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Pulmonary Histoplasmosis: A Clinical Update. J Fungi (Basel) 2023; 9:jof9020236. [PMID: 36836350 PMCID: PMC9964986 DOI: 10.3390/jof9020236] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
Histoplasma capsulatum, the etiological agent for histoplasmosis, is a dimorphic fungus that grows as a mold in the environment and as a yeast in human tissues. The areas of highest endemicity lie within the Mississippi and Ohio River Valleys of North America and parts of Central and South America. The most common clinical presentations include pulmonary histoplasmosis, which can resemble community-acquired pneumonia, tuberculosis, sarcoidosis, or malignancy; however, certain patients can develop mediastinal involvement or progression to disseminated disease. Understanding the epidemiology, pathology, clinical presentation, and diagnostic testing performance is pivotal for a successful diagnosis. While most immunocompetent patients with mild acute or subacute pulmonary histoplasmosis should receive therapy, all immunocompromised patients and those with chronic pulmonary disease or progressive disseminated disease should also receive therapy. Liposomal amphotericin B is the agent of choice for severe or disseminated disease, and itraconazole is recommended in milder cases or as "step-down" therapy after initial improvement with amphotericin B. In this review, we discuss the current epidemiology, pathology, diagnosis, clinical presentations, and management of pulmonary histoplasmosis.
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Mushari NA, Soultanidis G, Duff L, Trivieri MG, Fayad ZA, Robson P, Tsoumpas C. Exploring the Utility of Radiomic Feature Extraction to Improve the Diagnostic Accuracy of Cardiac Sarcoidosis Using FDG PET. Front Med (Lausanne) 2022; 9:840261. [PMID: 35295595 PMCID: PMC8920041 DOI: 10.3389/fmed.2022.840261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThis study aimed to explore the radiomic features from PET images to detect active cardiac sarcoidosis (CS).MethodsForty sarcoid patients and twenty-nine controls were scanned using FDG PET-CMR. Five feature classes were compared between the groups. From the PET images alone, two different segmentations were drawn. For segmentation A, a region of interest (ROI) was manually delineated for the patients' myocardium hot regions with standardized uptake value (SUV) higher than 2.5 and the controls' normal myocardium region. A second ROI was drawn in the entire left ventricular myocardium for both study groups, segmentation B. The conventional metrics and radiomic features were then extracted for each ROI. Mann-Whitney U-test and a logistic regression classifier were used to compare the individual features of the study groups.ResultsFor segmentation A, the SUVmin had the highest area under the curve (AUC) and greatest accuracy among the conventional metrics. However, for both segmentations, the AUC and accuracy of the TBRmax were relatively high, >0.85. Twenty-two (from segmentation A) and thirty-five (from segmentation B) of 75 radiomic features fulfilled the criteria: P-value < 0.00061 (after Bonferroni correction), AUC >0.5, and accuracy >0.7. Principal Component Analysis (PCA) was conducted, with five components leading to cumulative variance higher than 90%. Ten machine learning classifiers were then tested and trained. Most of them had AUCs and accuracies ≥0.8. For segmentation A, the AUCs and accuracies of all classifiers are >0.9, but k-neighbors and neural network classifiers were the highest (=1). For segmentation B, there are four classifiers with AUCs and accuracies ≥0.8. However, the gaussian process classifier indicated the highest AUC and accuracy (0.9 and 0.8, respectively).ConclusionsRadiomic analysis of the specific PET data was not proven to be necessary for the detection of CS. However, building an automated procedure will help to accelerate the analysis and potentially lead to more reproducible findings across different scanners and imaging centers and consequently improve standardization procedures that are important for clinical trials and development of more robust diagnostic protocols.
