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Singh S, Allwood BW, Chiyaka TL, Kleyhans L, Naidoo CC, Moodley S, Theron G, Segal LN. Immunologic and imaging signatures in post tuberculosis lung disease. Tuberculosis (Edinb) 2022; 136:102244. [PMID: 36007338 PMCID: PMC10061373 DOI: 10.1016/j.tube.2022.102244] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/24/2022] [Accepted: 07/31/2022] [Indexed: 11/25/2022]
Abstract
Post Tuberculosis Lung Disease (PTLD) affects millions of tuberculosis survivors and is a global health burden. The immune mechanisms that drive PTLD are complex and have historically been under investigated. Here, we discuss two immune-mediated paradigms that could drive human PTLD. We review the characteristics of a fibrotic granuloma that favors the development of PTLD via an abundance of T-helper-2 and T-regulatory cells and an upregulation of TGF-β mediated collagen deposition. Next, we discuss the post-primary tuberculosis paradigm and the complex mixture of caseous pneumonia, cavity formation and fibrosis that can also lead to PTLD. We review the delicate balance between cellular subsets and cytokines of the innate and adaptive immune system in conjunction with host-derived proteases that can perpetuate the parenchymal lung damage seen in PTLD. Next, we discuss the role of novel host directed therapies (HDT) to limit the development of PTLD and in particular, the recent repurposing of established medications such as statins, metformin and doxycycline. Finally, we review the emerging role of novel imaging techniques as a non-invasive modality for the early recognition of PTLD. While access to computed tomography imaging is unlikely to be available widely in countries with a high TB burden, its use in research settings can help phenotype PTLD. Due to a lack of disease-specific biomarkers and controlled clinical trials, there are currently no evidence-based recommendations for the management of PTLD. It is likely that an integrated antifibrotic strategy that could simultaneously target inflammatory and pro-fibrotic pathways will probably emerge as a successful way to treat this complex condition. In a disease spectrum as wide as PTLD, a single immunologic or radiographic marker may not be sufficient and a combination is more likely to be a successful surrogate that could aid in the development of successful HDTs.
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Affiliation(s)
- S Singh
- NYU Langone Translational Lung Biology Laboratory, Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, NYU Langone Health, 550 First Avenue, MSB 594, New York, NY, USA.
| | - B W Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University & Tygerberg Hospital, South Africa.
| | - T L Chiyaka
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.
| | - L Kleyhans
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.
| | - C C Naidoo
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.
| | - S Moodley
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.
| | - G Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.
| | - L N Segal
- NYU Langone Translational Lung Biology Laboratory, Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, NYU Langone Health, 550 First Avenue, MSB 594, New York, NY, USA.
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The Value of 18F-FDG PET/CT in the Diagnosis of Tuberculous Pleurisy and in the Differential Diagnosis between Tuberculous Pleurisy and Pleural Metastasis from Lung Adenocarcinoma. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4082291. [PMID: 35965614 PMCID: PMC9357728 DOI: 10.1155/2022/4082291] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022]
Abstract
Objectives This study aims to investigate the diagnostic value of 18F-FDG PET/CT in tuberculous pleurisy (TBP) and the differential diagnostic value of 18F-FDG PET/CT between TBP and pleural metastasis from lung adenocarcinoma (PMLAC). Materials and Methods The features of pleura on PET and hybrid CT were retrospectively studied in 20 patients with TBP and 32 patients with PMLAC. The ROC curve was used to evaluate the diagnostic effectiveness of these indices for TBP and PMLAC, and binary logistic regression analysis was conducted to identify independent predictors of TBP and PMLAC. Results There were significant differences in pleural 18F-FDG uptake pattern on PET (P=0.001), pleural morphology pattern on CT (P=0.002), the maximum diameter of the pleural nodule (P=0.001), and interlobular fissure nodule (P=0.001) between TBP and PMLAC groups. The diffused pleural FDG uptake type on PET (odds ratio (OR) = 6.0, 95% CI 2.216–16.248, P=0.001) and the lamellar pleural thickening type on CT (OR = 4.4, 95% CI 2.536–7.635, P=0.001) were independent predictors of TBP, with 60% and 55% sensitivity, 96.6% and 90.6% specificity, and 82.7% and 77.0% accuracy. The combined diagnostic sensitivity, specificity, and accuracy for TBP were 70%, 87.5%, and 80.8%. The mixed pleural FDG uptake type on PET (OR = 5.106, 95% CI 2.024–12.879, P=0.001), the mixed pleural thickening type on CT (OR = 2.289, 95% CI 1.442–3.634, P=0.001), and the maximum diameter of the pleural nodule (OR = 1.027, 95% CI 1.012–1.042, P=0.001) were independent predictors of PMLAC, with 78.1%, 71.9%, and 87.5% sensitivity, 85%, 80%, and 85% specificity, and 80.8%, 75%, and 86.5% accuracy. The combined diagnostic sensitivity, specificity, and accuracy for PMLAC were 96.9%, 85%, and 90.4%. Conclusions 18F-FDG PET/CT is of great clinical value in the diagnosis of TBP and in the differential diagnosis between TBP and PMLAC.
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Bresser PL, Sathekge MM, Vorster M. PET/CT features of a novel gallium-68 labelled hypoxia seeking agent in patients diagnosed with tuberculosis: a proof-of-concept study. Nucl Med Commun 2022; 43:787-793. [PMID: 35506285 DOI: 10.1097/mnm.0000000000001580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Positron emission tomography/computed tomography (PET/CT) in infection and inflammation has yielded promising results across a range of radiopharmaceuticals. In particular, PET/CT imaging of tuberculosis (TB) allows for a better understanding of this complex disease by providing insights into molecular processes within the TB microenvironment. TB lesions are hypoxic with research primarily focussed on cellular processes occurring under hypoxic stress. With the development of hypoxia seeking PET/CT radiopharmaceuticals, that can be labelled in-house using a germanium-68/gallium-68 (68Ge/68Ga) generator, a proof-of-concept for imaging hypoxia in TB is presented. METHODS Ten patients diagnosed with TB underwent whole-body PET/CT imaging, 60-90 min after intravenous administration of 74-185 MBq (2-5 mCi) 68Ga-nitroimidazole. No oral or intravenous contrast was administered. Images were visually and semiquantitatively assessed for abnormal 68Ga-uptake in the lungs. RESULTS A total of 28 lesions demonstrating hypoxic uptake were identified. Low- to moderate-uptake was seen in nodules, areas of consolidation and cavitation as well as effusions. The mean standard uptake value (SUVmean) of the lesions was 0.47 (IQR, 0.32-0.82) and SUVmax was 0.71 (IQR, 0.41-1.11). The lesion to muscle ratio (median, 1.70; IQR, 1.15-2.31) was higher than both the left ventricular and the aorta lesion to blood ratios. CONCLUSION Moving towards the development of unique host-directed therapies (HDT), modulation of oxygen levels may improve therapeutic outcome by reprogramming TB lesions to overcome hypoxia. This proof-of-concept study suggests that hypoxia in TB lesions can be imaged and quantified using 68Ga-nitroimidazole PET/CT. Subsequently, hypoxic load can be estimated to inform personalised treatment plans of patients diagnosed with TB.
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Affiliation(s)
- Philippa L Bresser
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Department of Anatomy and Medical Imaging, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mike M Sathekge
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Mariza Vorster
- Department of Nuclear Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- Department of Nuclear Medicine, Inkosi Albert Luthuli Central Hospital, University of Kwazulu Natal, Durban, South Africa
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Gaur K, Shukla S, Choudhury S, Raj P, Patra S. A Case of Premenopausal Uterine Leiomyoma, Non-cirrhotic Portal Fibrosis, Hepatic Koch's, a PET Gone Astray-Morphology Antidotes a Confounding Concoction. IRANIAN JOURNAL OF PATHOLOGY 2022; 17:229-233. [PMID: 35463736 PMCID: PMC9013869 DOI: 10.30699/ijp.2022.540258.2743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/21/2022] [Indexed: 06/14/2023]
Abstract
Uterine leiomyoma with hepatic vasculopathy, specifically non-cirrhotic portal fibrosis (NCPF), has hitherto been undescribed. NCPF is characterized by elevated portal pressure sans cirrhosis and has previously not been described in association with a gynecological pathology. We report the case of a female under evaluation for a heterogeneously enhancing intrauterine mass with multiple hepatic lesions with increased uptake of fluorodeoxyglucose on positron emission analysis. Fibroscan values were increased. Histopathologic evaluations revealed a leiomyoma with liver tissue showing tubercular granulomas, thin wispy fibrotic strands, and rounded portal tracts pointed to NCPF. No evidence of malignancy was seen. Metabolic imaging may be unreliable to distinguish between benign and malignant uterine pathology and granulomatous and malignant hepatic lesions. Elastography may also be ineffective in diagnosing the etiology of liver fibrosis. Histopathological analysis hence remains essential despite noninvasive tests. Further research is required on females afflicted with NCPF to exclude a hormonal link.
