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Khan D, Phulia A, Kumar S, Sarswat S, Kv S, Sagar S. Role of 18 F-FDG PET/CT for providing a targeted approach for etiology of PUO. Nucl Med Commun 2024; 45:702-709. [PMID: 38832445 DOI: 10.1097/mnm.0000000000001855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
AIM This study aimed to evaluate the potential role of 18F-fluorodeoxyglucose PET/computed tomography (18F-FDG PET/CT) in providing a targeted approach for diagnosing the etiology of Pyrexia of Unknown Origin (PUO). METHODS A total of 573 PUO patients were included in this ambispective study, with a mean age of 39.40 ± 4.6 years. Patients underwent FDG PET/CT scans using dedicated hybrid scanners. PET/CT data were interpreted by experienced nuclear medicine physicians. The study analyzed the guidance provided by FDG PET/CT for appropriate biopsy sites and assessed concordance between PET/CT findings and histopathological examination. RESULTS Out of the 573 patients, a final diagnosis was reached for 219 patients, including malignancy, infectious causes, noninfectious inflammatory causes (NIID), and precancerous conditions. FDG PET/CT played a crucial role in guiding clinicians to appropriate biopsy sites, contributing to a higher diagnostic yield. Concordance between PET/CT findings and histopathological examination emphasized the noninvasive diagnostic potential of PET/CT in identifying underlying causes of PUO. Overall, FDG PET/CT contributed to guiding the appropriate site of biopsy or concordance of the first differential diagnosis with the final diagnosis in 50.05% of cases. CONCLUSION This study highlights the valuable role of FDG PET/CT in providing a targeted approach for diagnosing PUO, showcasing its potential in guiding clinicians towards appropriate biopsy sites and improving the diagnostic yield. The findings underscore the importance of integrating FDG PET/CT into the diagnostic pathway for PUO, ultimately enhancing patient management and outcomes. Further prospective studies are necessary to validate these results and refine the integration of FDG PET/CT in the diagnosis of PUO.
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Affiliation(s)
- Dikhra Khan
- Department of Nuclear Medicine, All India Institute of Medical Sciences,
| | | | - Suraj Kumar
- Department of Nuclear Medicine, PGI Chandigarh, Chandigarh and
| | | | - Sivasankar Kv
- Department of Nuclear Medicine, All India Institute of Medical Sciences,
| | - Sambit Sagar
- Department of Nuclear Medicine, All India Institute of Medical Sciences,
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Buchrits S, McNeil R, Avni T, Fredman D, Guz D, Gafter-Gvili A. The Contribution of 18F FDG PET-CT for the Investigation of Fever of Unknown Origin and Inflammation of Unknown Origin. Am J Med 2024; 137:629-639. [PMID: 38499136 DOI: 10.1016/j.amjmed.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Fever of unknown origin and inflammation of unknown origin are highly challenging diagnostic conditions. The current practice for evaluating patients is to conduct a positron emission tomography-computed tomography (PET-CT) scan as either a first- or a second-line modality. We aimed to assess the contributory effect of PET-CT to the diagnosis and compare it with the contributory effect of CT alone. METHODS We performed a systematic review and meta-analysis. We included all cohorts that examined the contribution of PET-CT to the investigation of classical fever of unknown origin and inflammation of unknown origin. The primary outcome was the contribution of PET-CT to the final diagnosis. Secondary outcomes were sensitivity and specificity of PET-CT and CT scans, and contribution of a CT scan. We pooled the results of all studies and calculated the pooled contributory effect of PET-CT. RESULT Thirty-six studies (3516 patients) were included in the systematic review. The pooled contribution of PET-CT was 75.4%. The compiled sensitivity and specificity values for all studies were 85.9% and 59.5%, respectively. Five studies (405 patients) compared between the PET-CT component and the total body CT component. The pooled contribution of a CT scan was 68%. The summed sensitivity and specificity values of a CT scan for all studies were 63.1% and 84.4%, respectively. CONCLUSIONS PET-CT has a contributory effect of 75% for the diagnosis of fever of unknown origin and inflammation of unknown origin. PET-CT had superior sensitivity and inferior specificity vs the CT scan.
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Affiliation(s)
- Shira Buchrits
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Rotem McNeil
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Tomer Avni
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Danielle Fredman
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dmitri Guz
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Anat Gafter-Gvili
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
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Hess S, Noriega-Álvarez E, Leccisotti L, Treglia G, Albano D, Roivainen A, Glaudemans AWJM, Gheysens O. EANM consensus document on the use of [ 18F]FDG PET/CT in fever and inflammation of unknown origin. Eur J Nucl Med Mol Imaging 2024; 51:2597-2613. [PMID: 38676736 PMCID: PMC11224117 DOI: 10.1007/s00259-024-06732-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
PURPOSE Patients with fever and inflammation of unknown origin (FUO/IUO) are clinically challenging due to variable clinical presentations with nonspecific symptoms and many differential diagnoses. Positron emission tomography/computed tomography (PET/CT) with 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) is increasingly used in FUO and IUO, but the optimal diagnostic strategy remains controversial. This consensus document aims to assist clinicians and nuclear medicine specialists in the appropriate use of [18F]FDG-PET/CT in FUO and IUO based on current evidence. METHODS A working group created by the EANM infection and inflammation committee performed a systematic literature search based on PICOs with "patients with FUO/IUO" as population, "[18F]FDG-PET/CT" as intervention, and several outcomes including pre-scan characteristics, scan protocol, diagnostic yield, impact on management, prognosis, and cost-effectiveness. RESULTS We included 68 articles published from 2001 to 2023: 9 systematic reviews, 49 original papers on general adult populations, and 10 original papers on specific populations. All papers were analysed and included in the evidence-based recommendations. CONCLUSION FUO and IUO remains a clinical challenge and [18F]FDG PET/CT has a definite role in the diagnostic pathway with an overall diagnostic yield or helpfulness in 50-60% of patients. A positive scan is often contributory by directly guiding treatment or subsequent diagnostic procedure. However, a negative scan may be equally important by excluding focal disease and predicting a favorable prognosis. Similar results are obtained in specific populations such as ICU-patients, children and HIV-patients.
