Aortitis Diagnosed by F–18–Fluorodeoxyglucose Positron Emission Tomography in a Patient with Syphilis and HIV Coinfection

Childhood-onset Takayasu arteritis and immunodeficiency: case-based review

Takayasu arteritis (TAK) has been rarely reported in patients with immunodeficiency. In this review, we present two cases with childhood-onset TAK (c-TAK) and primary immunodeficiency while reviewing similar cases in the literature. We reviewed the data for our two pediatric patients with c-TAK and primary immunodeficiency. We also reviewed the literature for patients with c-TAK and immunodeficiency from the inceptions of the databases up to November 2021. A 14-year-old patient had lipopolysaccharide-sensitive beige-like anchor (LRBA) deficiency, and a 16-year-old had X-linked severe combined immunodeficiency (X-linked SCID). During the follow-up, they developed findings suggestive of vasculitides such as hypertension, elevation in acute phase reactants, weakness, and weight loss. Thoracoabdominal computed tomography angiography revealed findings consistent with vasculitis involving the aorta and its major branches. Patients were diagnosed with c-TAK, and corticosteroids were given to both patients in the treatment. We identified 11 articles describing 17 TAK patients with immunodeficiency in our literature search. Two of the patients with c-TAK were infected with human immunodeficiency virus (HIV), another patient had Wiskott-Aldrich syndrome, and the other had idiopathic CD4 + T lymphocytopenia. Nine adult patients with TAK were infected with HIV, three patients had common variable immunodeficiency disorder (CVID), and the other had STAT1 gain-of-function mutation. Clinicians should consider that immunodeficiencies may be accompanied by vasculitic conditions such as TAK. Hypertension, increased inflammatory markers, and constitutional symptoms may be red flags for the development of TAK.

Many Different Patterns under a Common Flag: Aortic Pathology in HIV-A Review of Case Reports in Literature

BACKGROUND

Availability of highly active antiretroviral therapy (HAART) for HIV has prolonged life expectancy of patients but has also increased the incidence of non-AIDS comorbid conditions. Among these, there are cardiovascular diseases, and aortic involvement has been described in patients with HIV in the form of aortitis, aneurysms, or dissections. Our study aims to describe aortic pathology occurring in patients with HIV, focusing on clinical and surgical presentation, management, and outcome, through a review of cases published in literature.

METHODS

MEDLINE (www.ncbi.nlm.nih.gov/pubmed) database was reviewed for "aortitis" OR "aortic aneurysm" OR "aortic dissection" AND HIV. Research was restricted to English language. Only case reports were included. Data on patients' age, sex, traditional risk factors, timing from HIV diagnosis, pharmacological details, coinfection (syphilis, hepatitis C virus [HCV], and hepatitis B virus [HBV]), anatomical localization of lesion, presence of inflammatory involvement, rapid growing or rupture, and surgical treatment and outcomes were collected and summarized in tables.

RESULTS

Forty articles (51 cases) were included in the study. The mean age of patients was 48.8 ± 8.3 years. Male sex was preponderant (43 cases, 84.3%). Among traditional risk factors, hypertension and smoking were the most frequently reported ones (14 and 13 cases, respectively), followed by vasculopathy involving other arterial districts, dyslipidemia, diabetes, and drug addiction. In 3 cases, HIV was diagnosed in the same time as aortic pathology, whereas in most cases, aortic event occurred after five years from HIV diagnosis. In 30.5% of cases for which data on pharmacologic management were available, no treatment or poor adherence was reported. Coinfection occurred in some cases (syphilis in 6, HCV in 5, and HBV in 3). As for anatomical involvement, isolated thoracic lesions were more frequent (24, 47.1%), followed by abdominal and thoracoabdominal lesions. The etiology ranged from bacterial mycotic aneurysms to tertiary syphilis, postsurgical complications, or atherosclerosis. In 3 cases, HIV vasculitis was directly suggested, and in another 2, no other potential etiology had been diagnosed through cultural tests. Open surgical treatment was carried out in 30 cases (58.8%), and in addition, 10 endovascular (19.6%) and 2 hybrid procedures were described. Inflammatory features occurred in 7 cases, and a rapid evolution of lesions in 6. In 9 cases (17.6%), rupture occurred. Mortality was reported in 8 cases (15.7%).

