Sports-related lower limb muscle injuries: pattern recognition approach and MRI review

Muscle injuries of the lower limbs are currently the most common sport-related injuries, the impact of which is particularly significant in elite athletes. MRI is the imaging modality of choice in assessing acute muscle injuries and radiologists play a key role in the current scenario of multidisciplinary health care teams involved in the care of elite athletes with muscle injuries. Despite the frequency and clinical relevance of muscle injuries, there is still a lack of uniformity in the description, diagnosis, and classification of lesions. The characteristics of the connective tissues (distribution and thickness) differ among muscles, being of high variability in the lower limb. This variability is of great clinical importance in determining the prognosis of muscle injuries. Recently, three classification systems, the Munich consensus statement, the British Athletics Muscle Injury classification, and the FC Barcelona-Aspetar-Duke classification, have been proposed to assess the severity of muscle injuries. A protocolized approach to the evaluation of MRI findings is essential to accurately assess the severity of acute lesions and to evaluate the progression of reparative changes. Certain MRI findings which are seen during recovery may suggest muscle overload or adaptative changes and appear to be clinically useful for sport physicians and physiotherapists.

Impact of Systematic Whole-body 18F-Fluorodeoxyglucose PET/CT on the Management of Patients Suspected of Infective Endocarditis: The Prospective Multicenter TEPvENDO Study

Background Diagnostic and patients’ management modifications induced by whole-body 18F-FDG-PET/CT had not been evaluated so far in prosthetic valve (PV) or native valve (NV) infective endocarditis (IE)-suspected patients. Methods In sum, 140 consecutive patients in 8 tertiary care hospitals underwent 18F-FDG-PET/CT. ESC-2015-modified Duke criteria and patients’ management plan were established jointly by 2 experts before 18F-FDG-PET/CT. The same experts reestablished Duke classification and patients’ management plan immediately after qualitative interpretation of 18F-FDG-PET/CT. A 6-month final Duke classification was established. Results Among the 70 PV and 70 NV patients, 34 and 46 were classified as definite IE before 18F-FDG-PET/CT. Abnormal perivalvular 18F-FDG uptake was recorded in 67.2% PV and 24.3% NV patients respectively (P < .001) and extracardiac uptake in 44.3% PV and 51.4% NV patients. IE classification was modified in 24.3% and 5.7% patients (P = .005) (net reclassification index 20% and 4.3%). Patients’ managements were modified in 21.4% PV and 31.4% NV patients (P = .25). It was mainly due to perivalvular uptake in PV patients and to extra-cardiac uptake in NV patients and consisted in surgery plan modifications in 7 patients, antibiotic plan modifications in 22 patients and both in 5 patients. Altogether, 18F-FDG-PET/CT modified classification and/or care in 40% of the patients (95% confidence interval: 32–48), which was most likely to occur in those with a noncontributing echocardiography (P < .001) or IE classified as possible at baseline (P = .04), while there was no difference between NV and PV. Conclusions Systematic 18F-FDG-PET/CT did significantly and appropriately impact diagnostic classification and/or IE management in PV and NV-IE suspected patients. ClinicalTrial.gov identification number NCT02287792.

Clinical Characteristics and Outcome of Patients with Infective Endocarditis Diagnosed in a Department of Internal Medicine

Clinical manifestations of infective endocarditis (IE) can be highly non-specific. Our objective was to describe the clinical characteristics of patients initially referred to a department of internal medicine for a diagnostic work-up, and eventually diagnosed with IE. We retrospectively retrieved adult patients admitted to the department of internal medicine at Lille University Hospital between 2004 and 2015 who fulfilled Duke Classification criteria for definite IE. Thirty-five patients were included. The most frequently involved bacteria were non-hemolytic streptococci. Most patients presented with various systemic, cardiac, embolic, rheumatic, and immunological findings, with no sign or symptom displaying high sensitivity. The first transthoracic echocardiogram was negative in 42% of patients. Furthermore, definite diagnosis required performing at least 2 transesophageal examinations in 24% of patients. We observed a trend towards decreased survival in the subgroup of patients in whom the delay between onset of symptoms and diagnosis was >30 days. In conclusion, patients who are initially referred to internal medicine for a diagnosis work-up and who are ultimately diagnosed with IE have non-specific symptoms and a high percentage of initial normal echocardiography. Those patients require prolonged echocardiographic monitoring as a prolonged delay in diagnosis is associated with poorer outcomes such as death.