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Affiliation(s)
- Nouf A. Mushari
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- *Correspondence: Nouf A. Mushari
| | - Georgios Soultanidis
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lisa Duff
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- Institute of Medical and Biological Engineering, University of Leeds, Leeds, United Kingdom
| | - Maria G. Trivieri
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zahi A. Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Philip Robson
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Charalampos Tsoumpas
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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Eibschutz LS, Rabiee B, Asadollahi S, Gupta A, Assadi M, Alavi A, Gholamrezanezhad A. FDG-PET/CT of COVID-19 and Other Lung Infections. Semin Nucl Med 2022; 52:61-70. [PMID: 34246449 PMCID: PMC8216878 DOI: 10.1053/j.semnuclmed.2021.06.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
While not conventionally used as the first-line modality, [18F]-2-fluoro-2-deoxy-D-glucose (FDG) - positron emission tomography/computed tomography (PET/CT) can identify infection and inflammation both earlier and with higher sensitivity than anatomic imaging modalities [including chest X-ray (CXR), computed tomography (CT), and magnetic resonance imaging (MRI)]. The extent of inflammation and, conversely, recovery within the lungs, can be roughly quantified on FDG-PET/CT using maximum standardized uptake value (SUVmax) values. The Coronavirus disease 2019 (COVID-19) pandemic has highlighted the value of FDG-PET/CT in diagnosis, elucidation of acute pulmonary and extrapulmonary manifestations, and long-term follow up. Similarly, many other pulmonary infections such as previously documented coronaviruses, aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, histoplasmosis, mucormycosis, and typical/atypical mycobacterial infections have all been identified and characterized using FDG-PET/CT imaging. The goal of this review is to summarize the actual and potential benefits of FDG-PET/CT in the imaging of COVID-19 and other lung infections. Further research is necessary to determine the best indications and clinical applications of FDG-PET/CT, improve its specificity, and ultimately ascertain how this modality can best be utilized in the diagnostic work up of infectious pathologies.
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Affiliation(s)
- Liesl S. Eibschutz
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA
| | - Behnam Rabiee
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Shadi Asadollahi
- Professor of Radiology, Director of Research Education, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Amit Gupta
- Department of Radiology, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Majid Assadi
- Department of Nuclear Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Abass Alavi
- Professor of Radiology, Director of Research Education, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA,Address reprint requests to Ali Gholamrezanezhad, MD, Department of Radiology, Division of Emergency Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033
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Iyer H, Anand A, Sryma PB, Gupta K, Naranje P, Damle N, Mittal S, Madan NK, Mohan A, Hadda V, Tiwari P, Guleria R, Madan K. Mediastinal lymphadenopathy: a practical approach. Expert Rev Respir Med 2021; 15:1317-1334. [PMID: 33888038 DOI: 10.1080/17476348.2021.1920404] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Mediastinal lymphadenopathy is secondary to various benign and malignant etiologies. There is a variation in the underlying cause in different demographic settings. The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes. For a confident diagnosis, the clinician must choose from several available options and integrate the clinical, radiological, and pathology findings. An accurate diagnosis is necessary for optimal management.Areas covered: We performed a search of the PUBMED database to identify relevant articles on the causes, imaging modalities, and interventional modalities to diagnose these conditions. We discuss a practical approach toward the evaluation of a patient with mediastinal lymphadenopathy.Expert opinion: Mediastinal lymphadenopathy is a commonly encountered clinical problem. Treating physicians need to be aware of the clinico-radiological manifestations of the common diagnostic entities. Selecting an appropriate tissue diagnosis modality is crucial, with an intent to use the least invasive technique with good diagnostic yield. Endosonographic modalities (EBUS-TBNA, EUS-FNA, and EUS-B-FNA) have emerged as the cornerstone to most patients' diagnosis. An accurate diagnosis translates into favorable treatment outcomes.
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Affiliation(s)
- Hariharan Iyer
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Abhishek Anand
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - P B Sryma
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Kartik Gupta
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Priyanka Naranje
- Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nishikant Damle
- Department of Nuclear Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Stasiak CES, Nigri DH, Cardoso FR, de Mattos RSDAR, Gonçalves Martins PA, Carvalho ARS, Altino de Almeida S, Rodrigues RS, Rosado-de-Castro PH. Case Report: Incidental Finding of COVID-19 Infection after Positron Emission Tomography/CT Imaging in a Patient with a Diagnosis of Histoplasmosis and Recurring Fever. Am J Trop Med Hyg 2021; 104:1651-1654. [PMID: 33798100 PMCID: PMC8103480 DOI: 10.4269/ajtmh.20-0952] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/28/2021] [Indexed: 12/14/2022] Open
Abstract
This is a case report of a 37-year-old woman evaluated with 18F-fludeoxyglucose (18F-FDG) positron emission computed tomography/CT with recurrent fever after treatment with itraconazole for 6 weeks for histoplasmosis. The examination demonstrated a decrease in the dimensions of the pulmonary opacities previously identified in the left lower lobe and attributed to histoplasmosis. In addition to these pulmonary opacities, increased FDG uptake was also observed in lymph nodes present in the cervical region, mediastinum, left lung hilum, and hepatic hilum. Notably, other pulmonary opacities with ground-glass pattern that were not present in the previous computed tomography were detected in the right lower lobe, with mild 18F-FDG uptake. Nasal swab performed shortly after the examination was positive for COVID-19. In this case, the 18F-FDG positron emission computed tomography/CT study demonstrated findings consistent with active COVID-19 infection coexisting with inflammatory changes associated with histoplasmosis infection.
