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Year : 2017  |  Volume : 32  |  Issue : 4  |  Page : 345-347  

Clinically occult rectal carcinoma identified in a case of Streptococcus bovis Endocarditis on fluorodeoxyglucose positron emission tomography/computed tomography: A case report and review of literature

1 Department of Nuclear Medicine, MIOT International, Chennai, Tamil Nadu, India
2 Department of Surgical Oncology, MIOT International, Chennai, Tamil Nadu, India

Date of Web Publication12-Oct-2017

Correspondence Address:
Piyush Chandra
Department of Nuclear Medicine, MIOT International, Manapakkam, Chennai - 600 056, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnm.IJNM_71_17

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Numerous studies over past four decades have implicated a strong association of Streptoccus bovis infection with colorectal carcinomas. Strong is this association that a screening colonoscopy for identifying malignancy is considered mandatory in patients whose blood/fecal cultures show growth of this particular pathogen. Here, we report an interesting case of a 61-year-old female patient who presented with pyrexia of unknown origin for 3 weeks. Positron emission tomography/computed tomography, in addition to helping diagnose mitral valve endocarditis, also identified a clinically occult T2N0 rectal carcinoma.

Keywords: Bovis, carcinoma, endocarditis, fluoro-deoxy-glucose, positron emission tomography/computed tomography, rectal, Streptococcus

How to cite this article:
Chandra P, Nath S, Kumar S. Clinically occult rectal carcinoma identified in a case of Streptococcus bovis Endocarditis on fluorodeoxyglucose positron emission tomography/computed tomography: A case report and review of literature. Indian J Nucl Med 2017;32:345-7

How to cite this URL:
Chandra P, Nath S, Kumar S. Clinically occult rectal carcinoma identified in a case of Streptococcus bovis Endocarditis on fluorodeoxyglucose positron emission tomography/computed tomography: A case report and review of literature. Indian J Nucl Med [serial online] 2017 [cited 2022 Aug 12];32:345-7. Available from:

   Case Report Top

A 61-year-old female with no previous history of any medical illness presented with high-grade fever for 3 weeks. The initial routine blood investigations were normal, except for raised erythrocyte sedimentation rate, and C-reactive protein. Transthoracic echocardiocardiography (TTE) showed severe mitral valve regurgitation, but no vegetations were identified. Whole body positron emission tomography/computed tomography (PET/CT) was done to localize possible infective foci. 2-fluoro-deoxy-glucose (FDG) PET/CT scan showed increased FDG uptake most prominently in the marrow of axial skeleton and mildly enlarged spleen-suggestive of systemic inflammation [Figure 1]a. Low-grade FDG uptake was noted in the perivalvular region of the mitral valve [Figure 1]b and [Figure 1]c which was more apparent on the delayed image acquired at 2.5 h [Figure 1]d and [Figure 1]e and was reported as being suspicious for infective endocarditis (IE). PET/CT also revealed a large rectal polyp (3.5 cm-maximum standardized uptake value 25.19) for which the patient was completely asymptomatic [Figure 2]. A transesophageal echocardiogram (TEE) was done after 1 week which identified small freely mobile vegetations. Subsequent blood cultures reported growth of Streptoccus bovis. The patient responded well to antibiotics. In view of this atypical organism's growth on blood culture, PET/CT findings, and its known association with colonic malignancy, a surveillance colonoscopy was done which revealed a large rectal polyp. Rectal biopsy was suggestive of tubular adenoma with adenocarcinoma-like changes. Low anterior resection was done with the dissection of locoregional nodes. Histopathology report was suggestive of pT2N0 well-differentiated adenocarcinoma of rectum. In view of stage II disease, she did not need adjuvant chemotherapy. The patient is being planned for mitral valve surgery.
Figure 1: (a) Whole body PET-maximum intensity projection image-anterior/posterior view-showing low-grade diffuse fluorodeoxyglucose uptake in the marrow and spleen. Zoomed MIP image of thorax (b) and transaxial PET/CT of the heart showing low-grade focal fluorodeoxyglucose uptake in the periphery of mitral valve (thin white arrow, c), which is more apparent on delayed ECG-gated PET images (black arrow, d and bold white arrow e) after gradual washout of the physiologic myocardial fluorodeoxyglucose uptake. PET/CT: Positron emission tomography/computed tomography

