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 Table of Contents     
CASE REPORT
Year : 2014  |  Volume : 29  |  Issue : 2  |  Page : 102-104  

Malaria masquerading as relapse of Hodgkin's lymphoma on contrast enhanced 18 F-fluorodeoxyglucose positron emission tomography/computed tomography: A diagnostic dilemma


Department of Nuclear Medicine and PET-CT, Diwan Chand Satyapal Aggarwal Imaging and Research Center, New Delhi, India

Date of Web Publication9-Apr-2014

Correspondence Address:
Sunil Jeph
Department of Nuclear Medicine and PET-CT, 10-B, K.G. Marg, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-3919.130299

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   Abstract 

18 Flurodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (PET/CT) is nowadays routinely used in management of lymphoma patients. We here present a case of Hodgkin's lymphoma which showed 18 F-FDG avid splenomegaly on PET/CT done for clinically suspected relapse. Further evaluation by peripheral smear examination revealed malaria. The patient was then started on anti-malarial medications and follow-up PET/CT revealed resolution of hypermetabolic splenomegaly. This report highlights that in endemic regions malaria can cause 18 F-FDG avid splenomegaly and might mimic relapse of lymphoma.

Keywords: 18 F-Flurodeoxyglucose, lymphoma, malaria, positron emission tomography/computed tomography, spleen


How to cite this article:
Jeph S, Thakur K, Shamim SA, Aggarwal A. Malaria masquerading as relapse of Hodgkin's lymphoma on contrast enhanced 18 F-fluorodeoxyglucose positron emission tomography/computed tomography: A diagnostic dilemma. Indian J Nucl Med 2014;29:102-4

How to cite this URL:
Jeph S, Thakur K, Shamim SA, Aggarwal A. Malaria masquerading as relapse of Hodgkin's lymphoma on contrast enhanced 18 F-fluorodeoxyglucose positron emission tomography/computed tomography: A diagnostic dilemma. Indian J Nucl Med [serial online] 2014 [cited 2019 Dec 9];29:102-4. Available from: http://www.ijnm.in/text.asp?2014/29/2/102/130299


   Introduction Top


018 Flurodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (PET/CT) has become the imaging modality of choice for initial staging, follow-up and treatment response assessment in patients with Hodgkin's lymphoma and has proved superior to contrast enhanced CT (CECT) in these settings. 18 F-FDG PET/CT has accuracy of almost 100% in diagnosing primary splenic involvement during initial staging of lymphoma. However, in the post-therapy setting its role for evaluation of secondary splenic involvement is limited. One of the pattern of splenic activity that help to detect splenic involvement on PET/CT is diffusely increased 18 F-FDG uptake greater than that in the liver and bone marrow with or without corresponding CT lesions. In this context, we report a case of a patient with Hodgkin's lymphoma in remission presenting with 18 F-FDG avid splenomegaly.


   Case Report Top


The present case report is about a 22-year-old male patient who presented with enlarged right cervical lymph node. Biopsy revealed-Hodgkin's lymphoma (mixed cellularity). 18 F-FDG PET/CECT performed for staging revealed metabolically active lymph nodes on either side of the diaphragm [[Figure 1]a, broken arrows], enlarged spleen with multiple hypodense hypermetabolic, lesions [[Figure 1]a, arrow] (SUV max = 9.4; Spleen SUV max /liver SUV max ratio = 3.76) and bone lesion. He was then given 6 cycles of chemotherapy and 18 F-FDG PET/CECT was done for response evaluation. PET/CT showed complete metabolic response, with normal spleen uptake [[Figure 1]b, arrow] (Spleen SUV max = 2.5, Liver SUV max = 2.6 S/L ratio = 0.96). At 1-year later routine follow-up the patient complained of mild fever, lethargy and listlessness. In view of previous history of Hodgkin's lymphoma, relapse was suspected and 18 F-FDG PET/CECT was advised. PET/CT revealed enlarged spleen with diffusely increased FDG uptake [[Figure 2]a-c, arrow] (SUV max = 5.3; Liver SUV max = 2.3 S/L ratio = 2.30). The first differential in the given clinical scenario was splenic relapse of lymphoma, however, a second differential diagnosis of some infective/inflammatory process was considered. On further evaluation, peripheral smear showed evidence of malaria parasite infection (Plasmodium vivax). The patient was then started on anti-malarials with complete clinical improvement. Follow-up PET/CT after 7 months revealed normalization of size and 18 F-FDG uptake of spleen [[Figure 2]d, arrow] (SUV max = 3.0; Liver SUV max = 2.7 S/L ratio = 1.1). This clinical case can be easily misinterpreted as lymphoma relapse. Hence, malaria and other relevant (endemic) infective possibilities (Kala-Azar etc.) should be considered and further investigation, if warranted, should be advised.
Figure 1: 18F-flurodeoxyglucose (18F-FDG) positron emission tomography/ computed tomography (PET/CT) done for staging and response evaluation. (a) Staging maximum intensity projection (MIP) PET image showing multiple metabolically active lymph nodes in thorax, abdomen and pelvis (broken arrows) with splenic (arrow) and bone lesion (left femur). (b) MIP PET image done for response evaluation demonstrates complete metabolic response with normal splenic FDG uptake (arrow). Physiological gastric FDG uptake noted (bent arrow)