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Affiliation(s)
| | | | - Fabrícius Rocha Cardoso
- Department of Radiology, D’Or Institute for Research and Education, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Alysson Roncally Silva Carvalho
- Cardiovascular R&D Centre (UnIC), Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal;,Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luiz Coimbra Institute of Post-Graduation, Research in Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil;,Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sérgio Altino de Almeida
- Department of Radiology, D’Or Institute for Research and Education, Botafogo, Rio de Janeiro, Brazil
| | | | - Paulo Henrique Rosado-de-Castro
- Department of Radiology, D’Or Institute for Research and Education, Botafogo, Rio de Janeiro, Brazil;,Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil;,Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil,Address correspondence to Paulo Henrique Rosado-de-Castro, D’Or Institute for Research and Education, Rua Diniz Cordeiro 30, Botafogo, 22281-100, Rio de Janeiro/RJ, Brazil. E-mail:
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Yu J, Du F, Yang L, Chen L, He Y, Geng R, Wu L, Xie B. Identification of potential serum biomarkers for simultaneously classifying lung adenocarcinoma, squamous cell carcinoma and small cell carcinoma. Cancer Biomark 2021; 30:331-342. [PMID: 33361584 DOI: 10.3233/cbm-201440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Histological subtypes of lung cancer are crucial for making treatment decisions. However, multi-subtype classifications including adenocarcinoma (AC), squamous cell carcinoma (SqCC) and small cell carcinoma (SCLC) were rare in the previous studies. This study aimed at identifying and screening potential serum biomarkers for the simultaneous classification of AC, SqCC and SCLC. PATIENTS AND METHODS A total of 143 serum samples of AC, SqCC and SCLC were analyzed by 1HNMR and UPLC-MS/MS. The stepwise discriminant analysis (DA) and multilayer perceptron (MLP) were employed to screen the most efficient combinations of markers for classification. RESULTS The results of non-targeted metabolomics analysis showed that the changes of metabolites of choline, lipid or amino acid might contribute to the classification of lung cancer subtypes. 17 metabolites in those pathways were further quantified by UPLC-MS/MS. DA screened out that serum xanthine, S-adenosyl methionine (SAM), carcinoembryonic antigen (CEA), neuron-specific enolase (NSE) and squamous cell carcinoma antigen (SCC) contributed significantly to the classification of AC, SqCC and SCLC. The average accuracy of 92.3% and the area under the receiver operating characteristic curve of 0.97 would be achieved by MLP model when a combination of those five variables as input parameters. CONCLUSION Our findings suggested that metabolomics was helpful in screening potential serum markers for lung cancer classification. The MLP model established can be used for the simultaneous diagnosis of AC, SqCC and SCLC with high accuracy, which is worthy of further study.