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Affiliation(s)
- Kavita Gaur
- Department of Pathology, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India
| | - Shailaja Shukla
- Department of Pathology, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India
| | - Shinjini Choudhury
- Department of Pathology, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India
| | - Pankaj Raj
- Department of Pathology, Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India
| | - Sharda Patra
- Department of Obstetrics and Gynaecology Lady Hardinge Medical College, Shaheed Bhagat Singh Marg, New Delhi, India
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Bilici Salman R, Gülbahar Ateş S, Satiş H, Tufan A, Akdemir ÜÖ, Yapar D, Ataş N, Güler AA, Karadeniz H, Babaoglu H, Aydos U, Göker B, Haznedaroğlu Ş, Atay LÖ, Öztürk MA. Diagnostic Role of 18F-Fluorodeoxyglucose Positron Emission Tomography for the Evaluation of Patients With Inflammation of Unknown Origin. J Clin Rheumatol 2021; 27:219-225. [PMID: 32195847 DOI: 10.1097/rhu.0000000000001297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sometimes, the underlying causes of inflammation cannot be established despite meticulous investigation, including medical history, physical examination, laboratory tests, and radiologic procedures. Rheumatologists are often faced with patients whose condition is known as inflammation of unknown origin (IUO). Differential diagnosis of IUO is diverse, and investigation of these cases is challenging and time-consuming. OBJECTIVE The study aimed to assess the diagnostic role of positron emission tomography/computed tomography (PET/CT) in the evaluation of patients with IUO. METHODS The study sample consisted of 97 adult patients with IUO who have not been previously diagnosed with an infectious, inflammatory, or malignant disease. The necessary data were collected from January 2015 to June 2018 with a 6-month follow-up period. The patients were screened using PET/CT after a specific diagnosis could not be established with detailed laboratory and radiologic evaluations. RESULTS A final diagnosis was established at follow-up, and 47 (54%) of the 97 patients had inflammatory diseases, 30 (34.4%) had malignancies, and 10 (11.4%) had infections. Despite meticulous investigation, 10 patients were left undiagnosed in the follow-up. PET/CT aided diagnosis in 59 patients (60.8%), but it was not helpful in 38 patients (39.2%). PET/CT was positive in 30 (63%) of the 47 patients with inflammatory diseases, whose final diagnosis was inflammatory rheumatic disease, as follows: large-vessel vasculitis in 19 patients, polymyalgia rheumatica in 7 patients, and seronegative arthritis or other rare miscellaneous diseases in 4 patients. The sensitivity of PET/CT was 67% with a specificity and diagnostic accuracy of 100% and 71%, respectively. CONCLUSIONS Investigation of the underlying etiology of IUO is time-consuming and challenging. PET/CT may help identify the final diagnosis more quickly by locating an obscure inflammatory site; thus, it may reduce the number of unnecessary biopsies, diagnostic time, anxiety, work loss, morbidity, and mortality.
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Affiliation(s)
| | | | - Hasan Satiş
- From the Division of Rheumatology, Department of Internal Medicine
| | | | | | - Dilek Yapar
- Department of Public Health, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nuh Ataş
- From the Division of Rheumatology, Department of Internal Medicine
| | | | - Hazan Karadeniz
- From the Division of Rheumatology, Department of Internal Medicine
| | - Hakan Babaoglu
- From the Division of Rheumatology, Department of Internal Medicine
| | | | - Berna Göker
- From the Division of Rheumatology, Department of Internal Medicine
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Rafique A, Rasheed R, Shamim S, Ijaz M, Murtaza G. A Review on Nuclear Imaging as a Promising Modality for Efficient Diagnosis of Tuberculosis. Curr Med Imaging 2021; 18:18-31. [PMID: 34238164 DOI: 10.2174/1573405617666210707150811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/30/2021] [Accepted: 05/11/2021] [Indexed: 11/22/2022]
Abstract
Tuberculosis (TB) is an infectious disease and is declared a global health issue by the World Health Organization in 1993. Due to the complex pathophysiology of Mycobacterium tuberculosis, it remains a global threat. This article reviews the conventional diagnostic modalities for tuberculosis, their limitations to detect latent TB, multiple drug-resistant TB, human immunodeficiency virus co-infected TB lesions, and TB in children. Moreover, this review illustrates the importance of nuclear medicine imaging for early, non-invasive diagnosis of TB to detect disease stages and monitor therapy response. Currently, single-photon emission computed tomography and positron emission tomography with their specific radionuclides have been extensively used for a thorough assessment of TB.
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Affiliation(s)
- Asma Rafique
- Department of Pharmacy, COMSATS University Islamabad, Abbottabad Campus 22600. Pakistan
| | - Rashid Rasheed
- Institute of Nuclear Medicines, Oncology,and Radiations (INOR), Ayub Medical Hospital, Abbottabad. Pakistan
| | - Saba Shamim
- Institute of Molecular Biology and Biotechnology, the University of Lahore, Lahore. Pakistan
| | - Munazza Ijaz
- Institute of Molecular Biology and Biotechnology, the University of Lahore, Lahore. Pakistan
| | - Ghulam Murtaza
- Department of Pharmacy, COMSATS University Islamabad, Lahore Campus 54000. Pakistan
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Odia T, Malherbe ST, Meier S, Maasdorp E, Kleynhans L, du Plessis N, Loxton AG, Zak DE, Thompson E, Duffy FJ, Kuivaniemi H, Ronacher K, Winter J, Walzl G, Tromp G. The Peripheral Blood Transcriptome Is Correlated With PET Measures of Lung Inflammation During Successful Tuberculosis Treatment. Front Immunol 2021; 11:596173. [PMID: 33643286 PMCID: PMC7902901 DOI: 10.3389/fimmu.2020.596173] [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: 08/18/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary tuberculosis (PTB) is characterized by lung granulomas, inflammation and tissue destruction. Here we used within-subject peripheral blood gene expression over time to correlate with the within-subject lung metabolic activity, as measured by positron emission tomography (PET) to identify biological processes and pathways underlying overall resolution of lung inflammation. We used next-generation RNA sequencing and [18F]FDG PET-CT data, collected at diagnosis, week 4, and week 24, from 75 successfully cured PTB patients, with the [18F]FDG activity as a surrogate for lung inflammation. Our linear mixed-effects models required that for each individual the slope of the line of [18F]FDG data in the outcome and the slope of the peripheral blood transcript expression data correlate, i.e., the slopes of the outcome and explanatory variables had to be similar. Of 10,295 genes that changed as a function of time, we identified 639 genes whose expression profiles correlated with decreasing [18F]FDG uptake levels in the lungs. Gene enrichment over-representation analysis revealed that numerous biological processes were significantly enriched in the 639 genes, including several well known in TB transcriptomics such as platelet degranulation and response to interferon gamma, thus validating our novel approach. Others not previously associated with TB pathobiology included smooth muscle contraction, a set of pathways related to mitochondrial function and cell death, as well as a set of pathways connecting transcription, translation and vesicle formation. We observed up-regulation in genes associated with B cells, and down-regulation in genes associated with platelet activation. We found 254 transcription factor binding sites to be enriched among the 639 gene promoters. In conclusion, we demonstrated that of the 10,295 gene expression changes in peripheral blood, only a subset of 639 genes correlated with inflammation in the lungs, and the enriched pathways provide a description of the biology of resolution of lung inflammation as detectable in peripheral blood. Surprisingly, resolution of PTB inflammation is positively correlated with smooth muscle contraction and, extending our previous observation on mitochondrial genes, shows the presence of mitochondrial stress. We focused on pathway analysis which can enable therapeutic target discovery and potential modulation of the host response to TB.