CONCLUSIONS

Aortic pathology may occur in patients with HIV. The entanglement of different patterns of pathological involvement of the aortic wall, secondary to immune dysregulation, infectious process, or atherosclerotic damage that may co-occur in one single case, results in a very challenging management of the condition. Because of the increased life expectancy of patients and immigration from regions with both high HIV and coinfection prevalence, the incidence of aortic pathology could increase in the upcoming years, suggesting the urgent need for further studies to optimize management in these very complex cases.

Usefulness of Positron Emission Tomography in Patients with Syphilis: A Systematic Review of Observational Studies

Background:

Diagnosis of syphilis is difficult. Follow-up and therapy evaluation of syphilitic patients are poor. Little is known about positron emission tomography (PET) in syphilis. This review was to systematically review usefulness of PET for diagnosis, disease extent evaluation, follow-up, and treatment response assessment in patients with syphilis.

Methods:

We searched PubMed, EMBASE, SCOPUS, Cochrane Library, Web of Science, ClinicalTrials.gov, and three Chinese databases (SinoMed, Wanfang, and CNKI) for English and Chinese language articles from inception to September 2016. We also collected potentially relevant studies and reviews using a manual search. The search keywords included the combined text and MeSH terms “syphilis” and “positron emission tomography”. We included studies that reporting syphilis with a PET scan before and/or after antibiotic treatment. The diagnosis of syphilis was based on serological criteria or dark field microscopy. Outcomes include pre- and post-treatment PET scan, pre- and post-treatment computed tomography, and pre- and post-treatment magnetic resonance imaging. We excluded the articles not published in English or Chinese or not involving humans.

Results:

Of 258 identified articles, 34 observational studies were included. Thirty-three studies were single-patient case reports and one study was a small case series. All patients were adults. The mean age of patients was 48.3 ± 12.1 years. In primary syphilis, increased fluorodeoxyglucose (FDG) accumulation could be seen at the site of inoculation or in the regional lymph nodes. In secondary syphilis with lung, bone, gastrointestinal involvement, or generalized lymphadenopathy, increased FDG uptake was the most commonly detected changes. In tertiary syphilis, increased glucose metabolic activity, hypometabolic lesions, or normal glucose uptake might be seen on PET. There were five types of PET scans in neurosyphilis. A repeated PET scan after treatment revealed apparent or complete resolution of the asymmetry of radiotracer uptake.

Conclusion:

PET is helpful in targeting diagnostic interventions, characterizing disease extent, assessing nodal involvement, and treatment efficacy for syphilis.

Transient aortitis documented by positron emission tomography in a case series of men and transgender women infected with syphilis

OBJECTIVES

Syphilis infection persists globally contributing to preventable and treatable morbidity and mortality. How extensive early syphilis disseminates is unknown. To better understand the relationship between early syphilis infection and inflammation over time, our study enrolled six individuals recently infected with syphilis for sequential positron emission tomography (PET) scans.

METHODS

We evaluated a case series of six individuals with high syphilis titres (two secondary, two early latent and two latent, unknown duration, but with high titre) who received sequential PET scans to assess inflammation over time and its response to treatment.

RESULTS

At time of PET scan, four of the six individuals were co-infected with HIV. One of the four was not on antiretroviral therapy and three of the four were not virally suppressed (viral load of >400 copies/mL). Baseline rapid plasma reagin (RPR) titres ranged from 1:64 to 1:256 (four of the six participants had prior non-reactive RPR results). Five of the six participants had mild to intense hypermetabolic PET scan activity consistent with cervical (n=5), axillary (n=4), inguinal (n=5) and retroperitoneal (n=1) adenopathy. Mild hypermetabolic activity in the thoracic aortic wall, suggesting aortitis, was present among the same five participants and resolved within 30 days for four of the five participants and 60 days for the other participant. However, widespread lymphadenopathy remained present in PET scans up to 3 months following treatment in two participants. We did not find any abnormal PET scan activity of the central nervous system.