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Affiliation(s)
- Jiangqing Yu
- Department of Pharmaceutics, Medical College of Jiaxing University, Jiaxing, Zhejiang, China.,Department of Respiratory and Critical Care Medicine, Huadu District People's Hospital of Guangzhou, Southern Medical University, Guangzhou, Guangdong, China
| | - Fen Du
- Department of Pharmaceutics, Medical College of Jiaxing University, Jiaxing, Zhejiang, China.,School of Pharmaceutical Science, Nanchang University, Nanchang, Jiangxi, China
| | - Liping Yang
- Medical Oncology, People's Hospital of Gansu Province, Lanzhou, Gansu, China
| | - Ling Chen
- School of Pharmaceutical Science, Nanchang University, Nanchang, Jiangxi, China
| | - Yuanxiang He
- Thoracic Surgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ruijin Geng
- School of Pharmaceutical Science, Nanchang University, Nanchang, Jiangxi, China
| | - Le Wu
- Department of Pharmaceutics, Medical College of Jiaxing University, Jiaxing, Zhejiang, China.,School of Pharmaceutical Science, Nanchang University, Nanchang, Jiangxi, China
| | - Baogang Xie
- Department of Pharmaceutics, Medical College of Jiaxing University, Jiaxing, Zhejiang, China.,School of Pharmaceutical Science, Nanchang University, Nanchang, Jiangxi, China
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Ruegg G, Zimmerli S, Trachsel M, Berezowska S, Engelbrecht S, Martin Y, Perrig M. Pulmonary Histoplasmosis Mimicking Metastatic Lung Cancer: A Case Report. Diagnostics (Basel) 2021; 11:diagnostics11020328. [PMID: 33671319 PMCID: PMC7922209 DOI: 10.3390/diagnostics11020328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 11/16/2022] Open
Abstract
Histoplasmosis is a well-known endemic fungal infection but experience in non-endemic regions is often limited, which may lead to delayed diagnosis and extensive testing. The diagnosis can be especially challenging, typically when the disease first presents with pulmonary nodules accompanied by hilar and mediastinal lymphadenopathy, suggesting a much more common malignant disease. In this situation, a greater FDG uptake in draining lymph nodes in comparison with the associated lung nodule seen in [18F]FDG-PET/CT, the so-called "flip-flop fungus" sign, can help to orientate further diagnostic measures. We report a case of a 56-year-old woman living in Switzerland, a non-endemic region, whose diagnosis of imported histoplasmosis was delayed since the findings had been initially misinterpreted as pulmonary malignancy. Further, histological workup was inconclusive due to lack of specific fungal staining, leading to ineffective treatment and non-resolving disease. This paper intends to highlight the pitfalls in diagnosing Histoplasma capsulatum and presents images of particularities of fungal infections in [18F]FDG-PET/CT, which in our case showed a "flip-flop fungus" sign.
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Affiliation(s)
- Gion Ruegg
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
- Department of Intensive Care Medicine, University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence: ; Tel.: +41-31-632-5300; Fax: +41-31-632-1771
| | - Stefan Zimmerli
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Maria Trachsel
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
| | - Sabina Berezowska
- Institute of Pathology, University of Bern, 3008 Bern, Switzerland;
- Department of Laboratory Medicine and Pathology, Institute of Pathology, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Swantje Engelbrecht
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Yonas Martin
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
| | - Martin Perrig
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.T.); (Y.M.); (M.P.)
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Katal S, Amini H, Gholamrezanezhad A. PET in the diagnostic management of infectious/inflammatory pulmonary pathologies: a revisit in the era of COVID-19. Nucl Med Commun 2021; 42:3-8. [PMID: 32991395 PMCID: PMC7720808 DOI: 10.1097/mnm.0000000000001299] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/01/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Sanaz Katal
- Department of Diagnostic Radiology, Keck School of Medicine, University of Southern California (USC), Los Angles, California, USA
| | - Hamidreza Amini
- Department of Diagnostic Radiology, Keck School of Medicine, University of Southern California (USC), Los Angles, California, USA
| | - Ali Gholamrezanezhad
- Department of Diagnostic Radiology, Keck School of Medicine, University of Southern California (USC), Los Angles, California, USA
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The value of 4D fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in the diagnosis of lung lesions. Nucl Med Commun 2020; 41:1306-1312. [DOI: 10.1097/mnm.0000000000001289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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10
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Denham ST, Wambaugh MA, Brown JCS. How Environmental Fungi Cause a Range of Clinical Outcomes in Susceptible Hosts. J Mol Biol 2019; 431:2982-3009. [PMID: 31078554 PMCID: PMC6646061 DOI: 10.1016/j.jmb.2019.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/18/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
Environmental fungi are globally ubiquitous and human exposure is near universal. However, relatively few fungal species are capable of infecting humans, and among fungi, few exposure events lead to severe systemic infections. Systemic infections have mortality rates of up to 90%, cost the US healthcare system $7.2 billion annually, and are typically associated with immunocompromised patients. Despite this reputation, exposure to environmental fungi results in a range of outcomes, from asymptomatic latent infections to severe systemic infection. Here we discuss different exposure outcomes for five major fungal pathogens: Aspergillus, Blastomyces, Coccidioides, Cryptococcus, and Histoplasma species. These fungi include a mold, a budding yeast, and thermal dimorphic fungi. All of these species must adapt to dramatically changing environments over the course of disease. These dynamic environments include the human lung, which is the first exposure site for these organisms. Fungi must defend themselves against host immune cells while germinating and growing, which risks further exposing microbe-associated molecular patterns to the host. We discuss immune evasion strategies during early infection, from disruption of host immune cells to major changes in fungal cell morphology.
