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Wong A, Sharma A, Ramcharitar R. Cardiovascular manifestations of Erdheim-Chester disease: A narrative review with two cases. Vasc Med 2024; 29:313-319. [PMID: 38469821 DOI: 10.1177/1358863x241228271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
Erdheim-Chester disease (ECD) is a rare 'L' (Langerhans) group histiocytic neoplasm that affects a multitude of organ systems, causing osteosclerotic bone lesions, periaortic encasement ('coated' aorta), retroperitoneal fibrosis involving kidneys and ureters ('hairy kidney'), and infiltration of the central nervous system. Cardiovascular involvement can occur in up to 70% of patients and is usually found during computed tomography/magnetic resonance imaging evaluation. When present, cardiovascular symptoms can have wide variability in presentation from asymptomatic to pericarditis, fatal cardiac tamponade, myocardial infarction, conduction abnormalities, heart failure, renal artery stenosis, and claudication. Cardiac involvement found on imaging includes right atrial pseudotumor, right atrioventricular groove infiltration, and pericardial effusions. ECD can involve the large- and medium-sized arteries, often seen as periarterial thickening (commonly coating the aorta) with stenosis/occlusion. Although more cardiovascular ECD cases have begun to be published in the literature, more data are needed on the outcomes of these patients, as well as how cardiovascular manifestations respond to treatment of ECD.
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Affiliation(s)
- Alan Wong
- Department of Vascular Medicine, Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aditya Sharma
- Department of Vascular Medicine, Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Randy Ramcharitar
- Department of Vascular Medicine, Division of Cardiovascular Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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2
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van der Geest KSM, Sandovici M, Bley TA, Stone JR, Slart RHJA, Brouwer E. Large vessel giant cell arteritis. THE LANCET. RHEUMATOLOGY 2024; 6:e397-e408. [PMID: 38574745 DOI: 10.1016/s2665-9913(23)00300-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 04/06/2024]
Abstract
Giant cell arteritis is the principal form of systemic vasculitis affecting people over 50. Large-vessel involvement, termed large vessel giant cell arteritis, mainly affects the aorta and its branches, often occurring alongside cranial giant cell arteritis, but large vessel giant cell arteritis without cranial giant cell arteritis can also occur. Patients mostly present with constitutional symptoms, with localising large vessel giant cell arteritis symptoms present in a minority of patients only. Large vessel giant cell arteritis is usually overlooked until clinicians seek to exclude it with imaging by ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), or [18F]fluorodeoxyglucose-PET-CT. Although the role of imaging in treatment monitoring remains uncertain, imaging by MRA or CTA is crucial for identifying aortic aneurysm formation during patient follow up. In this Series paper, we define the large vessel subset of giant cell arteritis and summarise its clinical challenges. Furthermore, we identify areas for future research regarding the management of large vessel giant cell arteritis.
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Affiliation(s)
- Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thorsten A Bley
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University Hospital Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - James R Stone
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Netherlands; Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Gheysens O, de Ponfilly MP, Nocturne G, Seror R, Besson FL, Jamar F. [ 18F]FDG-PET/CT in Polymyalgia Rheumatica: An Update and Future Aspects. Semin Nucl Med 2024; 54:371-378. [PMID: 38030423 DOI: 10.1053/j.semnuclmed.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023]
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory disorder usually diagnosed in patients older than 50 years of age. It is characterized by sudden onset pain and prolonged morning stiffness in the scapular and/or pelvic girdle, sometimes debilitating and accompanied by constitutional symptoms such as weight loss. In approximately 20% of the cases, it is linked to giant cell arteritis (GCAV) representing a disease continuum. The diagnosis is mainly clinical and noninvasive imaging such as ultrasound of joints may be helpful. In atypical PMR cases, whole body imaging using [18F]FDG-PET/CT may be useful. First, to confirm or rule out the diagnosis of PMR, secondly, to assess the coexistence of a GCA, and thirdly to establish the differential diagnosis with other types of arthritides encountered in this age group, such as elderly-onset rheumatoid arthritis, spondyloarthropathies, crystal-induced arthropathies or the rare remittent seronegative symmetrical synovitis with pitting edema. Relatively typical patterns of [18F]FDG-PET/CT are well known, based on the clinical distribution of the disease (eg, scapular and pelvic girdle, interspinous bursae, sterno-costoclavicular joints, entheses), especially the hypermetabolism at the interspinous lumbar bursae that has shown the best post-test likelihood ratio in a meta-analysis. This article focuses on the differential diagnosis and on the visual and semi-quantitative tools that can be used to guide to the correct diagnosis of PMR as an add-on to the clinical picture. Further, we briefly discuss the options that can improve molecular imaging in the future for inflammatory rheumatisms in elderly.
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Affiliation(s)
- Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires St-Luc and Institute for Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Marie Péan de Ponfilly
- Department of Rheumatology, Hôpital Bicêtre Assistance Publique -Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Gaetane Nocturne
- Department of Rheumatology, Hôpital Bicêtre Assistance Publique -Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Raphaële Seror
- Department of Rheumatology, Université Paris-Saclay, INSERM U1184: Centre for Immunology of Viral Infections and Autoimmune Diseases, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin Bicêtre, Paris, France
| | - Florent L Besson
- Department of Nuclear Medicine-Molecular Imaging, Hôpitaux Universitaire Paris-Saclay, AP-HP, DMU SMART IMAGING, CHU Bicêtre Le Kremlin-Bicêtre, France; Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, Paris, France; Université Paris-Saclay, Commissariat à l'énergie atomique et aux énergies alternatives (CEA), Centre National de la Recherche Scientifique (CNRS), Inserm, BioMaps, Le Kremlin-Bicêtre, France
| | - François Jamar
- Department of Nuclear Medicine, Cliniques Universitaires St-Luc and Institute for Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium.