CONCLUSION

We found abnormal aortic wall PET scan activity suggesting aortitis to be common in a case series of patients with early syphilis. In research settings, PET scans may be a sensitive tool to monitor inflammation associated with syphilis.

Probable Syphilitic Aortitis Documented by Positron Emission Tomography

Positron emission tomography (PET) has been used to aid in diagnosis of inflammatory and infectious disease. We describe the case of a patient with early latent syphilis with increased metabolic activity along the aorta detected via PET, suggesting probable aortitis. Three months after treatment, the PET showed apparent resolution of the aortitis.

A case of secondary syphilis involving tonsil, pulmonary, and multiple lymph nodes: 18F-FDG PET/CT findings

A 50-year-old man with general fatigue and weight loss underwent FDG PET/CT scan to detect possible occult malignancy. The images revealed abnormal FDG activity in the tonsils, right lung, and in the cervical, axillary, and inguinal lymph nodes. Lymphoma was initially suspected. However, pathologic examination after cervical lymph node biopsy revealed only reactive hyperplasia. Further examinations including serologic tests led to a diagnosis of secondary syphilis. A follow-up PET/CT scan after a 6-month benzylpenicillin therapy showed significant interval improvement.

Large-vessel vasculitis: interobserver agreement and diagnostic accuracy of 18F-FDG-PET/CT

Introduction. ¹⁸F-FDG-PET visualises inflammation. Both atherosclerosis and giant cell arteritis cause vascular inflammation, but distinguishing the two may be difficult. The goal of this study was to assess interobserver agreement and diagnostic accuracy of ¹⁸F-FDG-PET for the detection of large artery involvement in giant cell arteritis (GCA). Methods. 31 ¹⁸F-FDG-PET/CT scans were selected from 2 databases. Four observers assessed vascular wall ¹⁸F-FDG uptake, initially without and subsequently with predefined observer criteria (i.e., vascular wall ¹⁸F-FDG uptake compared to liver or femoral artery ¹⁸F-FDG uptake). External validation was performed by two additional observers. Sensitivity and specificity of ¹⁸F-FDG-PET were determined by comparing scan results to a consensus diagnosis. Results. The highest interobserver agreement (kappa: 0.96 in initial study and 0.79 in external validation) was observed when vascular wall ¹⁸F-FDG uptake higher than liver uptake was used as a diagnostic criterion, although agreement was also good without predefined criteria (kappa: 0.68 and 0.85). Sensitivity and specificity were comparable for these methods. The criterion of vascular wall ¹⁸F-FDG uptake equal to liver ¹⁸F-FDG uptake had low specificity. Conclusion. Standardization of image assessment for vascular wall ¹⁸F-FDG uptake promotes observer agreement, enables comparative studies, and does not appear to result in loss of diagnostic accuracy compared to nonstandardized assessment.

The role of 18F-FDG PET/CT in large-vessel vasculitis: appropriateness of current classification criteria?

Patients with clinical suspicion of large-vessel vasculitis (LVV) may present with nonspecific signs and symptoms and increased inflammatory parameters and may remain without diagnosis after routine diagnostic procedures. Both the nonspecificity of the radiopharmaceutical ¹⁸F-FDG and the synergy of integrating functional and anatomical images with PET/CT offer substantial benefit in the diagnostic work-up of patients with clinical suspicion for LVV. A negative temporal artery biopsy, an ultrasonography without an arterial halo, or a MRI without aortic wall thickening or oedema do not exclude the presence of LVV and should therefore not exclude the use of ¹⁸F-FDG PET/CT when LVV is clinically suspected. This overview further discusses the notion that there is substantial underdiagnosis of LVV. Late diagnosis of LVV may lead to surgery or angioplasty in occlusive forms and is often accompanied by serious aortic complications and a fatal outcome. In contrast to the American College of Rheumatology 1990 criteria for vasculitis, based on late LVV effects like arterial stenosis and/or occlusion, ¹⁸F-FDG PET/CT sheds new light on the classification of giant cell arteritis (GCA) and Takayasu arteritis (TA). The combination of these observations makes the role of ¹⁸F-FDG PET/CT in the assessment of patients suspected for having LVV promising.