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Affiliation(s)
- Steven T Denham
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Morgan A Wambaugh
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Jessica C S Brown
- Division of Microbiology and Immunology, Pathology Department, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
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Purandare NC, Pramesh CS, Agarwal JP, Agrawal A, Shah S, Prabhash K, Karimundackal G, Jiwnani S, Tandon S, Rangarajan V. Solitary pulmonary nodule evaluation in regions endemic for infectious diseases: Do regional variations impact the effectiveness of fluorodeoxyglucose positron emission tomography/computed tomography. Indian J Cancer 2018; 54:271-275. [PMID: 29199704 DOI: 10.4103/0019-509x.219563] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has become a preferred imaging modality for the evaluation of solitary pulmonary nodule (SPN), particularly in the developed world. Since FDG can concentrate in infective/inflammatory lesions, the diagnostic utility of FDG-PET can be questioned, particularly in regions endemic for infectious decisions. AIM To evaluate the accuracy of FDG-PET/CT in evaluation of SPNs in a population endemic for infectious disease and to assess if regional variations have an impact on its effectiveness. MATERIALS AND METHODS All patients who underwent an FDG/PET-CT with a clinico-radiological diagnosis of SPN categorized as indeterminate were included. Based on a maximum standardized uptake values (SUVmax) cut-off of 2.5, lesions were classified as benign (<2.5) or malignant (>2.5) and compared with gold standard histopathology. The diagnostic accuracy of PET-CT to detect malignancy was calculated. On the basis of final histopathology, lesions were grouped as (a) malignant nodules (b) infective/granulomatous nodules with a specific diagnosis and (c) nonspecific inflammatory nodules. The SUVmaxbetween these groups was compared using nonparametric statistical tests. RESULTS A total of 191 patients (129 males, 62 females) with a median age of 64 years (range: 36-83) were included. Totally, 144 nodules (75.3%) were malignant and 47 were benign (24.7%). Adenocarcinoma (n = 84) was the most common malignancy. Tuberculosis (n = 16) and nonspecific infections (n = 24) were the two most common benign pathologies. There was a significant overlap in the metabolic uptake of malignant (median SUVmax-11.2, range: 3.3-34.6) and tuberculous nodules (median SUVmax-10.3, range: 2.7-22.5) with no statistically difference between their SUVmaxvalues (P = 0.43). The false-positive rate was 65.2% and the false-negative rate was 5.5%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG-PET/CT for detecting malignancy were 94.4%, 34.7%, 81.9%, 66.6%, and 79.5%, respectively. CONCLUSIONS Though FDG-PET scans show a very high sensitivity for malignant nodules, it has a high false-positive rate and reduced specificity when characterizing SPNs in an infectious endemic region. Physicians must be aware of this limitation in the workup of lung nodules, and regional variations must be considered before further management decisions are taken.
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Affiliation(s)
- N C Purandare
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - J P Agarwal
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - A Agrawal
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - S Shah
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - K Prabhash
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - G Karimundackal
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - S Jiwnani
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - S Tandon
- Department of Chest Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - V Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Centre, Mumbai, Maharashtra, India
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12
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What, where and why: exploring fluorodeoxyglucose-PET's ability to localise and differentiate infection from cancer. Curr Opin Infect Dis 2018; 30:552-564. [PMID: 28922285 DOI: 10.1097/qco.0000000000000405] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To review the utility of FDG-PET imaging in detecting the cause of fever and infection in patients with cancer. RECENT FINDINGS FDG-PET has been shown to have high sensitivity and accuracy for causes of neutropenic fever, leading to higher diagnostic certainty in this group. Recent advances in pathogen-specific labelling in PET to identify Aspergillus spp. and Yersinia spp. infections in mice, as well as differentiating between Gram-positive, Gram-negative and mycobacterial infections are promising. SUMMARY Patients with cancer are vulnerable to infection and fever, and the causes of these are frequently unclear using conventional diagnostic methods leading to high morbidity and mortality, length of stay and costs of care. FDG-PET/CT, with its unique complementary functional and anatomical information as well as its whole-body imaging capability, has demonstrated use in detecting occult infection in immunocompromised patients, including invasive fungal and occult bacterial infections, as well as defining extent of infection. By demonstrating disease resolution following treatment and allowing earlier cessation of therapy, FDG-PET acts as a key tool for antimicrobial and antifungal stewardship. Limitations include at times poor differentiation between infection, malignancy and sterile inflammation, however, exciting new technologies specific to infectious pathogens may help alleviate that issue. Further prospective randomised research is needed to explore these benefits in a nonbiased fashion.