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Figure 2: (a) Whole body PET-maximum intensity projection image-lateral view showing intense focal tracer uptake in the rectal area (thin black arrow). Transaxial and sagittal CT (bold white arrow, (b and c) and correlated PET/CT images (bold white arrow, d and e) showing fluorodeoxyglucose avid well-defined enhancing lesion in the lower rectum. PET/CT: Positron emission tomography/computed tomography

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   Discussion Top

IE caused by S. bovis is rare and seen in up to 4% of all patients with IE.[1] IE caused by S. bovis is seen predominantly in older populations, associated with smaller vegetations, more commonly involvement of native valves, with less in-hospital mortality/complications and with higher association of colonic tumors, compared to the other common organisms causing endocarditis.[1] Echocardiography and blood cultures are main investigations for diagnosing IE. The sensitivity for diagnosing IE of TTE is 75%, less compared to TEE which ranges from 85% to 90%. Echocardiography may be falsely negative in 15% of cases, particularly in the cases of severe mitral valve prolapse and prosthetic valves.[2]

The addition of imaging such as CT, PET/CT, and SPECT/CT to the diagnostic the evaluation of IE improves the overall sensitivity of the duke's criteria and are now included in the European Society of Cardiology 2015 modified duke's criteria. FDG PET/CT is an established modality in the diagnosis of IE and has been included as one of the major criteria for diagnosing prosthetic valve endocarditis (PIE).[2] The sensitivity and specificity for diagnosing cardiac device infection are 89% and 86%, respectively. In addition to diagnosing the valve infection, PET/CT can also detect metastatic and embolic infections (seen in about 20%–50% patients), which might be clinically occult/missed on conventional imaging, thereby impacting clinical management.[2] In comparison to the PIE, PET/CT is conventionally considered to have a low sensitivity in diagnosing native-valve endocarditis (NIE) and hence not routinely done.[2],[3] A systematic review of multiple studies, including 1402 patients showed a sensitivity of 14% for PET/CT for the diagnosis of NIE. This very low sensitivity of FDG PET/CT in diagnosing NIE however can be improved by better patient preparation suppressing the physiological FDG uptake by the myocardium (low carbohydrate-high fat diet) or integration of CT angiography in the PET/CT protocol, rather than using low-dose CT.[3] Dual point imaging using a delayed image acquisition (at 2-3 h following a negative PET/CT at 1 h) may also improve the infection/background activity ratio, thereby improving the diagnosis of NIE on FDG PET/CT.[4],[5] In addition, electrocardiogram (ECG) gated PET acquisition would generate a better image contrast and can further improve the sensitivity.[6] In our case, we were able to localize the mitral valve infection better with a delayed ECG gated acquisition image at 2.5 h.

Evidence of association of bacterial infections with cancer has been demonstrated with (most convincingly) Helicobacter pylori (with gastric cancers and mucosa-associated lymphoid tissue lymphoma) and few other organisms such as  Salmonella More Details typhi (gall bladder cancers) and Chlamydia pneumonia (with lung cancers). Another such bacterium called S. bovis, is increasingly being recognized as an important risk factor for the developing colorectal cancers.[7] One of the first such evidence of this association was reported in a study done by Klein et al., which showed high prevalence of S. bovis in fecal cultures of patients with colonic carcinoma compared to controls.[8]S. bovis is a commensal of human gastrointestinal tract and found in 15% of normal fecal specimens. Phylogenetically, it is classified into two biotypes, Type I (Streptococcus gallolyticus) and Type II (Streptococcus pasturianus). Type I is more commonly associated with colonic cancers with incidence ranging from 18% to 62%.[9],[10] Production of inflammatory cytokines, causing chronic colonic inflammation and subsequent cancer transformation is postulated as one of the pathophysiologic mechanism of such association.[9] However, whether S. bovis is an etiology or a biomarker of colorectal cancers remains an unsolved question. Nonetheless, the association of the infection and colorectal cancer is so strong that a surveillance colonoscopy is considered mandatory in case of S. bovis bacteremia.[9],[10],[11]