Risk-benefit Assessment of Systematic Thoracoabdominal-pelvic Computed Tomography in Infective Endocarditis

Background In the management of infective endocarditis (IE), the presence of extracardiac complications has an influence on both diagnosis and treatment. Current guidelines suggest that systematic thoracoabdominal-pelvic computed tomography (TAP-CT) may be helpful. Our objective was to describe how systematic TAP-CT affects the diagnosis and the management of IE. Methods In this multicenter cohort study, between January 2013 and July 2016 we included consecutive patients who had definite or possible IE according to the Duke modified criteria, validated by endocarditis teams. We analyzed whether the Duke classification and therapeutic management were modified regarding the presence or the absence of IE-related lesion on CT and investigated the tolerance of this examination. Results Of the 522 patients included in this study, 217 (41.6%) had 1 or more IE-related lesions. On the basis of CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only 4 cases (0.8%). The presence of IE-related lesions on CT did not modify the duration of antibiotic treatment (P = .55), nor the decision of surgical treatment (P = .39). Specific treatment of the lesion was necessary in 42 patients (8.0%), but only 9 of these lesions (1.9%) were asymptomatic and diagnosed only on the TAP-CT. Acute kidney injury (AKI) within 5 days of CT was observed in 78 patients (14.9%). Conclusions The TAP-CT findings slightly affected diagnosis and treatment of IE in a very small proportion of asymptomatic patients. Furthermore, contrast media should be used with caution because of the high risk of AKI.

1086. Impact of Systematic Thoraco-Abdomino-Pelvic CT Scan on the Diagnosis of Infective Endocarditis

Background The incidence of embolic events (EE) is high in patients with infective endocarditis (IE). EE influence patient management in different settings because they are minor criteria in the Duke classification and may lead to changes medical therapy or surgical strategy. If current guidelines suggest that systematic thoraco-abdominopelvic CT scan (TAP-CT) may be helpful, reliable data are lacking. The main objective of this study was to describe how systematic TAP-CT affects the diagnosis of patients with IE. Secondary objectives were to assess the impact of the TAP-CT on the management of patients with IE and the incidence of contrast-induced acute kidney injury (CI-AKI). Methods In this multicenter cohort study between January 2013 and July 2016, we included consecutive patients who had definite or possible acute IE according to the Duke-modified criteria, and after validation by the endocarditis teams. The main exclusion criterion was the absence of TAP-CT scan. We compared the Duke classification diagnosis data and treatment data (medical and/or surgical) regarding the presence or the absence of EE on the CT and investigated the tolerance of this examination as well. Results Of the 522 patients included in this study, 217 (41.6%) had one or more EE on the TAP-CT. The two major Duke modified criteria were found in 397 patients (76,1%) and 457 patients (87,6%) had a definite endocarditis. On the basis of TAP-CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only four cases which represent 0.8% of the population. The presence of EE on CT did not modify the duration of antibiotic treatment (P = 0.55) and the decision of surgical treatment (P = 0.39). Specific treatment of the EE was necessary in 42 patients (8.0%) but only nine of these EE (1.9%) were asymptomatic. CI-AKI was observed in 78 patients (14.9%). Conclusion The CT-scan findings slightly affected diagnosis of IE. The impact on the therapeutic management is low and the incidence of CI-AKI should not be underestimated. Additional studies are needed to assess whether CT-scan improves patient outcomes, leads to unnecessary procedures and increased costs. Disclosures All authors: No reported disclosures.