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Affiliation(s)
- Trust Odia
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,Bioinformatics Unit, South African Tuberculosis Bioinformatics Initiative, Stellenbosch University, Cape Town, South Africa.,Centre for Bioinformatics and Computational Biology, Stellenbosch University, Stellenbosch, South Africa
| | - Stephanus T Malherbe
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Stuart Meier
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,Bioinformatics Unit, South African Tuberculosis Bioinformatics Initiative, Stellenbosch University, Cape Town, South Africa.,Centre for Bioinformatics and Computational Biology, Stellenbosch University, Stellenbosch, South Africa
| | - Elizna Maasdorp
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,Bioinformatics Unit, South African Tuberculosis Bioinformatics Initiative, Stellenbosch University, Cape Town, South Africa.,Centre for Bioinformatics and Computational Biology, Stellenbosch University, Stellenbosch, South Africa
| | - Léanie Kleynhans
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Nelita du Plessis
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Andre G Loxton
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Daniel E Zak
- Center for Infectious Disease Research, Seattle, WA, United States
| | - Ethan Thompson
- Center for Infectious Disease Research, Seattle, WA, United States
| | - Fergal J Duffy
- Center for Infectious Disease Research, Seattle, WA, United States.,Seattle Children's Research Institute, Center for Global Infectious Disease Research, Seattle, WA, United States
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - Katharina Ronacher
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,Translational Research Institute, Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - Jill Winter
- Catalysis Foundation for Health, San Ramon, CA, United States
| | - Gerhard Walzl
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,Bioinformatics Unit, South African Tuberculosis Bioinformatics Initiative, Stellenbosch University, Cape Town, South Africa
| | - Gerard Tromp
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa.,DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,South African Medical Research Council Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa.,Bioinformatics Unit, South African Tuberculosis Bioinformatics Initiative, Stellenbosch University, Cape Town, South Africa.,Centre for Bioinformatics and Computational Biology, Stellenbosch University, Stellenbosch, South Africa
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Bomanji J, Sharma R, Mittal BR, Gambhir S, Qureshy A, Begum SMF, Paez D, Sathekge M, Vorster M, Sobic Saranovic D, Pusuwan P, Mann V, Vinjamuri S, Zumla A, Pascual TNB. Sequential 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scan findings in patients with extrapulmonary tuberculosis during the course of treatment—a prospective observational study. Eur J Nucl Med Mol Imaging 2020; 47:3118-3129. [DOI: 10.1007/s00259-020-04888-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/21/2020] [Indexed: 02/03/2023]
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Priftakis D, Riaz S, Zumla A, Bomanji J. Towards more accurate 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) imaging in active and latent tuberculosis. Int J Infect Dis 2020; 92S:S85-S90. [DOI: 10.1016/j.ijid.2020.02.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/10/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022] Open
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Giraudo C, Evangelista L, Fraia AS, Lupi A, Quaia E, Cecchin D, Casali M. Molecular Imaging of Pulmonary Inflammation and Infection. Int J Mol Sci 2020; 21:ijms21030894. [PMID: 32019142 PMCID: PMC7037834 DOI: 10.3390/ijms21030894] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/14/2022] Open
Abstract
Infectious and inflammatory pulmonary diseases are a leading cause of morbidity and mortality worldwide. Although infrequently used in this setting, molecular imaging may significantly contribute to their diagnosis using techniques like single photon emission tomography (SPET), positron emission tomography (PET) with computed tomography (CT) or magnetic resonance imaging (MRI) with the support of specific or unspecific radiopharmaceutical agents. 18F-Fluorodeoxyglucose (18F-FDG), mostly applied in oncological imaging, can also detect cells actively involved in infectious and inflammatory conditions, even if with a low specificity. SPET with nonspecific (e.g., 67Gallium-citrate (67Ga citrate)) and specific tracers (e.g., white blood cells radiolabeled with 111Indium-oxine (111In) or 99mTechnetium (99mTc)) showed interesting results for many inflammatory lung diseases. However, 67Ga citrate is unfavorable by a radioprotection point of view while radiolabeled white blood cells scan implies complex laboratory settings and labeling procedures. Radiolabeled antibiotics (e.g., ciprofloxacin) have been recently tested, although they seem to be quite unspecific and cause antibiotic resistance. New radiolabeled agents like antimicrobic peptides, binding to bacterial cell membranes, seem very promising. Thus, the aim of this narrative review is to provide a comprehensive overview about techniques, including PET/MRI, and tracers that can guide the clinicians in the appropriate diagnostic pathway of infectious and inflammatory pulmonary diseases.
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Affiliation(s)
- Chiara Giraudo
- Department of Medicine-DIMED,Institute of Radiology, University of Padova, 35100 Padova, Italy; (A.S.F.); (A.L.); (E.Q.)
- Correspondence: ; Tel.: +39-049-821-2357; Fax: +39-049-821-1878
| | - Laura Evangelista
- Nuclear Medicine Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy; (L.E.); (D.C.)
| | - Anna Sara Fraia
- Department of Medicine-DIMED,Institute of Radiology, University of Padova, 35100 Padova, Italy; (A.S.F.); (A.L.); (E.Q.)
| | - Amalia Lupi
- Department of Medicine-DIMED,Institute of Radiology, University of Padova, 35100 Padova, Italy; (A.S.F.); (A.L.); (E.Q.)
| | - Emilio Quaia
- Department of Medicine-DIMED,Institute of Radiology, University of Padova, 35100 Padova, Italy; (A.S.F.); (A.L.); (E.Q.)
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy; (L.E.); (D.C.)
- Padova Neuroscience Center (PNC), University of Padova, 35131 Padova, Italy
| | - Massimiliano Casali
- Azienda Unità Sanitaria Locale–IRCCS di Reggio Emilia, 42121 Reggio Emilia, Italy;
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12
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Kung BT, Seraj SM, Zadeh MZ, Rojulpote C, Kothekar E, Ayubcha C, Ng KS, Ng KK, Au-Yong TK, Werner TJ, Zhuang H, Hunt SJ, Hess S, Alavi A. An update on the role of 18F-FDG-PET/CT in major infectious and inflammatory diseases. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2019; 9:255-273. [PMID: 31976156 PMCID: PMC6971480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/27/2019] [Indexed: 06/10/2023]
Abstract
For decades, conventional nuclear medicine techniques have been utilized for the assessment of many infectious and inflammatory diseases. Most of these techniques have limitations such as the relatively low spatial resolution, being time consuming and low sensitivity or specificity. In recent years, FDG-PET/CT has shown promising role in the management of such diseases. An expanding set of studies illustrate the multifarious roles of FDG-PET/CT in the assessment of these conditions, both systemic diseases and more regional. Specifically, PET can provide vital information at a molecular level and consequently detect the disease activity at their earliest manifestation. With the continuing research on the diagnosis and treatment monitoring of patients with infectious and inflammatory diseases, the role of PET/CT can be further extended.
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Affiliation(s)
- Boom Ting Kung
- Clinical PET Centre and Nuclear Medicine Unit, Queen Elizabeth HospitalHong Kong, China
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
- Department of Radiology, Children’s Hospital of PhiladelphiaPA, USA
| | | | - Mahdi Zirakchian Zadeh
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
- Department of Radiology, Children’s Hospital of PhiladelphiaPA, USA
| | | | - Esha Kothekar
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
| | - Cyrus Ayubcha
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
| | - Kwok Sing Ng
- Clinical PET Centre and Nuclear Medicine Unit, Queen Elizabeth HospitalHong Kong, China
| | - Koon Kiu Ng
- Clinical PET Centre and Nuclear Medicine Unit, Queen Elizabeth HospitalHong Kong, China
| | - Ting Kun Au-Yong
- Clinical PET Centre and Nuclear Medicine Unit, Queen Elizabeth HospitalHong Kong, China
| | - Thomas J Werner
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
| | - Hongming Zhuang
- Department of Radiology, Children’s Hospital of PhiladelphiaPA, USA
| | - Stephen J Hunt
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
| | - Søren Hess
- Department of Radiology and Nuclear Medicine, Hospital of South West JutlandEsbjerg, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern DenmarkOdense, Denmark
| | - Abass Alavi
- Department of Radiology, Hospital of University of PennsylvaniaPA, USA
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13
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Bomanji J, Sharma R, Mittal BR, Gambhir S, Qureshy A, Begum SM, Paez D, Sathekge M, Vorster M, Sobic Saranovic D, Pusuwan P, Mann V, Vinjamuri S, Zumla A, Pascual TN. PET/CT features of extrapulmonary tuberculosis at first clinical presentation: a cross-sectional observational 18F-FDG imaging study across six countries. Eur Respir J 2019; 55:13993003.01959-2019. [DOI: 10.1183/13993003.01959-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/11/2019] [Indexed: 12/17/2022]
Abstract
BackgroundA large proportion of the huge global burden of extrapulmonary tuberculosis (EPTB) cases are treated empirically without accurate definition of disease sites and extent of multi-organ disease involvement. Positron emission tomography (PET) imaging using 2-deoxy-2-(fluorine-18) fluoro-d-glucose (18F-FDG) in tuberculosis could be a useful imaging technique for localising disease sites and extent of disease.MethodsWe conducted a study of HIV-negative adult patients with a new clinical diagnosis of EPTB across eight centres located in six countries: India, Pakistan, Thailand, South Africa, Serbia and Bangladesh, to assess the extent of disease and common sites involved at first presentation. 18F-FDG PET/computed tomography (CT) scans were performed within 2 weeks of presentation.Findings358 patients with EPTB (189 females; 169 males) were recruited over 45 months, with an age range of 18–83 years (females median 30 years; males median 38 years). 350 (98%) out of 358 patients (183 female, 167 male) had positive scans. 118 (33.7%) out of 350 had a single extrapulmonary site and 232 (66.3%) out of 350 had more than one site (organ) affected. Lymph nodes, skeleton, pleura and brain were common sites. 100 (28%) out of 358 EPTB patients had 18F-FDG PET/CT-positive sites in the lung. 110 patients were 18F-FDG PET/CT-positive in more body sites than were noted clinically at first presentation and 160 patients had the same number of positive body sites.Interpretation18F-FDG PET/CT scan has potential for further elucidating the spectrum of disease, pathogenesis of EPTB and monitoring the effects of treatment on active lesions over time, and requires longitudinal cohort studies, twinned with biopsy and molecular studies.