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Affiliation(s)
- Søren Hess
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Edel Noriega-Álvarez
- Department of Nuclear Medicine, University Hospital of Guadalajara, Guadalajara, Spain
| | - Lucia Leccisotti
- Section of Nuclear Medicine, Department of Radiological Sciences and Haematology, Università Cattolica del Sacro Cuore, Rome, Italy
- Unit of Nuclear Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Treglia
- Division of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Domenico Albano
- Nuclear Medicine, University of Brescia, ASST Spedali Civili Brescia, Brescia, Italy
| | - Anne Roivainen
- Turku PET Centre, University of Turku, Turku, Finland
- Turku PET Centre, Turku University Hospital, Turku, Finland
- InFLAMES Research Flagship, University of Turku, Turku, Finland
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Hanzeplein 1, Groningen, 9700 RB, The Netherlands.
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc and Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain, Brussels, Belgium
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Boulu X, Vaysse B, El Esper I, Meyer ME, Duhaut P, Salle V, Schmidt J. [Inflammatory syndrome of unknown origin and PET/CT: Economic and iatrogenic impacts of false positive]. Rev Med Interne 2024; 45:258-263. [PMID: 38000918 DOI: 10.1016/j.revmed.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/23/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023]
Abstract
INTRODUCTION PET/CT is regularly used to investigate inflammatory syndrome of unknown origin (IUO), but hypermetabolisms found are not always consistent with the final diagnosis. The objective of the study was to assess the cost attributed to the diagnostic work-up for these false positives. MATERIALS AND METHODS We conducted an ancillary study on a previous retrospective cohort from the internal medicine department at Amiens university hospital in patients who had a PET/CT scan between October 2004 and April 2017. Patients were included if PET/CT had been prescribed to investigate IUO. Among the 763 PET/CT performed, 144 met the inclusion criteria and a false-positive rate of 17.4% (n=25) was reported. RESULTS Among these 25 patients, 21 underwent further investigations. The most frequently found hypermetabolic territories were digestive (n=12, mean SUVmax 8 [±4.33]) and osteoarticular (n=11, mean SUVmax 4.33 [±1.15]). The total cost of the 13 prescribed consultations was €390, the total cost of the 40 additional tests was €4,476 (mainly digestive endoscopies and radiological tests) and the total cost of medical transport was €572. The total cost of the 35 days of hospitalization specifically required to investigate these false positives was €22,952. In 23.8% (n=5), these investigations led to the incidental discovery of tumor lesions. CONCLUSION The economic impact of false-positive PET/CT results does not appear to be negligible and merits a genuine prospective medico-economic study.
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Affiliation(s)
- X Boulu
- Médecine interne, CHU Amiens Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens Picardie, 80054 Amiens, France.
| | - B Vaysse
- Département d'information médicale, CHU Amiens Picardie, 80054 Amiens, France
| | - I El Esper
- Médecine nucléaire et traitement de l'image, CHU Amiens Picardie, 80054 Amiens, France
| | - M-E Meyer
- Médecine nucléaire et traitement de l'image, CHU Amiens Picardie, 80054 Amiens, France
| | - P Duhaut
- Médecine interne, CHU Amiens Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens Picardie, 80054 Amiens, France
| | - V Salle
- Médecine interne, CHU Amiens Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens Picardie, 80054 Amiens, France
| | - J Schmidt
- Médecine interne, CHU Amiens Picardie, 80054 Amiens, France; RECIF Amiens, CHU Amiens Picardie, 80054 Amiens, France
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Liu B, Ma R, Shum E, Hormiz M, Lee ST, Poon AMT, Scott AM. FDG-PET/CT for investigation of pyrexia of unknown origin: a cost of illness analysis. Eur J Nucl Med Mol Imaging 2024; 51:1287-1296. [PMID: 38057651 DOI: 10.1007/s00259-023-06548-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/26/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Our study aims to explore the current utilisation of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the diagnostic pathway of pyrexia of unknown origin (PUO) and associated cost of illness in a large tertiary teaching hospital in Australia. METHOD 1257 febrile patients between June 2016 and September 2022 were retrospectively reviewed. There were 57 patients who met the inclusion criteria of "classical PUO", of which FDG-PET/CT was performed in 31 inpatients, 15 outpatients and 11 inpatients did not have an FDG-PET/CT scan. The patient demographics, clinical characteristics and inpatient cost were analysed, together with the diagnostic performance of FDG-PET/CT and impact on clinical management. RESULT The mean age, length of stay and total cost of admission were higher for inpatients who received FDG-PET/CT versus those who did not. The median cost per patient-bed-day did not differ between the two groups. Inpatients who received earlier FDG-PET/CTs (≤ 7 days from admission) had shorter length of stays and lower total cost compared to those who received a later scan. A negative FDG-PET/CT scan, demonstrating no serious or life-threatening abnormalities resulted in subsequent discharge from hospital or outpatient clinic in 7/10 (70%) patients. There were 11/40 (28%) scans where ancillary abnormalities were identified, requiring further evaluation. CONCLUSION FDG-PET/CT showed high diagnostic accuracy and significant impact on patient management in patients with PUO. FDG-PET/CT performed earlier in admission for PUO was associated with shorter length of stay and lower total cost.
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Affiliation(s)
- Bonnia Liu
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia.
- Department of Rheumatology, Austin Health, Melbourne, VIC, Australia.