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Abstract
With increasing numbers of travelers and immunocompromised patients, histoplasmosis, caused by the dimorphic fungus Histoplasma capsulatum, has become a disease of national extent. The clinical spectrum of histoplasmosis is very wide, in terms of disease cadence, onset, distribution, and severity. A multipronged approach is recommended for diagnosis. Manifestations that are always treated include moderate to severe acute pulmonary histoplasmosis, disseminated disease, and histoplasmosis in immunocompromised individuals. Amphotericin B is the drug of choice for moderate to severe and disseminated presentations, whereas itraconazole is appropriate for mild disease and as step-down therapy.
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Spectrum of Physiologic and Pathologic Skeletal Muscle18F-FDG Uptake on PET/CT. AJR Am J Roentgenol 2015; 205:W141-9. [DOI: 10.2214/ajr.14.13457] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Maturu VN, Agarwal R, Aggarwal AN, Mittal BR, Bal A, Gupta N, Gupta D. Dual-Time Point Whole-Body 18 F-Fluorodeoxyglucose PET/CT Imaging in Undiagnosed Mediastinal Lymphadenopathy. Chest 2014; 146:e216-e220. [DOI: 10.1378/chest.14-1827] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Deppen SA, Blume JD, Kensinger CD, Morgan AM, Aldrich MC, Massion PP, Walker RC, McPheeters ML, Putnam JB, Grogan EL. Accuracy of FDG-PET to diagnose lung cancer in areas with infectious lung disease: a meta-analysis. JAMA 2014; 312:1227-36. [PMID: 25247519 PMCID: PMC4315183 DOI: 10.1001/jama.2014.11488] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Positron emission tomography (PET) combined with fludeoxyglucose F 18 (FDG) is recommended for the noninvasive diagnosis of pulmonary nodules suspicious for lung cancer. In populations with endemic infectious lung disease, FDG-PET may not accurately identify malignant lesions. OBJECTIVES To estimate the diagnostic accuracy of FDG-PET for pulmonary nodules suspicious for lung cancer in regions where infectious lung disease is endemic and compare the test accuracy in regions where infectious lung disease is rare. DATA SOURCES AND STUDY SELECTION Databases of MEDLINE, EMBASE, and the Web of Science were searched from October 1, 2000, through April 28, 2014. Articles reporting information sufficient to calculate sensitivity and specificity of FDG-PET to diagnose lung cancer were included. Only studies that enrolled more than 10 participants with benign and malignant lesions were included. Database searches yielded 1923 articles, of which 257 were assessed for eligibility. Seventy studies were included in the analysis. Studies reported on a total of 8511 nodules; 5105 (60%) were malignant. DATA EXTRACTION AND SYNTHESIS Abstracts meeting eligibility criteria were collected by a research librarian and reviewed by 2 independent reviewers. Hierarchical summary receiver operating characteristic curves were constructed. A random-effects logistic regression model was used to summarize and assess the effect of endemic infectious lung disease on test performance. MAIN OUTCOME AND MEASURES The sensitivity and specificity for FDG-PET test performance. RESULTS Heterogeneity for sensitivity (I2 = 87%) and specificity (I2 = 82%) was observed across studies. The pooled (unadjusted) sensitivity was 89% (95% CI, 86%-91%) and specificity was 75% (95% CI, 71%-79%). There was a 16% lower average adjusted specificity in regions with endemic infectious lung disease (61% [95% CI, 49%-72%]) compared with nonendemic regions (77% [95% CI, 73%-80%]). Lower specificity was observed when the analysis was limited to rigorously conducted and well-controlled studies. In general, sensitivity did not change appreciably by endemic infection status, even after adjusting for relevant factors. CONCLUSIONS AND RELEVANCE The accuracy of FDG-PET for diagnosing lung nodules was extremely heterogeneous. Use of FDG-PET combined with computed tomography was less specific in diagnosing malignancy in populations with endemic infectious lung disease compared with nonendemic regions. These data do not support the use of FDG-PET to diagnose lung cancer in endemic regions unless an institution achieves test performance accuracy similar to that found in nonendemic regions.