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14
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Russo A, Graziano E, Carnelutti A, Sponza M, Cadeo B, Sartor A, Righi E, Bassetti M. Management of vertebral osteomyelitis over an eight-year period: The UDIPROVE (UDIne PROtocol on VErtebral osteomyelitis). Int J Infect Dis 2019; 89:116-121. [PMID: 31629078 DOI: 10.1016/j.ijid.2019.10.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Vertebral osteomyelitis (VO) is a compelling clinical entity for clinicians because of its insidious and indolent course, which makes diagnosis difficult. METHODS All patients with a suspected diagnosis of VO were analyzed over an 8-year period (January 2009 to January 2017). The UDIPROVE protocol (UDIne PROtocol on VErtebral osteomyelitis) was applied in all cases. The primary endpoint was the performance of the UDIPROVE protocol to obtain the causal bacteria of infection. RESULTS During the study period, 133 episodes of confirmed VO were observed. The etiology of infection was obtained in 73.6% of cases: 70.5% were gram-positive, 16.3% were gram-negative, and 13.2% were mycobacteria. 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) showed that for tubercular VO, the median standard uptake value (SUV) was higher when compared with VO caused by other bacteria. Clinical cure at the end of therapy was reported in 85.7% of patients. Previous antimicrobial therapy and a delay of more than 5 days in performing biopsy were associated with an undiagnosed etiology of VO. Targeted antibacterial therapy and follow-up with FDG-PET/CT were associated with clinical cure at the end of therapy, while the involvement of more than two vertebrae and inadequate drainage were associated with failure. CONCLUSIONS Rigorous application of the UDIPROVE protocol allowed the causative pathogens of VO to be obtained - at about twice the rate reported in the literature. The use of FDG-PET/CT for the follow-up of infection was more reliable when compared to magnetic resonance imaging (MRI).
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Affiliation(s)
- Alessandro Russo
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Elena Graziano
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Alessia Carnelutti
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Massimo Sponza
- Division of Vascular and Interventional Radiology, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Barbara Cadeo
- Infectious Diseases Clinic, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Assunta Sartor
- Microbiology Unit, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Elda Righi
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy.
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15
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Yu WY, Lu PX, Assadi M, Huang XL, Skrahin A, Rosenthal A, Gabrielian A, Tartakovsky M, Wáng YXJ. Updates on 18F-FDG-PET/CT as a clinical tool for tuberculosis evaluation and therapeutic monitoring. Quant Imaging Med Surg 2019; 9:1132-1146. [PMID: 31367568 DOI: 10.21037/qims.2019.05.24] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Tuberculosis (TB) is currently the world's leading cause of infectious mortality. The complex immune response of the human body to Mycobacterium tuberculosis (M.tb) results in a wide array of clinical manifestations, thus the clinical and radiological diagnosis can be challenging. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) scan with/without computed tomography (CT) component images the whole body and provides a metabolic map of the infection, enabling clinicians to assess the disease burden. 18F-FDG-PET/CT scan is particularly useful in detecting the disease in previously unknown sites, and allows the most appropriate site of biopsy to be selected. 18F-FDG-PET/CT is also very valuable in assessing early disease response to therapy, and plays an important role in cases where conventional microbiological methods are unavailable and for monitoring response to therapy in cases of multidrug-resistant TB or extrapulmonary TB. 18F-FDG-PET/CT cannot reliably differentiate active TB lesion from malignant lesions and false positives can also be due to other infective or inflammatory conditions. 18F-FDG PET is also unable to distinguish tuberculous lymphadenitis from metastatic lymph node involvement. The lack of specificity is a limitation for 18F-FDG-PET/CT in TB management.
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Affiliation(s)
- Wei-Ye Yu
- Shenzhen Center for Chronic Disease Control, Shenzhen 518055, China
| | - Pu-Xuan Lu
- Shenzhen Center for Chronic Disease Control, Shenzhen 518055, China
| | - Majid Assadi
- The Persian Gulf Nuclear Medicine Research Center, Bushehr University Of Medical Sciences, Bushehr, Iran
| | - Xi-Ling Huang
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
| | - Aliaksandr Skrahin
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis, Ministry of Health, Minsk, Belarus.,Belarus State Medical University, Minsk, Belarus
| | - Alex Rosenthal
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Andrei Gabrielian
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Michael Tartakovsky
- Office of Cyber Infrastructure and Computational Biology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland, USA
| | - Yì Xiáng J Wáng
- Department of Imaging and Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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16
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Zhang Z, Ordonez AA, Wang H, Li Y, Gogarty KR, Weinstein EA, Daryaee F, Merino J, Yoon GE, Kalinda AS, Mease RC, Iuliano JN, Smith-Jones PM, Jain SK, Tonge PJ. Positron Emission Tomography Imaging with 2-[ 18F]F- p-Aminobenzoic Acid Detects Staphylococcus aureus Infections and Monitors Drug Response. ACS Infect Dis 2018; 4:1635-1644. [PMID: 30067329 PMCID: PMC6226330 DOI: 10.1021/acsinfecdis.8b00182] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
![]()
Staphylococcus aureus is the leading cause of life-threatening
infections, frequently originating from unknown or deep-seated foci.
Source control and institution of appropriate antibiotics remain challenges,
especially with infections due to methicillin-resistant S. aureus (MRSA). In this study, we developed a radiofluorinated analog of para-aminobenzoic acid (2-[18F]F-PABA) and demonstrate
that it is an efficient alternative substrate for the S. aureus dihydropteroate synthase (DHPS). 2-[18F]F-PABA rapidly
accumulated in vitro within laboratory and clinical
(including MRSA) strains of S. aureus but not
in mammalian cells. Biodistribution in murine and rat models demonstrated
localization at infection sites and rapid renal elimination. In a
rat model, 2-[18F]F-PABA positron emission tomography (PET)
rapidly differentiated S. aureus infection from
sterile inflammation and could also detect therapeutic failures associated
with MRSA. These data suggest that 2-[18F]F-PABA has the
potential for translation to humans as a rapid, noninvasive diagnostic
tool to identify, localize, and monitor S. aureus infections.