- Department of Nuclear Medicine, Royal Melbourne Hospital, 300 Grattan St, Melbourne, VIC, Australia.
| | - Ronald Ma
- Department of Finance, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Evonne Shum
- Department of General Medicine, Austin Health, Melbourne, VIC, Australia
| | - Maria Hormiz
- Department of General Medicine, Austin Health, Melbourne, VIC, Australia
| | - Sze-Ting Lee
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia
- La Trobe University, Melbourne, VIC, Australia
| | - Aurora M T Poon
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Andrew M Scott
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia
- La Trobe University, Melbourne, VIC, Australia
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Boulu X, El Esper I, Meyer ME, Duhaut P, Salle V, Schmidt J. Value of Positron Emission Tomography Coupled With Computed Tomography for the Diagnosis of Inflammatory Syndrome of Unknown Origin in an Internal Medicine Department. Mayo Clin Proc Innov Qual Outcomes 2023; 7:178-186. [PMID: 37206378 PMCID: PMC10189090 DOI: 10.1016/j.mayocpiqo.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/19/2023] [Accepted: 04/05/2023] [Indexed: 05/21/2023] Open
Abstract
Objective To evaluate the usefulness of positron emission tomography (PET) coupled with computed tomography (CT) in the diagnostic workup for inflammatory syndrome of undetermined origin (IUO) and to determine the diagnostic delay in an internal medicine department. Patients and methods We retrospectively studied a cohort of patients for whom a PET/CT scan had been prescribed in an indication of IUO in an internal medicine department (Amiens University Medical Center, Amiens, France) between October 2004 and April 2017. The patients were grouped according to the PET/CT findings: very useful (enabling an immediate diagnosis), useful, not useful, and misleading. Results We analyzed 144 patients. The median (interquartile range) age was 67.7 years (55.8-75.8 years). The final diagnosis was an infectious disease in 19 patients (13.2%), cancer in 23 (16%), inflammatory disease in 48 (33%), and miscellaneous diseases in 12 (8.3%). No diagnosis was made in 29.2% of the cases; half of the remaining had a spontaneously favorable outcome. Fever was observed in 63 patients (43%). Positron emission tomography coupled with CT was determined to be very useful in 19 patients (13.2%), useful in 37 (25.7%), not useful in 63 (43.7%), and misleading in 25 (17.4%). The median diagnostic delay (ie, the time interval between the first admission and a confirmed diagnosis) was significantly shorter in the useful (71 days [38-170 days]) and very useful (55 days [13-79 days]) groups than that in the not useful group (175 days [51-390 days]; P<.001). The median time interval between the PET/CT scan and the diagnosis was twice as long in the not useful group than that in the pooled misleading, useful, or very useful groups (P=.03). In a univariate analysis, the poor overall condition (P=.007) and the absence of fever (P=.005) were predictive of usefulness of PET/CT. Conclusion Positron emission tomography coupled with CT seems to be useful in the diagnosis of IUO and might shorten the diagnostic delay.
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Affiliation(s)
- Xavier Boulu
- Department of Internal Medicine, Amiens University Medical Center, Amiens, France
- RECIF Amiens, Amiens University Medical Center, Amiens, France
- Correspondence: Address to Xavier Boulu, MD, Department of Internal Medicine Amiens University Medical Center, F-80054, Amiens, France.
| | - Isabelle El Esper
- Department of Nuclear Medicine, Amiens University Medical Center, Amiens, France
| | - Marc-Etienne Meyer
- Department of Nuclear Medicine, Amiens University Medical Center, Amiens, France
| | - Pierre Duhaut
- Department of Internal Medicine, Amiens University Medical Center, Amiens, France
- RECIF Amiens, Amiens University Medical Center, Amiens, France
| | - Valery Salle
- Department of Internal Medicine, Amiens University Medical Center, Amiens, France
- RECIF Amiens, Amiens University Medical Center, Amiens, France
| | - Jean Schmidt
- Department of Internal Medicine, Amiens University Medical Center, Amiens, France
- RECIF Amiens, Amiens University Medical Center, Amiens, France
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van Rijsewijk ND, IJpma FFA, Wouthuyzen-Bakker M, Glaudemans AWJM. Molecular Imaging of Fever of Unknown Origin: An Update. Semin Nucl Med 2023; 53:4-17. [PMID: 35902280 DOI: 10.1053/j.semnuclmed.2022.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 01/28/2023]
Abstract
18F-FDG PET/CT, 67Ga-citrate and white blood cell (WBC) scintigraphy are molecular imaging techniques currently used in the diagnostic workup of fever of unknown origin. However, it is unknown which technique fits which patient group best. A systematic literature search has been performed for original articles regarding the use of molecular imaging in fever of unknown origin. A total of 820 eligible studies were screened of which 63 articles evaluating 5094 patients met the inclusion criteria. 18F-FDG PET/CT provided good diagnostic accuracy (with a weighted mean sensitivity, specificity, positive predicting value, negative predictive value, accuracy and helpfulness of 84.4%, 61.8%, 80.7%, 67.8%, 76.3%, and 61.1%, respectively). Even within specific patient groups such as children, elderly, patients with connective tissue diseases, patients on renal replacement therapy, and HIV-infected patients, 18F-FDG PET/CT provided good diagnostic values. For 67Ga-citrate scintigraphy, the weighted mean sensitivity, specificity, positive predictive value, negative predictive value, and helpfulness were 42.2%, 80.3%, 82.4%, 41.9%, and 42.2%, respectively. WBC scintigraphy shows a weighted mean sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 73.5%, 86.3%, 79.1%, 82.4%, and 79.5%, respectively. However, compared to 67Ga-citrate and WBC scintigraphy, significantly more research has been performed using 18F-FDG PET/CT and 18F-FDG PET/CT has the advantage of relatively short procedural duration; it is therefore the preferred molecular diagnostic imaging technique. 67Ga-citrate and WBC scintigraphy can only be considered if 18F-FDG PET/CT is not available.
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Affiliation(s)
- Nick D van Rijsewijk
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Frank F A IJpma
- Department of Trauma Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Andor W J M Glaudemans
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Minamimoto R. Optimal use of the FDG-PET/CT in the diagnostic process of fever of unknown origin (FUO): a comprehensive review. Jpn J Radiol 2022; 40:1121-1137. [PMID: 35781177 PMCID: PMC9616755 DOI: 10.1007/s11604-022-01306-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/09/2022] [Indexed: 11/24/2022]
Abstract
Numerous studies have clarified the usefulness of 18F-fluorodeoxyglucose (FDG)-PET/CT (positron emission tomography) for diagnosing the cause of fever of unknown origin (FUO). Various types of disease can cause FUO, but the cause remains unknown in a certain proportion of FUO, even when the advanced diagnostic methodologies are used. FDG-PET/CT is regarded as a second-line modality in the diagnostic process of FUO, and its potential to identify the cause of FUO will be maximized when the appropriate clinical considerations are understood. Accordingly, this review presents basic knowledge regarding FUO, and reports the current status of FDG-PET/CT applied to diagnosing the cause of FUO, including diagnostic performance, test protocols, possible factors influencing the diagnostic result, outcomes, and cost-effectiveness. This knowledge will enable effective future use of FDG-PET/CT to improve outcomes in patients with FUO.
