author)

[en] Objective: To determine the frequency of various patterns of cytopenias with Methotrexate-treated rheumatoid arthritis patients and the correlation of pancytopenia with various factors. Study Design: Cross-sectional study. Place and Duration of Study: Rheumatology/General Medicine Department, Pak Emirates Military Hospital Rawalpindi from May 2019 to Mar 2020. Methodology: Patients with rheumatoid arthritis who were managed with Methotrexate for more than six months were included in the study. Full blood counts were performed for all the patients from the laboratory of the hospital. The frequency of monocytopenia, bi-cytopenia and pancytopenia were calculated. Results: Mean age of the study participants was 37.41±5.72 years. One hundred and sixty-eight 168(84%) patients had the presence of any cytopenia, while 32 (16%) did not show the presence of any cytopenia on full blood count. The advancing age and use of polypharmacy had a statistically significant association with cytopenias among patients with rheumatoid arthritis managed with Methotrexate (p-value <0.05). Conclusion: The presence of cytopenia emerged as a relatively common finding among rheumatoid arthritis patients managed with Methotrexate. Advanced age of the patient and patients who required more than one medication to control the symptoms of RA were found at a higher risk for developing pancytopenia while being managed with Methotrexate for rheumatoid arthritis. (author)

[en] Primitive neuroectodermal tumor is a malignant small round cell tumor of presumed neural crest origin, usually affecting the bony structures of the nasal cavity and its clinical and radiological features may be confused with those of infection and malignancy. I report a case with primitive neuroectodermal tumor of the nasal cavity showing increased tracer uptake on ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography mimicking an another primary malignancy in a 17-year-old boy.

[en] Human immune deficiency virus (HIV) is a leading cause of death. It attacks the immune system, thereby rendering the infected host susceptible to many HIV-associated infections, malignancies and neurocognitive disorders. The altered immune system affects the way the human host responds to disease, resulting in atypical presentation of these disorders. This presents a diagnostic challenge and the clinician must use all diagnostic avenues available to diagnose and manage these conditions. The advent of highly active antiretroviral therapy (HAART) has markedly reduced the mortality associated with HIV infection but has also brought in its wake problems associated with adverse effects or drug interaction and may even modulate some of the HIV-associated disorders to the detriment of the infected human host. Nuclear medicine techniques allow non-invasive visualisation of tissues in the body. By using this principle, pathophysiology in the body can be targeted and the treatment of diseases can be monitored. Being a functional imaging modality, it is able to detect diseases at the molecular level, and thus it has increased our understanding of the immunological changes in the infected host at different stages of the HIV infection. It also detects pathological changes much earlier than conventional imaging based on anatomical changes. This is important in the immunocompromised host as in some of the associated disorders a delay in diagnosis may have dire consequences. Nuclear medicine has played a huge role in the management of many HIV-associated disorders in the past and continues to help in the diagnosis, prognosis, staging, monitoring and assessing the response to treatment of many HIV-associated disorders. As our understanding of the molecular basis of disease increases nuclear medicine is poised to play an even greater role. In this review we highlight the functional basis of the clinicopathological correlation of HIV from a metabolic view and discuss how the use of nuclear medicine techniques, with particular emphasis of F-18 fluorodeoxyglucose, may have impact in the setting of HIV. We also provide an overview of the role of nuclear medicine techniques in the management of HIV-associated disorders

[en] To compare computed tomography (CT) and fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) findings of benign pleural changes with those of recurrent malignant pleural lesions in patients with a history of underlying malignancy after talc pleurodesis. Of 194 patients who underwent talc pleurodesis, we retrospectively reviewed 16 patients for whom both follow-up CT and FDG-PET/CT were performed. The morphologic CT findings and maximum standard uptake values (SUVmax) were evaluated and compared between benign pleural changes and recurrent malignant pleural lesions. Twenty-two lesions were found in 16 patients; six patients had no evidence of active pleural disease (group 1) and 10 patients had recurrent malignant pleural lesions on radiological or clinical follow-up (group 2). Characteristic high-density pleural deposits [mean, 131 Hounsfield unit (HU); range, 28-251 HU] were seen along the pleural thickenings (mean, 13.4 mm; range, 4.9-62.3 mm) in 15 patients. The shape and thickness on CT and the SUVmax on FDG-PET/CT showed no significant differences between the two groups. On CT, the pre-contrast attenuation was higher in group 1 than group 2 (165 HU vs. 101 HU, respectively, p = 0.030), and the degree of enhancement was higher in group 2 than that in group 1 (29 HU vs. 48 HU, respectively, p = 0.048). Pleural effusions (n = 5) and other pleural thickening without high-density foci (n = 4) were observed only in group 2; however, no statistical significance was observed between the two groups. Malignant pleural lesions can be characterized by lower pre-contrast attenuation and higher contrast enhancement, whereas benign pleural changes after talc pleurodesis are characterized by higher pre-contrast attenuation and lower contrast enhancement on CT.