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Affiliation(s)
- Zhuo Zhang
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Alvaro A. Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Hui Wang
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Yong Li
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Kayla R. Gogarty
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Edward A. Weinstein
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Fereidoon Daryaee
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Jonathan Merino
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Grace E. Yoon
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
- The Facility for Experimental Radiopharmaceutical Manufacturing, Department of Psychiatry, Stony Brook University, Stony Brook, New York 11794, United States
| | - Alvin S. Kalinda
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Ronnie C. Mease
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - James N. Iuliano
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
| | - Peter M. Smith-Jones
- The Facility for Experimental Radiopharmaceutical Manufacturing, Department of Psychiatry, Stony Brook University, Stony Brook, New York 11794, United States
| | - Sanjay K. Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, United States
| | - Peter J. Tonge
- Institute for Chemical Biology & Drug Discovery, Department of Chemistry and Radiology, Stony Brook University, 100 Nicolls Road, 633 Chemistry, Stony Brook, New York 11794, United States
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17
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Ganchua SKC, Cadena AM, Maiello P, Gideon HP, Myers AJ, Junecko BF, Klein EC, Lin PL, Mattila JT, Flynn JL. Lymph nodes are sites of prolonged bacterial persistence during Mycobacterium tuberculosis infection in macaques. PLoS Pathog 2018; 14:e1007337. [PMID: 30383808 PMCID: PMC6211753 DOI: 10.1371/journal.ppat.1007337] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/13/2018] [Indexed: 02/07/2023] Open
Abstract
Tuberculosis is commonly considered a chronic lung disease, however, extrapulmonary infection can occur in any organ. Even though lymph nodes (LN) are among the most common sites of extrapulmonary Mycobacterium tuberculosis (Mtb) infection, and thoracic LNs are frequently infected in humans, bacterial dynamics and the effect of Mtb infection in LN structure and function is relatively unstudied. We surveyed thoracic LNs from Mtb-infected cynomolgus and rhesus macaques analyzing PET CT scans, bacterial burden, LN structure and immune function. FDG avidity correlated with the presence of live bacteria in LNs at necropsy. Lymph nodes have different trajectories (increasing, maintaining, decreasing in PET activity over time) even within the same animal. Rhesus macaques are more susceptible to Mtb infection than cynomolgus macaques and this is in part due to more extensive LN pathology. Here, we show that Mtb grows to the same level in cynomolgus and rhesus macaque LNs, however, cynomolgus macaques control Mtb at later time points post-infection while rhesus macaques do not. Notably, compared to lung granulomas, LNs are generally poor at killing Mtb, even with drug treatment. Granulomas that form in LNs lack B cell-rich tertiary lymphoid structures, disrupt LN structure by pushing out T cells and B cells, introduce large numbers of macrophages that can serve as niches for Mtb, and destroy normal vasculature. Our data support that LNs are not only sites of antigen presentation and immune activation during infection, but also serve as important sites for persistence of significant numbers of Mtb bacilli. Since tuberculosis is commonly considered a chronic lung disease, most studies in tuberculosis focus on the lungs while lymph nodes are almost always depicted only as sites of antigen presentation and immune activation. However, lymph nodes are among the most frequently infected sites of Mycobacterium tuberculosis (Mtb) aside from the lungs. The effect of Mtb infection and how lymph nodes respond to Mtb infection is currently unknown. To investigate this, we examined the lymph nodes of two macaque species, cynomolgus and rhesus macaques, at different time points after Mtb infection. We found that overall lymph nodes are not effective killers of Mtb; the lymph nodes of rhesus macaques being less effective at killing Mtb than cynomolgus macaques. Mtb infection also resulted in the destruction of the lymph node structure and this was associated with increased bacterial burden. After a short course of anti-TB drug therapy, the reduction in bacterial burden was lower in lymph nodes compared to lung granulomas. Our data show that aside from being sites of antigen presentation and immune activation, lymph nodes are also niches of Mtb growth and persistence.
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Affiliation(s)
- Sharie Keanne C. Ganchua
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Anthony M. Cadena
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Pauline Maiello
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Hannah P. Gideon
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Amy J. Myers
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
| | - Beth F. Junecko
- Department of Infectious Disease and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, United States of America
| | - Edwin C. Klein
- Division of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Philana Ling Lin
- Department of Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Joshua T. Mattila
- Department of Infectious Disease and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, United States of America
| | - JoAnne L. Flynn
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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18
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Prospective Serial FDG PET/CT During Treatment of Extrapulmonary Tuberculosis in HIV-Infected Patients: An Exploratory Study. Clin Nucl Med 2018; 43:635-640. [PMID: 30015658 DOI: 10.1097/rlu.0000000000002187] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to prospectively describe evolution of F-FDG uptake of extrapulmonary tuberculosis (TB) throughout the course of TB treatment in HIV patients to evaluate F-FDG PET/CT as a monitoring tool of treatment response. METHODS We performed baseline FDG PET/CT, PET-2 after 2 months, and PET-3 at the end of TB treatment in 18 HIV/TB patients. We correlated evolution of FDG uptake with clinical outcome of patients. RESULTS After 2 months of treatment, 78% of the patients had a significant metabolic response. Lymph node (LN) metabolic response was heterogeneous, with 57% of LN sites showing decreased SUVmax and 41% showing unchanged FDG uptake. Organs other than LNs showed more homogeneous response. The FDG PET/CT performed at the end of TB treatment showed a complete response of all infected organs and a drastic response in terms of active LNs in 95% of the patients (SUVmax mean decrease = 85%, median = 100%). A complete metabolic response after TB treatment was seen in only 47% of patients. CONCLUSIONS In difficult-to-treat entities such as extrapulmonary TB in HIV patients, FDG PET/CT is a potential tool in monitoring TB treatment response and should be explored in larger studies.
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19
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Geadas C, Acuna-Villaorduna C, Mercier G, Kleinman MB, Horsburgh CR, Ellner JJ, Jacobson KR. FDG-PET/CT activity leads to the diagnosis of unsuspected TB: a retrospective study. BMC Res Notes 2018; 11:464. [PMID: 30001743 PMCID: PMC6044021 DOI: 10.1186/s13104-018-3564-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/05/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Mycobacterium tuberculosis infection leads to latent or active tuberculosis (TB). Increased uptake on 18F-fluoro-2-deoxy-glucose-positron emission tomography/computed tomography (FDG-PET/CT) has been reported in the lungs and lymph nodes of individuals with recent infection and active TB, but not in individuals without known recent exposure or suggestive symptoms. We describe five patients with lung nodules not suspected to be due to TB in whom abnormalities on FDG-PET/CT scans ultimately were attributed to TB infection. Results Patient records were searched using the words “positron emission tomography/computed tomography” and 24 codes for TB between 2004 and 2013. Patients with a diagnosis of TB and a PET/CT scan were included. Clinical and radiographic data were retrieved. PET/CT images were reviewed by an experienced radiologist. FDG-PET/CT scans revealed elevated FDG-uptake in lungs of five patients subsequently diagnosed with active (n = 3) or clinically inactive (n = 2) tuberculosis. Uptake magnitude was unrelated to disease activity. These findings suggest that tuberculosis latency may include periods of percolating inflammation of uncertain relationship to future disease risk.
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Affiliation(s)
- Carolina Geadas
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA.
| | - Carlos Acuna-Villaorduna
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA
| | - Gustavo Mercier
- Section of Molecular Imaging and Nuclear Medicine, Department of Radiology, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
| | - Mary B Kleinman
- Infectious Disease Prevention and Health Services Bureau, Prevention and Health Promotion Administration, Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA
| | - C Robert Horsburgh
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jerrold J Ellner
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA
| | - Karen R Jacobson
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA.
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20
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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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21
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Ankrah AO, Glaudemans AWJM, Maes A, Van de Wiele C, Dierckx RAJO, Vorster M, Sathekge MM. Tuberculosis. Semin Nucl Med 2017; 48:108-130. [PMID: 29452616 DOI: 10.1053/j.semnuclmed.2017.10.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tuberculosis (TB) is currently the world's leading cause of infectious mortality. Imaging plays an important role in the management of this disease. The complex immune response of the human body to Mycobacterium tuberculosis results in a wide array of clinical manifestations, making clinical and radiological diagnosis challenging. 18F-FDG-PET/CT is very sensitive in the early detection of TB in most parts of the body; however, the lack of specificity is a major limitation. 18F-FDG-PET/CT images the whole body and provides a pre-therapeutic metabolic map of the infection, enabling clinicians to accurately assess the burden of disease. It enables the most appropriate site of biopsy to be selected, stages the infection, and detects disease in previously unknown sites. 18F-FDG-PET/CT has recently been shown to be able to identify a subset of patients with latent TB infection who have subclinical disease. Lung inflammation as detected by 18F-FDG-PET/CT has shown promising signs that it may be a useful predictor of progression from latent to active infection. A number of studies have identified imaging features that might improve the specificity of 18F-FDG-PET/CT at some sites of extrapulmonary TB. Other PET tracers have also been investigated for their use in TB, with some promising results. The potential role and future perspectives of PET/CT in imaging TB is considered. Literature abounds on the very important role of 18F-FDG-PET/CT in assessing therapy response in TB. The use of 18F-FDG for monitoring response to treatment is addressed in a separate review.
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Affiliation(s)
- Alfred O Ankrah
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa; Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Alex Maes
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa; Department of Nuclear Medicine, AZ Groeninge, Kortrijk, Belgium; Department of Morphology and Medical Imaging, University Hospital Leuven, Leuven, Belgium
| | - Christophe Van de Wiele
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa; Department of Nuclear Medicine and Radiology, University of Ghent, Ghent, Belgium
| | - Rudi A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Mariza Vorster
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa.