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Affiliation(s)
- Ryogo Minamimoto
- Division of Nuclear Medicine, Department of Radiology, National Center for Global Health and Medicine, 1-21-1, Toyama, Shinjyuku-ku, Tokyo, 162-8655, Japan.
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Mulders-Manders CM, Kouijzer IJ, de Geus-Oei LF. 18F-FDG-PET/CT imaging in fever and inflammation of unknown origin. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00035-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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10
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Characteristics and Clinical Value of 18F-FDG PET/CT in the Management of Adult-Onset Still's Disease: 35 Cases. J Clin Med 2021; 10:jcm10112489. [PMID: 34199846 PMCID: PMC8200084 DOI: 10.3390/jcm10112489] [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: 04/16/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/11/2022] Open
Abstract
While the diagnosis of adult-onset Still’s disease (AOSD) involves the exclusion of differential diagnoses, the characteristics and value of 18F-Fluorodeoxyglucose (18F-FDG) Positron Emission Tomography coupled with CT (PET/CT) in the management of AOSD remain poorly known. Our retrospective study included patients from four centers, fulfilling Yamaguchi or Fautrel criteria, who underwent a PET/CT during an active AOSD. Thirty-five patients were included. At the time of PET/CT, the Yamaguchi criteria were met in 23 of 29 evaluable cases. PET/CT showed bone marrow (74.3%), lymph node (74.3%), and splenic (48.6%) FDG uptake. Despite arthralgia or arthritis in most patients, joints were rarely the sites of 18F-FDG accumulation. The spatial distribution of 18F-FDG uptake was nonspecific, and its intensity could be similar to malignant disease. Lymph node or bone marrow biopsy was performed after PET/CT in 20 patients (57.1%). The intensity of bone marrow; splenic and lymph node hypermetabolism appeared to be correlated with disease activity. Abnormal PET/CT in the cervical lymph nodes and age ≥ 60 years seemed to be predictive factors for monocyclic evolution. The clinical value of PET/CT is not in direct diagnosis; but as an aid in excluding differential diagnoses by searching for their scintigraphic features and guiding biopsy.
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Zhu W, Cao W, Zheng X, Li X, Li Y, Chen B, Zhang J. The diagnostic value of 18F-FDG PET/CT in identifying the causes of fever of unknown origin. Clin Med (Lond) 2021; 20:449-453. [PMID: 32934036 DOI: 10.7861/clinmed.2020-0268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study investigated the clinical significance of 18F-fluorodeoxyglucose positron emission tomography / computed tomography (18F-FDG PET/CT) in identifying the causes of fever of unknown origin (FUO). METHODS Patients with a fever who received an 18F-FDG PET/CT examination were retrospectively selected. The means of the two groups were compared using an independent-samples t-test. RESULTS Among the 89 included patients, 66 were diagnosed using 18F-FDG PET/CT. The sensitivity, specificity and diagnostic accuracy of 18F-FDG PET/CT for the diagnosis of patients with FUO were 84.5%, 25.8%, and 64.0%, respectively. The detection rates of 18F-FDG PET/CT for neoplastic diseases, infectious diseases and non-infectious inflammatory diseases were 100%, 61.3%, and 75%, respectively. The difference in C-reactive protein (CRP) levels between the two groups was statistically significant. CONCLUSIONS 18F-FDG PET/CT has great clinical importance in diagnosing and identifying causes of FUO and improves the accuracy of FUO diagnosis when combined with serum CRP levels.
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Affiliation(s)
- Wan Zhu
- The First Hospital of China Medical University, Shenyang, China
| | - Wenxia Cao
- The First Hospital of China Medical University, Shenyang, China
| | - Xuting Zheng
- The First Hospital of China Medical University, Shenyang, China
| | - Xuena Li
- The First Hospital of China Medical University, Shenyang, China
| | - Yaming Li
- The First Hospital of China Medical University, Shenyang, China
| | - Baiyi Chen
- The First Hospital of China Medical University, Shenyang, China
| | - Jingping Zhang
- The First Hospital of China Medical University, Shenyang, China
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PET/Computed Tomography in the Evaluation of Fever of Unknown Origin and Infectious/Inflammatory Disease in Pediatric Patients. PET Clin 2021; 15:361-369. [PMID: 32498991 DOI: 10.1016/j.cpet.2020.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Fever in children is common. If it persists and its cause cannot be identified in a reasonable time, along with laboratory and conventional imaging investigations, it is defined as fever of unknown origin (FUO). 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) is well established in the evaluation of malignancy, which is a possible cause of FUO. FDG often locates inflammatory and infectious lesions considered nonspecific or false-positive for oncology; however, these findings are beneficial in FUO evaluation because infectious and inflammatory diseases are important FUO causes. FDG-PET/CT is being increasingly used for investigation of FUO as well as infectious/inflammatory disease.
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Abstract
Fever of unknown origin, bacteremia, and febrile neutropenia are diagnostic challenges. FDG-PET/CT is a well-established modality in infection imaging and the literature increasingly supports its use in these settings. In fever of unknown origin, FDG-PET/CT is helpful, but diagnostic yield depends on patient selection and inflammatory markers. In bacteremia, FDG-PET/CT is cost-effective, reduces morbidity and mortality, and impacts treatment strategy. Although use of FDG-PET/CT in these domains is not established as part of a definitive diagnostic strategy, FDG-PET/CT may help establish final diagnosis in a difficult population and should be considered early in the diagnostic process.