[en] Objective: To study the safety profile of MTX+LEF combination in patients with active RA at 03 and 06 months. Study Design: Quasi-experimental study. Place and Duration of Study: Rheumatology department, Fauji Foundation Hospital Rawalpindi, from Jun 2015 to Dec 2015. Material and Methods: This quasi-experimental study was conducted at Rheumatology department, Fauji Foundation Hospital, Rawalpindi. Seventy two patients who had an active RA despite optimal dose (20- 25mg/week) of MTX were enrolled and leflunomide 20mg/day was added. Patients underwent clinical and laboratory review at 0, 1, 3 and 6 months to note any adverse effects. Results: Seventy two patients were enrolled with a mean age (years) ± SD of 51.5 ± 9.1 and a mean duration of disease (years) of 8.25 ± 6.1. Patients had active disease at baseline with a mean disease activity score (DAS28) of 6.2 ± 0.7. At 6 months the most frequent side effects (mostly mild); were abdominal pain and nausea. Fifty Seven patients (79.1%) continued with the combination therapy. Only 3 patients stopped the treatment temporarily (due to raised ALT and vomiting). Twelve patients discontinued treatment due to diarrhea, severe oral ulcers, markedly raised ALT; (Each affecting 2 patients) and severe vomiting, abscess, MTX Induced pneumonitis, severe chest infection (each affecting 1 patient). Conclusion: MTX + LEF combination is safe to use in RA patients if vigilant clinical and laboratory monitoring is ensured. (author)

[en] Objective: To determine the characteristics and subsequent pregnancy outcomes in patients with a previous ectopic pregnancy (EP). Study Design: Descriptive-cross sectional study. Place and Duration of Study: Department of Obstetrics-Gynaecology, Etlik Zubeyde Hanim Maternity and Women’s Health Teaching and Research Hospital, Ankara, Turkey, between January 2014 and December December 2018. Methodology: The data of nulliparous patients diagnosed with tubal ectopic pregnancy (EP) was analysed retrospectively. Reproductive outcomes within the first two years after ectopic pregnancy diagnosis were used as “short-term” reproductive outcomes. Their EP treatment and pregnancy outcome were determined. Results: Expectant management was chosen in 5.8% of the patients, while the surgical intervention was 32.3%. Medical therapy involving methotrexate (MTX) was given to the remaining patients (61.9%). The tubal rupture was confirmed in 12% of the cases that received MTX. In the 2-year follow-up period after the ectopic event, the most common outcome of the subsequent pregnancies was a live birth (47.7%). Recurrent EP occurred in 4.6%. Conclusion: The subsequent short-term pregnancy outcomes in this study were not related to the chosen treatment modality. (author)

[en] Highlights: • The optimal treatment modality for CSP is unknown. • CT-guided needle aspiration and methotrexate injection may be used for management of CSP. • Three cases of CSPs successfully treated with CT-guided methotrexate injection.

[en] To evaluate the advantages of contrast enhanced F-18-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-contrast enhanced CT [CECT]) when used as an initial imaging modality in patients presenting with metastatic malignancy of undefined primary origin (MUO). A total of 243 patients with fine needle aspiration cytology/biopsy proven MUO were included in this prospective study. Patients who were thoroughly evaluated for primary or primary tumor was detected by any other investigation were excluded from the analysis. Totally, 163 patients with pathological diagnosis of malignancy but no apparent sites of the primary tumor were finally selected for analysis. The site of probable primary malignancy suggested by PET-CECT was confirmed by biopsy/follow-up. PET-CECT suggested probable site of primary in 128/163 (78.52%) patients. In 30/35 remaining patients, primary tumor was not detected even after extensive work-up. In 5 patients, where PET-CECT was negative, primary was found on further extensive investigations or follow-up. The sensitivity, specificity, positive predictive value and negative predictive value of the study were 95.76%, 66.67%, 88.28% and 85.71% respectively. F-18 FDG PET-CECT aptly serves the purpose of initial imaging modality owing to high sensitivity, negative and positive predictive value. PET-CECT not only surveys the whole body for the primary malignancy but also stages the disease accurately. Use of contrast improves the diagnostic utility of modality as well as help in staging of the primary tumor. Although benefits of using PET-CECT as initial diagnostic modality are obvious from this study, there is a need for a larger study comparing conventional methods for diagnosing primary in patients with MUO versus PET-CECT