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Affiliation(s)
- Stephen A. Deppen
- Veterans Affairs Hospital, Tennessee Valley Healthcare System, Nashville TN
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville TN
| | - Jeffrey D. Blume
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville TN
| | - Clark D. Kensinger
- Department of Surgery, Vanderbilt University Medical Center, Nashville TN
| | - Ashley M. Morgan
- School of Medicine, Vanderbilt University Medical Center, Nashville TN
| | - Melinda C. Aldrich
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville TN
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville TN
| | - Pierre P. Massion
- Veterans Affairs Hospital, Tennessee Valley Healthcare System, Nashville TN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville TN
| | - Ronald C. Walker
- Department of Medical Imaging, Tennessee Valley Healthcare System-Veterans Affairs, Nashville TN
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville TN
| | - Melissa L. McPheeters
- Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville TN
- Department of Medicine, Division of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville TN
| | - Joseph B. Putnam
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville TN
| | - Eric L. Grogan
- Veterans Affairs Hospital, Tennessee Valley Healthcare System, Nashville TN
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville TN
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Abstract
OBJECTIVE Combined anatomic and functional imaging with (18)F-FDG PET/CT is slowly gaining foothold in the management of various infective pathologic abnormalities. However, limited literature is available regarding the role of FDG PET/CT in patients with fungal infections. CONCLUSION Here, we briefly review the available literature and highlight the potential role that FDG PET/CT can play in the diagnosis and management of fungal infections.
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Povoski SP, Murrey DA, Smith SM, Martin EW, Hall NC. 18F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals derived from a single-institution 18F-FDG-directed surgery experience: feasibility and quantification of 18F-FDG accumulation within 18F-FDG-avid lesions and background tissues. BMC Cancer 2014; 14:453. [PMID: 24942656 PMCID: PMC4075626 DOI: 10.1186/1471-2407-14-453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 06/13/2014] [Indexed: 12/31/2022] Open
Abstract
Background 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) is a well-established imaging modality for a wide variety of solid malignancies. Currently, only limited data exists regarding the utility of PET/CT imaging at very extended injection-to-scan acquisition times. The current retrospective data analysis assessed the feasibility and quantification of diagnostic 18F-FDG PET/CT oncologic imaging at extended injection-to-scan acquisition time intervals. Methods 18F-FDG-avid lesions (not surgically manipulated or altered during 18F-FDG-directed surgery, and visualized both on preoperative and postoperative 18F-FDG PET/CT imaging) and corresponding background tissues were assessed for 18F-FDG accumulation on same-day preoperative and postoperative 18F-FDG PET/CT imaging. Multiple patient variables and 18F-FDG-avid lesion variables were examined. Results For the 32 18F-FDG-avid lesions making up the final 18F-FDG-avid lesion data set (from among 7 patients), the mean injection-to-scan times of the preoperative and postoperative 18F-FDG PET/CT scans were 73 (±3, 70-78) and 530 (±79, 413-739) minutes, respectively (P < 0.001). The preoperative and postoperative mean 18F-FDG-avid lesion SUVmax values were 7.7 (±4.0, 3.6-19.5) and 11.3 (±6.0, 4.1-29.2), respectively (P < 0.001). The preoperative and postoperative mean background SUVmax values were 2.3 (±0.6, 1.0-3.2) and 2.1 (±0.6, 1.0-3.3), respectively (P = 0.017). The preoperative and postoperative mean lesion-to-background SUVmax ratios were 3.7 (±2.3, 1.5-9.8) and 5.8 (±3.6, 1.6-16.2), respectively, (P < 0.001). Conclusions 18F-FDG PET/CT oncologic imaging can be successfully performed at extended injection-to-scan acquisition time intervals of up to approximately 5 half-lives for 18F-FDG while maintaining good/adequate diagnostic image quality. The resultant increase in the 18F-FDG-avid lesion SUVmax values, decreased background SUVmax values, and increased lesion-to-background SUVmax ratios seen from preoperative to postoperative 18F-FDG PET/CT imaging have great potential for allowing for the integrated, real-time use of 18F-FDG PET/CT imaging in conjunction with 18F-FDG-directed interventional radiology biopsy and ablation procedures and 18F-FDG-directed surgical procedures, as well as have far-reaching impact on potentially re-shaping future thinking regarding the “most optimal” injection-to-scan acquisition time interval for all routine diagnostic 18F-FDG PET/CT oncologic imaging.
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Affiliation(s)
- Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G, James Cancer Hospital and Richard J, Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
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