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Affiliation(s)
- Søren Hess
- Department of Radiology and Nuclear Medicine, Hospital of Southwest Jutland, Finsensgade 35, Esbjerg 6700, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
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Georga S, Exadaktylou P, Petrou I, Katsampoukas D, Mpalaris V, Moralidis EI, Arvaniti K, Papastergiou C, Arsos G. Diagnostic Value of 18F-FDG-PET/CT in Patients with FUO. J Clin Med 2020; 9:jcm9072112. [PMID: 32635566 PMCID: PMC7408628 DOI: 10.3390/jcm9072112] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/24/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022] Open
Abstract
Conventional diagnostic imaging is often ineffective in revealing the underlying cause in a considerable proportion of patients with fever of unknown origin (FUO). The aim of this study was to assess the diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in patients with FUO. We retrospectively reviewed 18F-FDG-PET/CT scans performed on 50 consecutive adult patients referred to our department for further investigation of classic FUO. Final diagnosis was based on histopathological and microbiological findings, clinical criteria, or clinical follow-up. Final diagnosis was established in 39/50 (78%) of the patients. The cause of FUO was infection in 20/50 (40%), noninfectious inflammatory diseases in 11/50 (22%), and malignancy in 8/50 (16%) patients. Fever remained unexplained in 11/50 (22%) patients. 18F-FDG-PET/CT scan substantially contributed to the diagnosis in 70% of the patients, either by identifying the underlying cause of FUO or by directing to the most appropriate site for biopsy. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of 18F-FDG-PET/CT for active disease detection in patients with FUO were 94.7%, 50.0%, 84.0%, 85.7%, and 75.0%, respectively. In conclusion, whole-body 18F-FDG-PET/CT is a highly sensitive method for detection of the underlining cause of FUO or for correctly targeting suspicious lesions for further evaluation.
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Affiliation(s)
- Stamata Georga
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
- Correspondence: ; Tel.: +30-6944687881
| | - Paraskevi Exadaktylou
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
| | - Ioannis Petrou
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
| | - Dimitrios Katsampoukas
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
| | - Vasilios Mpalaris
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
| | - Efstratios-Iordanis Moralidis
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
| | - Kostoula Arvaniti
- ICU and Antimicrobial Stewardship Unit, Papageorgiou General Hospital, 56403 Thessaloniki, Greece;
| | | | - Georgios Arsos
- 3rd Department of Nuclear Medicine, Aristotle University of Thessaloniki Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (P.E.); (I.P.); (D.K.); (V.M.); (E.-I.M.); (G.A.)
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15
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Hong FS, Fox LC, Chai KL, Htun K, Clucas D, Morgan S, Cole-Sinclair MF, Juneja S. Role of bone marrow biopsy for fever of unknown origin in the contemporary Australian context. Intern Med J 2020; 49:850-854. [PMID: 30350441 DOI: 10.1111/imj.14147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/23/2018] [Accepted: 10/15/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bone marrow biopsy (BMB) is an accepted investigation in fever of unknown origin (FUO) to uncover haematological malignancies, such as lymphoma, and sometimes infections. With the advance in imaging modalities, such as 18-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) to identify the focus of lymphoma, BMB may not contribute to the diagnosis when there are no other clinical features to suggest an underlying haematological disease. AIM To investigate the utility of BMB in determining the cause of FUO, when there are no other indications for BMB. METHODS Medical records of adult patients who had BMB performed for FUO or febrile illness from 1 January 2005 to 31 December 2014 in four metropolitan tertiary hospitals in Melbourne, Australia were reviewed. Patients with other concurrent indications for BMB, known human immunodeficiency virus infection and previously diagnosed connective tissue diseases were excluded. RESULTS Seventy-three patients were included in the study. Fifty-one patients had a final diagnosis for fever (systemic inflammatory diseases, infective, malignancy or other) while 22 patients had no diagnoses. In only 10 patients (13.7%) did BMB contribute to the diagnosis, finding either malignancy or granulomata. However, all these diagnoses could have been made without BMB. Two patients with diffuse large B-cell lymphoma had normal BMB. FDG-PET was helpful in making a diagnosis in eight (25%) out of 32 patients. CONCLUSION Performing BMB in patients with FUO and no other haematological abnormalities is of very limited value, and other investigations, such as FDG-PET, may be more likely to help establish a definitive diagnosis.
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Affiliation(s)
- Frank S Hong
- Department of Laboratory Haematology, Austin Health, Victoria, Australia
| | - Lucy C Fox
- Department of Laboratory Haematology, Austin Health, Victoria, Australia
| | - Khai Li Chai
- Laboratory Haematology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Kay Htun
- Laboratory Haematology, Alfred Health, Victoria, Australia
| | - Danielle Clucas
- Diagnostic Haematology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Susan Morgan
- Laboratory Haematology, Alfred Health, Victoria, Australia
| | | | - Surender Juneja
- Diagnostic Haematology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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16
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Kan Y, Wang W, Liu J, Yang J, Wang Z. Contribution of 18F-FDG PET/CT in a case-mix of fever of unknown origin and inflammation of unknown origin: a meta-analysis. Acta Radiol 2019; 60:716-725. [PMID: 30205705 DOI: 10.1177/0284185118799512] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are challenging medical problems. Previous studies have shown that 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) plays an important role in the diagnosis of FUO, but few studies have explored this diagnostic technique in relation to IUO. PURPOSE To systematically review and perform a meta-analysis of published data on the diagnostic performance of PET/CT in the diagnosis of FUO and IUO. MATERIAL AND METHODS A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines published in March 2018. Meta-analysis of diagnostic performance was performed using STATA 12.0 software. Subgroup analysis was performed by stratification based on study design, number of patients, geographic area, and final diagnosis based on 18F-FDG PET/CT. Meta-regression analyses were performed to recognize heterogeneity. RESULTS Our meta-analysis included 23 studies, comprising a total sample size of 1927 patients. The pooled diagnosis performance was calculated with a per-patient-based analysis: sensitivity = 0.84 (95% confidence interval [CI] = 0.79-0.89), specificity = 0.63 (95% CI = 0.49-0.75), positive likelihood ratio = 2.3 (95% CI = 1.5-3.4), negative likelihood ratio = 0.25 (95% CI = 0.16-0.38), diagnostic odds ratio = 9 (95% CI = 4.0-20), and AUC = 0.84 (95% CI = 0.81-0.87). CONCLUSION In patients with non-specific symptoms and signs, 18F-FDG PET/CT is very helpful for recognizing and excluding diseases, directing further diagnostic decisions, and avoiding unnecessary invasive examinations. We recommend that 18F-FDG PET/CT should be considered among the first-line diagnostic tools for patients with FUO and IUO.