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Abstract
Monitoring response to treatment is a key element in the management of infectious diseases, yet controversies still persist on reliable biomarkers for noninvasive response evaluation. Considering the limitations of invasiveness of most diagnostic procedures and the issue of expression heterogeneity of pathology, molecular imaging is better able to assay in vivo biologic processes noninvasively and quantitatively. The usefulness of 18F-FDG-PET/CT in assessing treatment response in infectious diseases is more promising than for conventional imaging. However, there are currently no clinical criteria or recommended imaging modalities to objectively evaluate the effectiveness of antimicrobial treatment. Therapeutic effectiveness is currently gauged by the patient's subjective clinical response. In this review, we present the current studies for monitoring treatment response, with a focus on Mycobacterium tuberculosis, as it remains a major worldwide cause of morbidity and mortality. The role of molecular imaging in monitoring other infections including spondylodiscitis, infected prosthetic vascular grafts, invasive fungal infections, and a parasitic disease is highlighted. The role of functional imaging in monitoring lipodystrophy associated with highly active antiretroviral therapy for human immunodeficiency virus is considered. We also discuss the key challenges and emerging data in optimizing noninvasive response evaluation.
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Affiliation(s)
- Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa..
| | - Alfred O Ankrah
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa.; Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Ismaheel Lawal
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa
| | - Mariza Vorster
- Department of Nuclear Medicine, University of Pretoria and Steve Biko Academic Hospital, South Africa
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Montes Ruiz-Cabello M, Guirao Arrabal E, Caminero Luna JA. Papel de la PET/TC en el seguimiento y respuesta al tratamiento de los pacientes con tuberculosis. Med Clin (Barc) 2017. [DOI: 10.1016/j.medcli.2017.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Higher fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) uptake in tuberculous compared to bacterial spondylodiscitis. Skeletal Radiol 2017; 46:777-783. [PMID: 28299432 DOI: 10.1007/s00256-017-2615-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 01/28/2017] [Accepted: 02/28/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tuberculous spondylodiscitis can be difficult to diagnose because of its nonspecific symptoms and the similarities with non-tubercular forms of spinal infection. Fluorine-18-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG PET-CT) is increasingly used for the diagnosis and monitoring of tubercular diseases. METHODS Retrospective, case-control study comparing tuberculous spondylodiscitis with biopsy-confirmed pyogenic spondylodiscitis in the period 2010-2012. RESULTS Ten cases of tuberculous spondylodiscitis and 20 controls were included. Compared to pyogenic, tuberculous spondylodiscitis was more frequent in younger patients (P = 0.01) and was more often associated with thoraco-lumbar tract lesions (P = 0.01) and multiple vertebral involvement (P = 0.01). Significantly higher maximum standardized uptake values (SUV) at FDG-PET were displayed by tuberculous spondylodiscitis compared to controls (12.4 vs. 7.3, P = 0.003). SUV levels above 8 showed the highest value of specificity (0.80). Mean SUV reduction of 48% was detected for tuberculous spondylodiscitis at 1-month follow-up. CONCLUSIONS Higher SUV levels at FDG-PET were detected in tuberculous compared with pyogenic spondylodiscitis. PET-CT use appeared useful in the disease follow-up after treatment initiation.
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Pelletier-Galarneau M, Martineau P, Zuckier LS, Pham X, Lambert R, Turpin S. 18 F-FDG-PET/CT Imaging of Thoracic and Extrathoracic Tuberculosis in Children. Semin Nucl Med 2017; 47:304-318. [DOI: 10.1053/j.semnuclmed.2016.12.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Ankrah AO, van der Werf TS, de Vries EFJ, Dierckx RAJO, Sathekge MM, Glaudemans AWJM. PET/CT imaging of Mycobacterium tuberculosis infection. Clin Transl Imaging 2016; 4:131-144. [PMID: 27077068 PMCID: PMC4820496 DOI: 10.1007/s40336-016-0164-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/09/2016] [Indexed: 12/17/2022]
Abstract
Tuberculosis has a high morbidity and mortality worldwide. Mycobacterium tuberculosis (Mtb) has a complex pathophysiology; it is an aerobic bacillus capable of surviving in anaerobic conditions in a latent state for a very long time before reactivation to active disease. In the latent tuberculosis infection, the individual has no clinical evidence of active disease, but exhibits a hypersensitive response to proteins of Mtb. Only some 5–10 % of latently infected individuals appear to have reactivation of tuberculosis at any one time point after infection, and neither imaging nor immune tests have been shown to predict tuberculosis reactivation reliably. The complex pathology of the organism provides multiple molecular targets for imaging the infection and targeting therapy. Positron emission tomography (PET) integrated with computer tomography (CT) provides a unique opportunity to noninvasively image the whole body for diagnosing, staging and assessing therapy response in many infectious and inflammatory diseases. PET/CT is a powerful noninvasive tool that can rapidly provide three-dimensional views of disease deep within the body and conduct longitudinal assessment over time in one particular patient. Some PET tracers, such as 18F-fluorodeoxyglucose (18F-FDG), have been found to be useful in various infectious diseases for detection, assessing disease activity, staging and monitoring response to therapy. This tracer has also been used for imaging tuberculosis. 18F-FDG PET relies on the glucose uptake of inflammatory cells as a result of the respiratory burst that occurs with infection. Other PET tracers have also been used to image different aspects of the pathology or microbiology of Mtb. The synthesis of the complex cell membrane of the bacilli for example can be imaged with 11C-choline or 18F-fluoroethylcholine PET/CT while the uptake of amino acids during cell growth can be imaged by 3′-deoxy-3′-[18F]fluoro-l-thymidine. PET/CT provides a noninvasive and sensitive method of assessing histopathological information on different aspects of tuberculosis and is already playing a role in the management of tuberculosis. As our understanding of the pathophysiology of tuberculosis increases, the role of PET/CT in the management of this disease would become more important. In this review, we highlight the various tracers that have been used in tuberculosis and explain the underlying mechanisms for their use.
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Affiliation(s)
- Alfred O Ankrah
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Gronigen, The Netherlands ; Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Tjip S van der Werf
- Department of Internal Medicine, Infectious Diseases, and Pulmonary Diseases and Tuberculosis, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Erik F J de Vries
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Gronigen, The Netherlands
| | - Rudi A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Gronigen, The Netherlands
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Pretoria, South Africa
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Gronigen, The Netherlands
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Skoura E, Zumla A, Bomanji J. Imaging in tuberculosis. Int J Infect Dis 2016; 32:87-93. [PMID: 25809762 DOI: 10.1016/j.ijid.2014.12.007] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 12/11/2022] Open
Abstract
Early diagnosis of tuberculosis (TB) is necessary for effective treatment. In primary pulmonary TB, chest radiography remains the mainstay for the diagnosis of parenchymal disease, while computed tomography (CT) is more sensitive in detecting lymphadenopathy. In post-primary pulmonary TB, CT is the method of choice to reveal early bronchogenic spread. Concerning characterization of the infection as active or not, CT is more sensitive than radiography, and (18)F-fluorodeoxyglucose positron emission tomography/CT ((18)F-FDG PET/CT) has yielded promising results that need further confirmation. The diagnosis of extrapulmonary TB sometimes remains difficult. Magnetic resonance imaging (MRI) is the preferred modality in the diagnosis and assessment of tuberculous spondylitis, while (18)F-FDG PET shows superior image resolution compared with single-photon-emitting tracers. MRI is considered superior to CT for the detection and assessment of central nervous system TB. Concerning abdominal TB, lymph nodes are best evaluated on CT, and there is no evidence that MRI offers added advantages in diagnosing hepatobiliary disease. As metabolic changes precede morphological ones, the application of (18)F-FDG PET/CT will likely play a major role in the assessment of the response to anti-TB treatment.
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Affiliation(s)
- Evangelia Skoura
- Institute of Nuclear Medicine, University College Hospitals NHS Trust, London NW1 2BU, UK
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, and NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Jamshed Bomanji
- Institute of Nuclear Medicine, University College Hospitals NHS Trust, London NW1 2BU, UK.
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Salazar-Austin N, Ordonez AA, Hsu AJ, Benson JE, Mahesh M, Menachery E, Razeq JH, Salfinger M, Starke JR, Milstone AM, Parrish N, Nuermberger EL, Jain SK. Extensively drug-resistant tuberculosis in a young child after travel to India. THE LANCET. INFECTIOUS DISEASES 2015; 15:1485-91. [PMID: 26607130 DOI: 10.1016/s1473-3099(15)00356-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023]
Abstract
Extensively drug-resistant (XDR) tuberculosis is becoming increasingly prevalent worldwide, but little is known about XDR tuberculosis in young children. In this Grand Round we describe a 2-year-old child from the USA who developed pneumonia after a 3 month visit to India. Symptoms resolved with empirical first-line tuberculosis treatment; however, a XDR strain of Mycobacterium tuberculosis grew in culture. In the absence of clinical or microbiological markers, low-radiation exposure pulmonary CT imaging was used to monitor treatment response, and guide an individualised drug regimen. Management was complicated by delays in diagnosis, uncertainties about drug selection, and a scarcity of child-friendly formulations. Treatment has been successful so far, and the child is in remission. This report of XDR tuberculosis in a young child in the USA highlights the risks of acquiring drug-resistant tuberculosis overseas, and the unique challenges in management of tuberculosis in this susceptible population.