The more you look, the more you find: challenging results on FDG-PET CT in a patient with neurofibromatosis type I

Background

FDG-PET/CT is part of the standard diagnostic management of a patients with a large variety of common and less common malignant tumors, based on the increased glucose metabolism within tumors.

Case presentation

A hybrid fluorodeoxyglucose positron emission tomography and computed tomography (FDG-PET/CT) was performed in a neurofibromatosis patient to rule out relapse of malignant peripheral nerve sheet tumor. The scan revealed non-malignant neurofibromas, a testis seminoma and hypermetabolic syphilitic granulomata.

Conclusion

This case stresses the need to rule out infectious diseases when atypical hypermetabolic lesions are present.

Usefulness of (18)F-FDG PET/CT in disease extent and treatment response assessment in a patient with syphilitic aortitis

A 40-year-old man was admitted to our hospital for surgical treatment of aortic insufficiency and coronary ostial stenosis. Histopathology and serological tests revealed a syphilitic aortitis. F-FDG PET/CT was performed to assess the extent of aortitis, showing increased radiopharmaceutical uptake along the ascending aortic wall. A repeated FDG PET/CT after antibiotic therapy showed a markedly reduced uptake in the aortic wall, suggesting resolution of the infection according to clinical and serological data. This case highlights the usefulness of FDG PET/CT for the assessment of disease extent and treatment response in patients with syphilitic aortitis.

Early recognition of aortitis of the aorta ascendens with ¹⁸F-FDG PET/CT: syphilitic?

We present the case of a 42-year-old woman known with a human leukocyte antigen B27 positive ankylosing spondylitis. Despite treatment with a tumor necrosis factor blocking agent, the patient was not pain free and inflammation markers remained elevated. An (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) was performed in an attempt to exclude possible other inflammatory processes. The (18)F-FDG PET/CT revealed increased metabolic activity in the ascending aortic wall, which appeared unexpectedly related to late syphilis. Based on this case and existing literature on this subject, we come to the conclusion that (18)F-FDG PET/CT can help in an early establishment of syphilitic aortitis before the possible life-threatening sequelae of syphilitic aortitis occur.

[Vasculitis assessment with [18F]FDG positron emission tomography]

[18F]fluorodeoxyglucose positron emission tomography (PET) is a noninvasive metabolic imaging modality that is well-suited to the assessment of activity and extent of large vessel vasculitis. PET imaging has demonstrated its usefulness in diagnosing giant cell arteritis (notably in its silent form), Takayasu's arteritis, and unclassified aortitis. PET imaging could be more effective than magnetic resonance imaging in detecting the earliest stages of vascular wall inflammation. The visual grading of vascular [18F]FDG uptake makes it possible to discriminate arteritis from active atherosclerosis, providing therefore high specificity. High sensitivity can also be achieved provided scanning is performed during active inflammatory phase, preferably before starting corticosteroid treatment. Prospective studies are needed to determine the exact value of PET imaging in assessing other vasculitis subsets, infectious aortitis, and large vessel vasculitis outcome and response to immunosuppressive treatment.

La tomographie d'émission de positons en médecine interne : applications actuelles et perspectives d'avenir

PURPOSE

Fluorodeoxyglucose positron emission tomography (FDG-PET) is a promising imaging technique that has already proven effective in modifying patient care in oncology. Fluorodeoxyglucose still remains the main radiopharmaceutical agent routinely used for PET imaging. A growing interest has recently lead to broaden PET research on benign disorders. The field of inflammatory or immune diseases and globally the field of internal medicine could also be impacted by FDG-PET.

MAIN POINTS

Great vessels vasculitides and fever of unknown origin have both been studied by several teams and could become indications for PET. In addition, current indications now extend to paraneoplastic syndromes. It is thus possible to foresee that the clinical applications for PET will continue to expand in these patients.

PERSPECTIVES AND PROJECTS

In the future, inflammatory arthritis, chronic inflammatory bowel diseases, systemic erythematous lupus, histiocytosis, or pulmonary and retroperitoneal fibrosis might benefit from PET even if, available data remains scarce to this day. Although PET will probably alter the landscape of patient management in internal medicine in the near future, additional clinical research is still needed to ascertain the exact role of PET.