Survival in colorectal cancers has improved remarkably in the last few decades, not just because of improvement in surgical techniques and advances in chemotherapeutics, but also due to screening.[12] Earlier detection of asymptomatic colorectal cancers in a high-risk patient such as S. bovis infection can be potentially curative, as seen in this case. Screening for colonic malignancies is traditionally done by colonoscopy and rarely CT colonography. CT colonography is a noninvasive highly sensitive investigation for the evaluation of colonic polyps (as sensitive as colonoscopy for lesions >1 cm) and is an excellent alternative to patients who are unfit or unwilling for colonoscopy.[13] Conventionally, PET/CT use is not recommended for screening or staging of early colonic cancers, due to lack of widespread availability of PET/CT, limitation of PET/CT in identifying small lesions, along with high physiologic radioactivity in colon. FDG PET/CT can be useful for identifying large obstructive colonic tumors which cannot be traversed by colonoscopy and for identifying synchronous tumors elsewhere in the colon.[14] In addition, PET/CT is the preferred investigation for the identification of any hepatic and extrahepatic distant metastasis in colorectal cancers. Combining PET with CT colonography have been found to be both clinically feasible and very accurate for staging colonic tumors.[14],[15] Hence, FDG/CT colonography can be used as a one-stop shop noninvasive approach for simultaneous evaluation of endocarditis as well as screening of colonic malignancies in patients with S. bovis endocarditis.

   Conclusion Top

This case report further consolidates the importance of colonic surveillance in cases of S. bovis bacteremia and important adjuvant role of FDG PET/CT to colonoscopy for screening/diagnosing early, potentially-curable, clinically occult colonic cancers. This case also demonstrates the utility of delayed ECG-gated PET acquisition at 2–3 h of FDG injection for improving the diagnostic accuracy of PET/CT in NIE.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Olmos C, Vilacosta I, Sarriá C, López J, Ferrera C, Sáez C, et al. Streptococcus bovis endocarditis: Update from a multicenter registry. Am Heart J 2016;171:7-13.  Back to cited text no. 1
Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36:3075-128.  Back to cited text no. 2
Gomes A, Glaudemans AW, Touw DJ, van Melle JP, Willems TP, Maass AH, et al. Diagnostic value of imaging in infective endocarditis: A systematic review. Lancet Infect Dis 2017;17:e1-14.  Back to cited text no. 3
Treglia G, Bertagna F. Factors influencing the sensitivity of 18F-FDG PET/CT in the detection of infective endocarditis. Eur J Nucl Med Mol Imaging 2013;40:1112-3.  Back to cited text no. 4
Caldarella C, Leccisotti L, Treglia G, Giordano A. Which is the optimal acquisition time for FDG PET/CT imaging in patients with infective endocarditis? J Nucl Cardiol 2013;20:307-9.  Back to cited text no. 5
Le Meunier L, Slomka PJ, Dey D, Ramesh A, Thomson LE, Hayes SW, et al. Motion frozen (18)F-FDG cardiac PET. J Nucl Cardiol 2011;18:259-66.  Back to cited text no. 6
Cummins J, Tangney M. Bacteria and tumours: Causative agents or opportunistic inhabitants? Infect Agent Cancer 2013;8:11.  Back to cited text no. 7
Klein RS, Recco RA, Catalano MT, Edberg SC, Casey JI, Steigbigel NH. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med 1977;297:800-2.  Back to cited text no. 8
Abdulamir AS, Hafidh RR, Abu Bakar F. The association of Streptococcus bovis/gallolyticus with colorectal tumors: The nature and the underlying mechanisms of its etiological role. J Exp Clin Cancer Res 2011;30:11.  Back to cited text no. 9
Boleij A, van Gelder MM, Swinkels DW, Tjalsma H. Clinical importance of Streptococcus gallolyticus infection among colorectal cancer patients: Systematic review and meta-analysis. Clin Infect Dis 2011;53:870-8.  Back to cited text no. 10
Ferrari A, Botrugno I, Bombelli E, Dominioni T, Cavazzi E, Dionigi P. Colonoscopy is mandatory after Streptococcus bovis endocarditis: A lesson still not learned. Case report. World J Surg Oncol 2008;6:49.  Back to cited text no. 11
Zauber AG. The impact of screening on colorectal cancer mortality and incidence: Has it really made a difference? Dig Dis Sci 2015;60:681-91.  Back to cited text no. 12
Laghi A. Computed tomography colonography in 2014: An update on technique and indications. World J Gastroenterol 2014;20:16858-67.  Back to cited text no. 13
Kijima S, Sasaki T, Nagata K, Utano K, Lefor AT, Sugimoto H. Preoperative evaluation of colorectal cancer using CT colonography, MRI, and PET/CT. World J Gastroenterol 2014;20:16964-75.  Back to cited text no. 14
Veit-Haibach P, Kuehle CA, Beyer T, Stergar H, Kuehl H, Schmidt J, et al. Diagnostic accuracy of colorectal cancer staging with whole-body PET/CT colonography. JAMA 2006;296:2590-600.  Back to cited text no. 15


  [Figure 1], [Figure 2]


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