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Figure 2: 18F-flurodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) done for recurrence detection and follow-up. (a-c) Follow-up PET/CT performed 1 year after chemotherapy showing enlarged spleen with diffusely increased FDG uptake (arrow). (d) Maximum intensity projection PET image performed after anti-malarial therapy, showing normalization of size and FDG uptake of spleen (arrow). (a and d) Focal FDG uptake noted in the pelvis is due to urinary FDG activity in the left ureter (curved arrows)

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   Discussion Top


PET/CT is a useful modality for staging and restaging of Hodgkin's lymphoma with high sensitivity and specificity. [1] Furthermore, it is a sensitive modality for early detection of relapse in asymptomatic patients making surveillance 18 F-FDG PET/CT clinically important. [2] Splenic uptake on 18 F-FDG PET can be due to a wide variety of causes such as lymphoma, anemia, granulocyte colony stimulating factor treatment, beta-thalassemia, inflammation and infections. [3],[4],[5],[6],[7],[8] Splenic uptake, greater than hepatic uptake, is a relatively reliable indicator of lymphomatous involvement of the spleen, in the absence of recent cytokine administration. In early stage HIV infection, diffusely increased splenic uptake is noted due to reactive stimulation of B-cells in the spleen. It can also be noted in sarcoidosis, malaria and many other inflammatory diseases. Post-therapeutic reactive splenic uptake is also noted after administration of granulocyte colony-stimulating factor for myelosuppression or high-dose interferon-alpha-2b adjuvant therapy for melanoma. Until date, only a single report by Liu et al. have demonstrated 18 F-FDG uptake in spleen in case of malaria. [9]

 
   References Top

1.Steinert HC. PET/CT in lymphoma patients. Radiologe 2004;44:1060-7.  Back to cited text no. 1
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2.García Vicente AM, Bellón Guardia M, Soriano Castrejón A, Calle Primo C, Cordero García JM, Palomar Muñoz A, et al. 18 F-FDG-PET/CT in the surveillance of patients with lymphoma: Detection of asymptomatic recurrences. Rev Esp Med Nucl Imagen Mol 2012;31:22-7.  Back to cited text no. 2
    
3.Rutherford SC, Andemariam B, Philips SM, Elstrom RL, Chadburn A, Furman RR, et al. FDG-PET in prediction of splenectomy findings in patients with known or suspected lymphoma. Leuk Lymphoma 2008;49:719-26.  Back to cited text no. 3
    
4.Pak K, Kim SJ, Kim IJ, Kim DU, Kim K, Kim H. Impact of cytokines on diffuse splenic 18 F-fluorodeoxyglucose uptake during positron emission tomography/computed tomography. Nucl Med Commun 2013;34:64-70.  Back to cited text no. 4
    
5.Nam HY, Kim SJ, Kim IJ, Kim BS, Pak K, Kim K. The clinical implication and prediction of diffuse splenic FDG uptake during cancer surveillance. Clin Nucl Med 2010;35:759-63.  Back to cited text no. 5
    
6.Abdel-Dayem HM, Rosen G, El-Zeftawy H, Naddaf S, Kumar M, Atay S, et al. Fluorine-18 fluorodeoxyglucose splenic uptake from extramedullary hematopoiesis after granulocyte colony-stimulating factor stimulation. Clin Nucl Med 1999;24:319-22.  Back to cited text no. 6
    
7.Wong CL, Fulham MJ. Increased splenic FDG uptake on PET in beta-thalassemia. Clin Nucl Med 2004;29:266-7.  Back to cited text no. 7
    
8.Núñez R, Rini JN, Tronco GG, Tomas MB, Nichols K, Palestro CJ. Correlation of hematologic parameters with bone marrow and spleen uptake in FDG PET. Rev Esp Med Nucl 2005;24:107-12.  Back to cited text no. 8
    
9.Liu Y. Clinical significance of diffusely increased splenic uptake on FDG-PET. Nucl Med Commun 2009;30:763-9.  Back to cited text no. 9
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