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Affiliation(s)
- Nicole Salazar-Austin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alvaro A Ordonez
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alice Jenh Hsu
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jane E Benson
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahadevappa Mahesh
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jafar H Razeq
- Maryland Department of Health and Mental Hygiene, Laboratories Administration, Baltimore, MD, USA
| | - Max Salfinger
- National Jewish Health Mycobacteriology Laboratory, Denver, CO, USA
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Hospital Epidemiology and Infection Control, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicole Parrish
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eric L Nuermberger
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sanjay K Jain
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Molton JS, Leek FAA, Ng LHS, Totman JJ, Paton NI. A Novel Approach to CT, MR, and PET Examination of Patients with Infections Requiring Stringent Airborne Precautions. Radiology 2015; 278:881-7. [PMID: 26402398 DOI: 10.1148/radiol.2015150289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate the feasibility of using a modified portable isolation chamber, which conforms to Centers for Disease Control and Prevention (CDC) isolation requirements, in the imaging of infectious patients. MATERIALS AND METHODS This study was approved by the ethics committee, and all participants gave written informed consent. In this prospective study, the isolation chamber was assessed for computed tomographic (CT), magnetic resonance (MR), and positron emission tomographic (PET) image uniformity and noise by using uniform phantoms. For each modality, equivalent phantom examinations were performed without the isolation chamber. Paired analyses of the differences from these baseline values were conducted by finding the mean difference in the matched sections for each image quality parameter. A potential increase in CT patient dose was assessed, and MR radiofrequency (RF) interference was monitored. Eight participants with active pulmonary tuberculosis (mean age, 48.1 years; age range, 26-88 years; five men, three women) were then examined within a hybrid PET/MR imager. The 95% confidence intervals for the difference in the two matched population means were determined by using the two-sided t distribution for each of the phantom study imaging modalities. RESULTS Phantom images were evaluated for image uniformity and noise. Increased image noise can affect low contrast resolution, which has the potential to mimic or mask abnormalities when the differences between healthy and diseased tissues are small; clinically, CT image noise is maintained at a constant level with dose modulation. Increased attenuation of annihilation photons, when not corrected for, could lead to photopenic areas on the PET image; PET image nonuniformity complied with guidelines. Artifacts on the MR image due to RF noise spikes could mask abnormalities; paired analysis of variations in MR imaging mean signal-to-noise ratio and uniformity from baseline were within 5% for both gradient-echo and spin-echo sequences. In the eight participants who underwent imaging, the increased radiation dose for the attenuation of the isolation chamber would have resulted in a mean increase in patient size-specific dose estimate of 0.32 mGy ± 0.04 (standard deviation). The RF noise assessment revealed no prominent increase at any frequency band. The eight participants were examined within the isolation chamber without incident. CONCLUSION A modified portable isolation chamber, which conforms to CDC infection control guidelines, was found to be feasible within the confines of CT, MR imaging, and PET environments.
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Affiliation(s)
- James S Molton
- From the University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 10, Singapore 119228 (J.S.M., N.I.P.); Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.S.M., N.I.P.); and A*STAR-NUS Clinical Imaging Research Centre, Singapore (F.A.A.L., L.H.S.N., J.J.T.)
| | - Francesca A A Leek
- From the University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 10, Singapore 119228 (J.S.M., N.I.P.); Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.S.M., N.I.P.); and A*STAR-NUS Clinical Imaging Research Centre, Singapore (F.A.A.L., L.H.S.N., J.J.T.)
| | - Lay Hong Stevia Ng
- From the University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 10, Singapore 119228 (J.S.M., N.I.P.); Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.S.M., N.I.P.); and A*STAR-NUS Clinical Imaging Research Centre, Singapore (F.A.A.L., L.H.S.N., J.J.T.)
| | - John J Totman
- From the University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 10, Singapore 119228 (J.S.M., N.I.P.); Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.S.M., N.I.P.); and A*STAR-NUS Clinical Imaging Research Centre, Singapore (F.A.A.L., L.H.S.N., J.J.T.)
| | - Nicholas I Paton
- From the University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 10, Singapore 119228 (J.S.M., N.I.P.); Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (J.S.M., N.I.P.); and A*STAR-NUS Clinical Imaging Research Centre, Singapore (F.A.A.L., L.H.S.N., J.J.T.)
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Tebruegge M, Ritz N, Curtis N, Shingadia D. Diagnostic Tests for Childhood Tuberculosis: Past Imperfect, Present Tense and Future Perfect? Pediatr Infect Dis J 2015; 34:1014-9. [PMID: 26107342 DOI: 10.1097/inf.0000000000000796] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Marc Tebruegge
- From the *Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; †Department of Paediatric Infectious Diseases & Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; ‡Institute for Life Sciences, University of Southampton, Southampton, United Kingdom; §NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom; ¶Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia; ‖University Children´s Hospital Basel, Paediatric Infectious Diseases and Pharmacology, University Basel, Basel, Switzerland; **Murdoch Children's Research Institute, Parkville, Victoria, Australia; ††Infectious Diseases Unit, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; ‡‡Department of Paediatric Infectious Diseases, Great Ormond Street Hospital, London, United Kingdom; and §§University College London Institute of Child Health, London, United Kingdom
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Chen RY, Dodd LE, Lee M, Paripati P, Hammoud DA, Mountz JM, Jeon D, Zia N, Zahiri H, Coleman MT, Carroll MW, Lee JD, Jeong YJ, Herscovitch P, Lahouar S, Tartakovsky M, Rosenthal A, Somaiyya S, Lee S, Goldfeder LC, Cai Y, Via LE, Park SK, Cho SN, Barry CE. PET/CT imaging correlates with treatment outcome in patients with multidrug-resistant tuberculosis. Sci Transl Med 2015; 6:265ra166. [PMID: 25473034 DOI: 10.1126/scitranslmed.3009501] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Definitive clinical trials of new chemotherapies for treating tuberculosis (TB) require following subjects until at least 6 months after treatment discontinuation to assess for durable cure, making these trials expensive and lengthy. Surrogate endpoints relating to treatment failure and relapse are currently limited to sputum microbiology, which has limited sensitivity and specificity. We prospectively assessed radiographic changes using 2-deoxy-2-[(18)F]-fluoro-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) at 2 and 6 months (CT only) in a cohort of subjects with multidrug-resistant TB, who were treated with second-line TB therapy for 2 years and then followed for an additional 6 months. CT scans were read semiquantitatively by radiologists and were computationally evaluated using custom software to provide volumetric assessment of TB-associated abnormalities. CT scans at 6 months (but not 2 months) assessed by radiologist readers were predictive of outcomes, and changes in computed abnormal volumes were predictive of drug response at both time points. Quantitative changes in FDG uptake 2 months after starting treatment were associated with long-term outcomes. In this cohort, some radiologic markers were more sensitive than conventional sputum microbiology in distinguishing successful from unsuccessful treatment. These results support the potential of imaging scans as possible surrogate endpoints in clinical trials of new TB drug regimens. Larger cohorts confirming these results are needed.