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Affiliation(s)
- Ying Kan
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Wei Wang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Jie Liu
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
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Kouijzer IJE, Mulders-Manders CM, Bleeker-Rovers CP, Oyen WJG. Fever of Unknown Origin: the Value of FDG-PET/CT. Semin Nucl Med 2017; 48:100-107. [PMID: 29452615 DOI: 10.1053/j.semnuclmed.2017.11.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fever of unknown origin (FUO) is commonly defined as fever higher than 38.3°C on several occasions during at least 3 weeks with uncertain diagnosis after a number of obligatory investigations. The differential diagnosis of FUO can be subdivided in four categories: infections, malignancies, noninfectious inflammatory diseases, and miscellaneous causes. In most cases of FUO, there is an uncommon presentation of a common disease. FDG-PET/CT is a sensitive diagnostic technique for the evaluation of FUO by facilitating anatomical localization of focally increased FDG uptake, thereby guiding further diagnostic tests to achieve a final diagnosis. FDG-PET/CT should become a routine procedure in the workup of FUO when diagnostic clues are absent. FDG-PET/CT appears to be a cost-effective routine imaging technique in FUO by avoiding unnecessary investigations and reducing the duration of hospitalization.
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Affiliation(s)
- Ilse J E Kouijzer
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina M Mulders-Manders
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Nuclear Medicine, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom.
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18
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Schönau V, Vogel K, Englbrecht M, Wacker J, Schmidt D, Manger B, Kuwert T, Schett G. The value of 18F-FDG-PET/CT in identifying the cause of fever of unknown origin (FUO) and inflammation of unknown origin (IUO): data from a prospective study. Ann Rheum Dis 2017; 77:70-77. [PMID: 28928271 DOI: 10.1136/annrheumdis-2017-211687] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 08/24/2017] [Accepted: 09/08/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are diagnostically challenging conditions. Diagnosis of underlying disease may be improved by 18F-fluorodesoxyglucose positron emission tomography (18F-FDG-PET). METHODS Prospective study to test diagnostic utility of 18F-FDG-PET/CT in a large cohort of patients with FUO or IUO and to define parameters that increase the likelihood of diagnostic 18F-FDG-PET/CT. Patients with FUO or IUO received 18F-FDG-PET/CT scanning in addition to standard diagnostic work-up. 18F-FDG-PET/CT results were classified as helpful or non-helpful in establishing final diagnosis. Binary logistic regression was used to identify clinical parameters associated with a diagnostic 18F-FDG-PET/CT. RESULTS 240 patients were enrolled, 72 with FUO, 142 with IUO and 26 had FUO or IUO previously (exFUO/IUO). Diagnosis was established in 190 patients (79.2%). The leading diagnoses were adult-onset Still's disease (15.3%) in the FUO group, large vessel vasculitis (21.1%) and polymyalgia rheumatica (18.3%) in the IUO group and IgG4-related disease (15.4%) in the exFUO/IUO group. In 136 patients (56.7% of all patients and 71.6% of patients with a diagnosis), 18F-FDG-PET/CT was positive and helpful in finding the diagnosis. Predictive markers for a diagnostic 18F-FDG-PET/CT were age over 50 years (p=0.019), C-reactive protein (CRP) level over 30 mg/L (p=0.002) and absence of fever (p=0.001). CONCLUSION 18F-FDG-PET/CT scanning is helpful in ascertaining the correct diagnosis in more than 50% of the cases presenting with FUO and IUO. Absence of intermittent fever, higher age and elevated CRP level increase the likelihood for a diagnostic 18F-FDG-PET/CT.
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Affiliation(s)
- Verena Schönau
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Kristin Vogel
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Jochen Wacker
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Daniela Schmidt
- Clinic of Nuclear Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Torsten Kuwert
- Clinic of Nuclear Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
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Frary EC, Hess S, Gerke O, Laustrup H. 18F-fluoro-deoxy-glucose positron emission tomography combined with computed tomography can reliably rule-out infection and cancer in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis suspected of disease relapse. Medicine (Baltimore) 2017; 96:e7613. [PMID: 28746217 PMCID: PMC5627843 DOI: 10.1097/md.0000000000007613] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a group of autoimmune diseases characterized by systemic inflammation in small- to medium-sized blood vessels. Although immunosuppressive therapy has greatly improved the prognosis for these patients, there are still significant comorbidities, such as cancer and infection, associated with AAV. These comorbidities are often indistinguishable from an underlying AAV disease relapse, and create a clinical conundrum, as these conditions are normally contraindications for immunosuppressive treatment. Thus, it is important to be able to rule out these comorbidities before initiation of immunosuppressive treatment. We examined F-fluoro-deoxy-glucose positron emission tomography combined with computed tomography (FDG-PET/CT)'s value in ruling out cancer or infection in patients with AAV.Data were obtained retrospectively for a clinically based cohort of AAV patients who underwent FDG-PET/CT during 2009 to 2014 owing to a suspicion of cancer, infection, or both cancer and infection indistinguishable from disease relapse. FDG-PET/CT conclusions were compared to the final diagnoses after follow-up analysis (mean 43 months).A total of 19 patients were included who underwent a total of 26 scans. The results of FDG-PET/CT outcome compared to final diagnosis were: 9 true positives, 3 false positives, 13 true negatives, and 1 false negative. The diagnostic probabilities for FDG-PET/CT with respect to overall comorbidity (i.e., cancer or infection) were: sensitivity 90% ( 95% confidence interval [CI] 60%-98%), specificity 81% ( 95% CI 57%-93%), positive predictive value 75% (95% CI 47%-91%), negative predictive value 93% (95% CI 68%-99%), and accuracy 84% (95% CI 66%-94%).FDG-PET/CT had a high negative predictive value and ruled out the comorbidities correctly in all but one case of urinary tract infection, a well-known limitation. Our study showed FGD-PET/CT's promise as an effective tool for ruling out cancer or infection in patients with AAV albeit in a limited population.
