Pericardial sarcoidosis presenting as PUO diagnosed on FDG PET CT scan

Document Type : Case report


1 Consultant, SPECT Lab, Nuclear Medicine Services, Pune, Maharashtra, India

2 Director Niramaya Hospital, Chinchwad, Pune, Maharashtra, India


Pyrexia of unknown origin (PUO) is a common problem in day-to-day practice. FDG PET CT is an established investigation that aids in identifying the cause of PUO. Due to its high sensitivity PET detects an occult hypermetabolic focus in the body where CT helps in anatomical localization, vascularity, enhancement characteristics of the lesion detected on PET. It helps to differentiate benign versus malignant cause and target biopsy. Tuberculosis, lymphoma, pyelonephritis, thyroiditis appear hypermetabolic on FDG PET CT. Pericardial sarcoidosis is rare and not reported in literature as a cause of PUO. Presented here is a case of PUO secondary to pericardial granulomatosis diagnosed on PET CT. Cardiac MRI also helps in better tissue characterization and associated myocardial involvement of sarcoidosis. Histology confirmed the diagnosis of pericardial sarcoidosis in this case.


Main Subjects

1. Boeck C. Multiple benign sarcoid of the skin. J Cutan Genitourin Dis1899; 17: 543-550.
2. Newman LS, Rose CS, Bresnitz EA, Rossman MD, Barnard J, Frederick M, et al. A case control etiologic study of sarcoidosis: environmental and occupational risk factors. Am J Respir Crit Care Med 2004; 170: 1324-1330.
3. Dubaniewicz A, Kampfer S, Singh M. Serum anti-mycobacterial heat shock proteins antibodies in sarcoidosis and tuberculosis. Tuberculosis (Edinb) 2006; 86: 60-67.
4. Baughman RP1, Teirstein AS, Judson MA, Rossman MD, Yeager H Jr, Bresnitz EA, et al. Case Control Etiologic Study of Sarcoidosis (ACCESS) research group. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001; 164(10 Pt 1):1885–1889.
5. Adams JS, Singer FR, Gacad MA, Sharma OP, Hayes MJ, Vouros P, et al. Isolation and structural identification of 1, 25‐dihydroxyvitamin D produced by cultured alveolar macrophages in sarcoidosis. J Clin Endocrinol Metab1985; 60: 960–965.
6. Fluschnik N1, Lund G1, Becher PM1, Blankenberg S1, Muellerleile K, et al. Fulminant isolated cardiac sarcoidosis with pericardial effusion and acute heart failure: Challenging aspects of diagnosis and treatment. World J Clic Cases 2016; 4(3):76-80.
7. Pierre Louis B, Prasad A, Frishman WH. Cardiac manifestations of sarcoidosis and therapeutic options. Cardiol rev 2009:17(4)15.
8. Garret J, O’Neill H, Blake S. Constrictive pericarditis associated with sarcoidosis. Am Heart J.1984; 107(2):394.
9. Uysal N, Ptacin M, Schapira R. Sarcoidosis of the pericardium: clinical observations and review. Clinical Pulmonary medicine. 2002; 9:177-181.
10. Angomachalelis N1, Hourzamanis A, Salem N, Vakalis D, Serasli E, Efthimiadis T, et al. Pericardial effusion concomitant with specific heart muscle disease in systemic sarcoidosis. Postgrad Med J 1994; 70(1):S8-S12.
11. Silverman KJ, Hutchins GM, Bulkley BH. Cardiac sarcoid: a clinicopathologic study of 84 unselected patients with systemic sarcoidosis. Circulation.1978; 58(6):1204-1211.
12. Pesola G, Teirstein AS, Goldman M. Sarcoidosis presenting with pericardial effusion. Sarcoidosis. 1987; 4: 42–44.
13. Darda S, Zughaib ME, Alenxander PB, Machado C E, David S W, Saba S. Cardiac sarcoidosis presenting as constrictive pericarditis. Ex Heart Inst J 2014: 41(3); 319-323.
14. Smith-Rohrberg D, Sharma SK. Tuberculin skin test among pulmonary sarcoidosis patients with and without tuberculosis: It’s utility for the screening of the two condition sin tuberculosis Endemic regions. Sarcoidosis Vasc Diffuse Lung Dis 2006; 23: 130-134.
15. Weiner R,Hoffer PB, Thakur ML. Lactoferrin: its role as a Ga-67-binding protein in polymorphonuclear leukocytes. J Nucl Med 1981; 22:32–37.
16. Sulavik SB, Spencer RP, Weed DA, Shapiro HR, Shiue ST, Castriotta RJ. Recognition of distinctive patterns of gallium-67 distribution in sarcoidosis. J Nucl Med 1990; 31:1909–1914.
17. Kurdziel KA. The panda sign. Radiology 2000; 215:884–885.
18. O'Connell JB, Robinson JA, Henkin RE, Gunnar RM. Gallium 67-citrate scanning for noninvasive detection of inflammation in pericardial diseases. Am J Cardiol.1980; 46: 879-884.
19. Taillefer R, Daniel D. Gallium67 uptake by the heart. Seminars in Nucl Med.1983; 13(2):176-178.
20. J. Gaál, I. Hegedüis, K. Dévényi, and L. Czirják, “Myocardial gallium-67 citrate scintigraphy in patients with systemic sclerosis,” Annals of the Rheumatic Diseases1995; 54:856–858.
21. Mochizuki T, Tsukamoto E, Kuge Y et al. FDG uptake and glucose transporter subtype expressions in experimental tumor and inflammation models. J Nucl Med2001; 42:1551–1555.
22. Keijsers RG, Grutters JC, Thomeer M, et al. Imaging the inflammatory activity of sarcoidosis: sensitivity and inter observer agreement of 67 Ga imaging and 18 F-FDG PET. Q J Nucl Med Mol imaging 2011; 55: 66–71.
23. Strobel K, Schuler R, Genoni M. Visualization of pericarditis with fluoro-deoxy-glucose-positron emission tomography/computed tomography. Eur Heart J 2008; 29(9):1212.
24. Mirakhur A, Anca N, Mikami Y, et al. T2-weighted imaging of the heart--a pictorial review. Eur J Radiol 2013; 82:1755–1762.
25. Takakura H, Sunada K, Shimizu K. Tubercular constrictive pericarditis detected on positron emission tomography. Kekkaku 2016; 91(2):65-68.
26. Wyplosz B, Marijon E, Dougados J, Pouchot J. Sarcoidosis an unusual cause of pericarditis.Acta Cardiol 2010; 65(1):83-84.
27. Yazaki Y, Isobe M, Hiroe M, Morimoto S, Hiramitsu S, Nakano T, et al. Prognostic determinants of long-term survival in Japanese patients with cardiac sarcoidosis treated with prednisone. Am J Cardiol 2001; 88(9):1006-1010.
28. Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999; 100(13): 1380-1386.
29. Bertog SC1, Thambidorai SK, Parakh K, Schoenhagen P, Ozduran V, Houghtaling PL, et al. Constrictive pericarditis: etiology and cause- specific survival after pericardiectomy. J Am Coll Cardiol 2004; 43(8):1445-1452.