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Affiliation(s)
- Ray Y Chen
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Lori E Dodd
- Biostatistics Research Branch, NIAID, NIH, Bethesda, MD 20892, USA
| | - Myungsun Lee
- International Tuberculosis Research Center, Changwon 631-710, South Korea
| | - Praveen Paripati
- NET Esolutions Corporation (NETE), NETE-FGI Imaging Team, McLean, VA 22102, USA
| | - Dima A Hammoud
- Division of Diagnostic Radiology, Clinical Center, NIH, Bethesda, MD 20892, USA
| | - James M Mountz
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Doosoo Jeon
- National Masan Hospital, Changwon 631-710, South Korea
| | - Nadeem Zia
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Homeira Zahiri
- Division of Diagnostic Radiology, Clinical Center, NIH, Bethesda, MD 20892, USA
| | - M Teresa Coleman
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Matthew W Carroll
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Jong Doo Lee
- Department of Nuclear Medicine, Yonsei University College of Medicine, Seoul 120-752, South Korea
| | - Yeon Joo Jeong
- Department of Diagnostic Radiology, Pusan National University School of Medicine, Busan 609-735, South Korea
| | | | - Saher Lahouar
- NET Esolutions Corporation (NETE), NETE-FGI Imaging Team, McLean, VA 22102, USA
| | - Michael Tartakovsky
- Office of Cyber Infrastructure and Computational Biology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Alexander Rosenthal
- Office of Cyber Infrastructure and Computational Biology, NIAID, NIH, Bethesda, MD 20892, USA
| | - Sandeep Somaiyya
- NET Esolutions Corporation (NETE), NETE-FGI Imaging Team, McLean, VA 22102, USA
| | - Soyoung Lee
- International Tuberculosis Research Center, Changwon 631-710, South Korea
| | - Lisa C Goldfeder
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Ying Cai
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Laura E Via
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | | | - Sang-Nae Cho
- International Tuberculosis Research Center, Changwon 631-710, South Korea. Department of Microbiology and Institute of Immunology and Immunological Disease, Yonsei University College of Medicine, Seoul 120-752, South Korea
| | - Clifton E Barry
- Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD 20892, USA. Institute of Infectious Disease and Molecular Medicine, and the Department of Clinical Laboratory Sciences, Faculty of Health Sciences, University of Cape Town, Rondebosch 7701, South Africa.
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Determination of [11C]rifampin pharmacokinetics within Mycobacterium tuberculosis-infected mice by using dynamic positron emission tomography bioimaging. Antimicrob Agents Chemother 2015; 59:5768-74. [PMID: 26169396 DOI: 10.1128/aac.01146-15] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/05/2015] [Indexed: 12/14/2022] Open
Abstract
Information about intralesional pharmacokinetics (PK) and spatial distribution of tuberculosis (TB) drugs is limited and has not been used to optimize dosing recommendations for new or existing drugs. While new techniques can detect drugs and their metabolites within TB granulomas, they are invasive, rely on accurate resection of tissues, and do not capture dynamic drug distribution in the tissues of interest. In this study, we assessed the in situ distribution of (11)C-labeled rifampin in live, Mycobacterium tuberculosis-infected mice that develop necrotic lesions akin to human disease. Dynamic positron emission tomography (PET) imaging was performed over 60 min after injection of [(11)C]rifampin as a microdose, standardized uptake values (SUV) were calculated, and noncompartmental analysis was used to estimate PK parameters in compartments of interest. [(11)C]rifampin was rapidly distributed to all parts of the body and quickly localized to the liver. Areas under the concentration-time curve for the first 60 min (AUC0-60) in infected and uninfected mice were similar for liver, blood, and brain compartments (P > 0.53) and were uniformly low in brain (10 to 20% of blood values). However, lower concentrations were noted in necrotic lung tissues of infected mice than in healthy lungs (P = 0.03). Ex vivo two-dimensional matrix-assisted laser desorption ionization (MALDI) imaging confirmed restricted penetration of rifampin into necrotic lung lesions. Noninvasive bioimaging can be used to assess the distribution of drugs into compartments of interest, with potential applications for TB drug regimen development.
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Akhtar MN, Agarwal S, Athar R. Clinico-radiological Approach to a Rare Case of Early Clavicle Tuberculosis: A Case Discussion Based Review of Differential Diagnosis. J Clin Diagn Res 2015; 9:RE01-5. [PMID: 26266175 DOI: 10.7860/jcdr/2015/11971.6079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 04/28/2015] [Indexed: 11/24/2022]
Abstract
A patient of 41 years of age presented with insidious onset atraumatic swelling arising from medial end of right clavicle with apparently normal radiograph. Initial computed tomography ascribed it to benign bony pathology requiring no specific treatment but patient did not respond to symptomatic management. FNAC done elsewhere was inconclusive, with no bacteria on Gram's staining and negative bacterial culture and AFB smear examinations. Patient had possible exposure to tuberculosis and Mantoux skin test done which showed significant induration. Possible differential diagnoses related to clavicle including infective, neoplastic, rheumatological, degenerative and idiopathic conditions considered. Magnetic resonance imaging (MRI) showed focal periosteal reaction with marrow signal changes with sparing of sternoclavicular joint. Correlation between patient's history, clinical findings and investigations done and diagnosis of isolated clavicle tuberculosis was made. Patient showed good response to anti-tubercular chemotherapy. Repeat MRI showed resolution of initial imaging findings. At the end of 2 years patient was completely symptom free.
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Affiliation(s)
- Mohammad Nasim Akhtar
- Assistant Professor, Department of Orthopaedics, ESI PGIMSR, ESIC Medical College and ESIC Hospital , The West Bengal University of Health Sciences, Kolkata (W.B.), India
| | - Sharat Agarwal
- Associate Professor, Department of Orthopaedics, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences , Shillong (Meghalaya), India
| | - Rizwan Athar
- Consultant Pathologist, Haji Abdul Majid Memorial Hospital , Hojai (Assam), India
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Omri HE, Hascsi Z, Taha R, Szabados L, Sabah HE, Gamiel A, Hijji IA. Tubercular Meningitis and Lymphadenitis Mimicking a Relapse of Burkitt's Lymphoma on (18)F-FDG-PET/CT: A Case Report. Case Rep Oncol 2015; 8:226-32. [PMID: 26078742 PMCID: PMC4464102 DOI: 10.1159/000430768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Tuberculosis (TB) can present with various forms and can occasionally be mistaken for malignancy. Hereby, we report a 53-year-old man diagnosed and treated for Burkitt's lymphoma in 2009 who achieved a complete remission confirmed by a computed tomography (CT) scan. During the follow-up 2 years later, he complained of left hip pain that warranted investigation with magnetic resonance imaging and whole-body 18F-fludeoxyglucose-positron emission tomography (FDG-PET)/CT which showed a benign lesion in the left hip associated with multiple lymph nodes in the chest and abdomen not amenable for biopsy. A follow-up PET/CT scan a few months later showed intense tracer uptake in the lymph nodes with size progression and appearance of new lymph nodes suspicious of lymphoma relapse. The patient was asymptomatic, and all investigations including viral and connective tissue disease studies were negative. Also the tuberculin skin test and QuantiFERON were negative. Lymph node biopsy was planned; however, the patient presented a few days earlier with fever, headache and photophobia. Cerebrospinal fluid (CSF) examination confirmed meningitis with lymphocytic pleocytosis and elevated protein. The CSF Gram stain, culture, viral and acid-fast bacilli were negative. CSF flow cytometry and cytopathology confirmed polyclonal lymphocytosis and suggested reactive causes. CSF TB culture grew Mycobacterium tuberculosis. Mediastinal lymph node biopsy also confirmed TB lymphadenitis. Four antituberculosis drugs were started. One year later, a PET/CT scan showed regression of all the involved lymph nodes. This case highlights the importance of excluding TB in patients with suspected malignancy, especially if they belong to endemic regions, and the increasing role of 18F-FDG-PET/CT in the early detection of extrapulmonary TB.
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Affiliation(s)
- Halima El Omri
- Department of Medical Oncology, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
| | - Zsolt Hascsi
- Department of PET/CT, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
| | - Ruba Taha
- Department of Medical Oncology, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
| | - Lajos Szabados
- Department of PET/CT, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
| | - Hesham El Sabah
- Department of Medical Oncology, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
| | - Amna Gamiel
- Department of Medical Oncology, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Al Hijji
- Department of PET/CT, National Center for Cancer Care & Research, Hamad Medical Corporation, Doha, Qatar
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Braquet P, Baptista G, Ilonca DA, Roubille F, Le Moing V, Jeandel C. FDG-PET in a myocardial tuberculoma. Age Ageing 2015; 44:173-4. [PMID: 25331974 DOI: 10.1093/ageing/afu147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pierre Braquet
- Centre Balmes-Geriatrics, CHU Montpellier, 39, Avenue Charles Flahaut, F-34295 Montpellier Cedex 5, France
| | - Gregory Baptista
- Department of Geriatrics, CHU Montpellier, Montpellier 34000, France
| | | | - François Roubille
- Department of Cardiology and Cardiovascular Medicine, CHU Montpellier, Montpellier, France
| | - Vincent Le Moing
- Department of Infectious Diseases and Tropical Medicine, CHU Montpellier, Montpellier, France
| | - Claude Jeandel
- Department of Geriatrics, University Hospital of Montpellier, Montpellier, France
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Revest M, Patrat-Delon S, Devillers A, Tattevin P, Michelet C. Contribution of 18fluoro-deoxyglucose PET/CT for the diagnosis of infectious diseases. Med Mal Infect 2014; 44:251-60. [DOI: 10.1016/j.medmal.2014.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 02/03/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
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