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Affiliation(s)
- Evan C. Frary
- Department of Nuclear Medicine, Odense University Hospital, Odense C
| | - Søren Hess
- Department of Nuclear Medicine, Odense University Hospital, Odense C
- Department of Radiology and Nuclear Medicine, Hospital of Southwest Jutland, Esbjerg
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, Odense C
- Center of Health Economics Research, University of Southern Denmark, Odense M
| | - Helle Laustrup
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C
- Department of Rheumatology, Odense University Hospital, Odense C, Denmark
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Abstract
Fever without source is a febrile illness without localizing signs or initial obvious cause. Early workup will often include chest radiography and computed tomography (CT) of the abdomen and pelvis, with or without CT of the chest. To evaluate localizing signs or symptoms or to further evaluate findings from initial studies, targeted imaging according to body part can be performed by using radiography, ultrasonography, CT, or magnetic resonance (MR) imaging. Nuclear medicine studies can provide imaging of the whole body and may be helpful when the clinical and conventional imaging workup findings are negative or equivocal in identifying a source of fever. Nuclear medicine studies can be used to detect pathologic changes early in a disease course, even in the absence of an anatomic abnormality. Gallium 67 scintigraphy, indium 111- and technetium 99m-labeled leukocyte scintigraphy, and fluorine 18 fluorodeoxyglucose positron emission tomography (PET)/CT studies are all useful in the evaluation of fever, but the radiopharmaceutical cost for PET/CT is much lower than that for radiolabeled leukocyte studies. The increased use of bundled payments for inpatient admissions requires updated cost evaluations for the preferred nuclear medicine study. For inpatients in whom the findings from the initial clinical workup and imaging studies are nondiagnostic, PET/CT examination may be preferable to radiolabeled leukocyte studies because of its high sensitivity and lower cost. Negative findings at PET/CT can be helpful in excluding a suspected site of infection, and positive findings at PET/CT can be helpful in confirming a suspected site of infection or in identifying an unexpected cause of fever. (©)RSNA, 2016.
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Affiliation(s)
- Elizabeth H Dibble
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Don C Yoo
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
| | - Richard B Noto
- From the Department of Diagnostic Imaging, Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, Providence, RI 02903
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The Value of 18F-FDG PET/CT in Diagnostic Procedure of Intravascular Large B-Cell Lymphoma Presenting Fever of Unknown Origin and Pulmonary Hypertension as an Initial Manifestation. Clin Nucl Med 2017; 41:506-7. [PMID: 26914573 DOI: 10.1097/rlu.0000000000001188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A 57-year-old man presented with fever of unknown origin and pulmonary hypertension. An F-FDG PET/CT scan was performed to evaluate the source of fever, which showed diffuse, homogeneously increased FDG uptake in both lungs, which prompted the transbronchial lung biopsy. The pathological examination from biopsy specimen demonstrated intravascular large B-cell lymphoma.
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Liu CP, Liu ZY, Liu JP, Kang Y, Mao CS, Shang J. Diagnostic Value of Common Inflammatory Markers on Fever of Unknown Origin. Jpn J Infect Dis 2016; 69:378-83. [PMID: 26743139 DOI: 10.7883/yoken.jjid.2015.470] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study was designed to evaluate the diagnostic value of common inflammatory markers with regard to fever of unknown origin (FUO). We investigated 383 patients who were hospitalized with FUO at the Henan Province People's hospital between January 2009 and June 2015. Of all the cases, infectious diseases accounted for 33.9%, neoplasms for 21.1%, collagen vascular diseases for 25.1%, miscellaneous diseases for 4.7%, and no diagnosis for 15.1%. Patients in the neoplasm group were older than those in the infectious disease, collagen vascular disease, and miscellaneous disease groups (p = 0.006, p < 0.0001, and p = 0.001, respectively). The duration of fever before admission of patients in the neoplasm and collagen vascular disease group was longer than that of patients in the infectious disease group (p = 0.002 and p = 0.007, respectively). The diagnostic time after admission of patients from the neoplasm and collagen vascular disease groups was longer than that for patients from the infectious disease group (both p < 0.0001). Serum ferritin levels of patients in the infectious disease group were lower than those of patients in the neoplasm and collagen vascular disease groups (p = 0.029 and p = 0.032, respectively), while serum procalcitonin (PCT) levels in the infectious disease group was higher than that in the neoplasm and collagen vascular disease groups (p = 0.016 and p = 0.007, respectively). Therefore, FUO remains a clinical problem in China and serum ferritin and PCT may be useful in discriminating infectious from non-infectious causes (neoplasms and collagen vascular diseases) in patients with FUO.
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Affiliation(s)
- Cui-Ping Liu
- Department of Infectious Diseases, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University
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23
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Determinants of diagnostic performance of 18F-FDG PET/CT in patients with fever of unknown origin. Nucl Med Commun 2016; 37:57-65. [DOI: 10.1097/mnm.0000000000000395] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Petersen H, Holdgaard PC, Madsen PH, Knudsen LM, Gad D, Gravergaard AE, Rohde M, Godballe C, Engelmann BE, Bech K, Teilmann-Jørgensen D, Mogensen O, Karstoft J, Johansen J, Christensen JB, Johansen A, Høilund-Carlsen PF. FDG PET/CT in cancer: comparison of actual use with literature-based recommendations. Eur J Nucl Med Mol Imaging 2015; 43:695-706. [PMID: 26519292 PMCID: PMC4764641 DOI: 10.1007/s00259-015-3217-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/06/2015] [Indexed: 12/22/2022]
Abstract
Purpose The Region of Southern Denmark (RSD), covering 1.2 of Denmark’s 5.6 million inhabitants, established a task force to (1) retrieve literature evidence for the clinical use of positron emission tomography (PET)/CT and provide consequent recommendations and further to (2) compare the actual use of PET/CT in the RSD with these recommendations. This article summarizes the results. Methods A Work Group appointed a professional Subgroup which made Clinician Groups conduct literature reviews on six selected cancers responsible for 5,768 (62.6 %) of 9,213 PET/CT scans in the RSD in 2012. Rapid Evidence Assessment was applied, using the methodology of systematic reviews with predefined limitations to search PubMed, Embase and the Cochrane Library for articles published in English/Danish/Swedish/Norwegian since 2002. PICO questions were defined, data recorded and quality appraised and rated with regard to strength and evidence level. Consequent recommendations for applications of PET/CT were established. The actual use of PET/CT was compared with these, where grades A and B indicated “established” and “useful” and grades C and D “potentially useful” and “non-recommendable” indications, respectively. Results Of 11,729 citations, 1,729 were considered for review, and 204 were included. The evidence suggested usefulness of PET/CT in lung, lymphoma, melanoma, head and neck, and colorectal cancers, whereas evidence was sparse in gynaecological cancers. The agreement between actual use of PET/CT and literature-based recommendations was high in the first five mentioned cancers in that 96.2 % of scans were made for grade A or B indications versus only 22.2 % in gynaecological cancers. Conclusion Evidence-based usefulness was reported in five of six selected cancers; evidence was sparse in the sixth, gynaecological cancers. Actual use of PET/CT agreed well with recommendations. Electronic supplementary material The online version of this article (doi:10.1007/s00259-015-3217-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | | | | | | | - Dorte Gad
- Department of Plastic Surgery, Odense University Hospital, Odense, Denmark
| | | | - Max Rohde
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Department of ORL Head & Neck Surgery, Odense University Hospital, Odense, Denmark
| | | | - Karsten Bech
- Organ Centre, Aabenraa Sygehus, Aabenraa, Denmark
| | | | - Ole Mogensen
- Department of Gynaecoligcal and Obstetrics, Odense University Hospital, Odense, Denmark
| | - Jens Karstoft
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - Allan Johansen
- Department of Nuclear Medicine, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark
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Pituitary Involvement of Langerhans Cell Histiocytosis in an Adult Unveiled by FDG PET/CT. Clin Nucl Med 2015; 40:509-11. [DOI: 10.1097/rlu.0000000000000654] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Sioka C, Assimakopoulos A, Fotopoulos A. The diagnostic role of (18)F fluorodeoxyglucose positron emission tomography in patients with fever of unknown origin. Eur J Clin Invest 2015; 45:601-8. [PMID: 25823953 DOI: 10.1111/eci.12439] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 03/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Identification of aetiology for fever of unknown origin (FUO) is challenging, due to the high rates of undiagnosed cases. The current diagnostic approach includes initially first-line procedures such as general examination and various laboratory tests and basic imaging techniques followed by second-line tests such as more advanced imaging techniques including (18)F fluorodeoxyglucose positron emission tomography (FDG PET) and tissue biopsies. If no diagnosis is obtained, more invasive measures may be in order such as liver biopsy and exploratory laparotomy. MATERIALS AND METHODS This review article is based on the relative published material found on MEDLINE and PubMed up to August 2014. We looked for the terms 'fever of unknown origin, FDG PET' in combination with 'cancer, infection and autoimmune disease'. RESULTS Several clinical studies have investigated the utility of the FDG PET during the diagnostic approach of FUO. Recent evidence suggests that FDG PET has the advantage of total body imaging and may depict all common causes of FUO such as infections, noninfectious inflammatory causes and tumours because they all exhibit glucose hypermetabolism. Depiction of an abnormal lesion on FDG PET could guide clinicians to the next diagnostic procedure (another imaging method, culture, biopsy or surgery) to establish the diagnosis. CONCLUSIONS Emerging evidence suggests that FDG PET, when available, may provide critical diagnostic information early during evaluation of FUO.
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Affiliation(s)
- Chrissa Sioka
- Neurosurgical Research Institute, University of Ioannina, Ioannina, Greece.,Department of Nuclear Medicine, University of Ioannina, Ioannina, Greece
| | | | - Andreas Fotopoulos
- Department of Nuclear Medicine, University of Ioannina, Ioannina, Greece
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Gafter-Gvili A, Raibman S, Grossman A, Avni T, Paul M, Leibovici L, Tadmor B, Groshar D, Bernstine H. [18F]FDG-PET/CT for the diagnosis of patients with fever of unknown origin. QJM 2015; 108:289-98. [PMID: 25208896 DOI: 10.1093/qjmed/hcu193] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS The diagnosis of patients with fever of unknown origin (FUO) remains a challenging medical problem. We aimed to assess the diagnostic contribution of 18-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET)/computed tomography (CT) for the evaluation of FUO. METHODS We performed a 4-year retrospective single-center study of all hospitalized patients that underwent FDG-PET/CT for evaluation of FUO. The final diagnosis of the febrile disease was based on clinical, microbiological, radiological and pathological data available at the final follow-up. Predictors for a contributory exam were sought. RESULTS One hundred and twelve patients underwent FDG-PET/CT for the investigation of FUO in the years 2008-2012 and were included in the study. A final diagnosis was determined in 83 patients (74%) and included: infectious disease in 49 patients (43%), non-infectious inflammatory disease in 17 patients (16%), malignancies in 15 patients (14%), other diagnoses in 2 patients (1.7%), FUO resolved with no diagnosis and no evidence of disease during a 6-month follow-up in 23 patients (20%), and death with fever and with no diagnosis in 6 patients (5%). Seventy-four FDG-PET/CT studies (66%) were considered clinically helpful and contributory to diagnosis (46% positive contributory value and 20.5% contributory to exclusion of diagnosis). PET/CT had a sensitivity of 72.2%, a specificity of 57.5%, a positive predictive value (PPV) of 74.2% and a negative predictive value (NPV) of 53.5%. On multivariable analysis, significant predictors of a positive PET/CT contributory to diagnosis were a short duration of fever and male gender. CONCLUSIONS PET/CT is an important diagnostic tool for patients with FUO.
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Affiliation(s)
- A Gafter-Gvili
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - S Raibman
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - A Grossman
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - T Avni
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - M Paul
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - L Leibovici
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - B Tadmor
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - D Groshar
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
| | - H Bernstine
- From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva From the Department of Medicine E, Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Infectious Disease Unit, Department of Nuclear Medicine, Beilinson Hospital, Rabin Medical Center, Petah-Tikva
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