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Liu B, Ma R, Shum E, Hormiz M, Lee ST, Poon AMT, Scott AM. FDG-PET/CT for investigation of pyrexia of unknown origin: a cost of illness analysis. Eur J Nucl Med Mol Imaging 2024; 51:1287-1296. [PMID: 38057651 DOI: 10.1007/s00259-023-06548-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 11/26/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Our study aims to explore the current utilisation of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in the diagnostic pathway of pyrexia of unknown origin (PUO) and associated cost of illness in a large tertiary teaching hospital in Australia. METHOD 1257 febrile patients between June 2016 and September 2022 were retrospectively reviewed. There were 57 patients who met the inclusion criteria of "classical PUO", of which FDG-PET/CT was performed in 31 inpatients, 15 outpatients and 11 inpatients did not have an FDG-PET/CT scan. The patient demographics, clinical characteristics and inpatient cost were analysed, together with the diagnostic performance of FDG-PET/CT and impact on clinical management. RESULT The mean age, length of stay and total cost of admission were higher for inpatients who received FDG-PET/CT versus those who did not. The median cost per patient-bed-day did not differ between the two groups. Inpatients who received earlier FDG-PET/CTs (≤ 7 days from admission) had shorter length of stays and lower total cost compared to those who received a later scan. A negative FDG-PET/CT scan, demonstrating no serious or life-threatening abnormalities resulted in subsequent discharge from hospital or outpatient clinic in 7/10 (70%) patients. There were 11/40 (28%) scans where ancillary abnormalities were identified, requiring further evaluation. CONCLUSION FDG-PET/CT showed high diagnostic accuracy and significant impact on patient management in patients with PUO. FDG-PET/CT performed earlier in admission for PUO was associated with shorter length of stay and lower total cost.
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Affiliation(s)
- Bonnia Liu
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia.
- Department of Rheumatology, Austin Health, Melbourne, VIC, Australia.
- Department of Nuclear Medicine, Royal Melbourne Hospital, 300 Grattan St, Melbourne, VIC, Australia.
| | - Ronald Ma
- Department of Finance, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Evonne Shum
- Department of General Medicine, Austin Health, Melbourne, VIC, Australia
| | - Maria Hormiz
- Department of General Medicine, Austin Health, Melbourne, VIC, Australia
| | - Sze-Ting Lee
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia
- La Trobe University, Melbourne, VIC, Australia
| | - Aurora M T Poon
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Andrew M Scott
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia
- La Trobe University, Melbourne, VIC, Australia
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Bengel FM, Di Carli MF. The Evolution of Cardiac Nuclear Imaging. J Nucl Med 2023; 64:1S-2S. [PMID: 37918847 DOI: 10.2967/jnumed.123.266845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023] Open
Affiliation(s)
- Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany; and
| | - Marcelo F Di Carli
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Knappe L, Bregenzer C, Gözlügöl N, Mingels C, Alberts I, Rominger A, Caobelli F. New thresholds in semi-quantitative [ 18F]FDG PET/CT are needed to assess large vessel vasculitis with long-axial field-of-view scanners. Eur J Nucl Med Mol Imaging 2023; 50:3890-3896. [PMID: 37676501 PMCID: PMC10611821 DOI: 10.1007/s00259-023-06423-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023]
Abstract
AIM [18F]FDG PET/CT proved accurate in the diagnostic work-up of large vessel vasculitis (LVV). While a visual interpretation is currently considered adequate, several attempts have been made to integrate it with a semiquantitative evaluation. In this regard, there is the need to validate current or new thresholds for the semiquantitative parameters on long-axial field of view (LAFOV) scanners. METHODS We retrospectively evaluated 100 patients (50 with LVV and 50 controls) who underwent [18F]FDG LAFOV PET/CT. Semiquantitative parameters (SUVmax and SUVmean) were calculated for large vessels in 3 districts (supra-aortic [SA], thoracic aorta [TA], and infra-aortic [IA]). Values were also normalized to liver activity (SUVmax/L-SUVmax, and SUVmax/L-SUVmean). RESULTS Of the 50 patients diagnosed with LVV, SA vessels were affected in 38 (76%), TA in 42 (84%) and IA vessels in 26 (52%). To-liver normalized values had higher diagnostic accuracy than non-normalized values (AUC always ≥ 0.90 vs. 0.74-0.89). For the SA vessels, best thresholds were 0.66 for SUVmax/L-SUVmax and 0.88 for SUVmax/L-SUVmean; for the TA, 1.0 for SUVmax/L-SUVmax and 1.30 for SUVmax/L-SUVmean; finally, for IA vessels, the best threshold was 0.83 for SUVmax/L-SUVmax and 1.11 for SUVmax/L-SUVmean. CONCLUSION LAFOV [18F]FDG-PET/CT is accurate in the diagnostic workup of LVV, but different threshold in semi-quantitative parameters than reported in literature for standard scanners should be considered.
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Affiliation(s)
- Luisa Knappe
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland
| | - Carola Bregenzer
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland
| | - Nasir Gözlügöl
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland
| | - Clemens Mingels
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland
| | - Ian Alberts
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland
| | - Federico Caobelli
- Department of Nuclear Medicine, Inselspital, University Hospital Bern, University of Bern, Freiburgstrasse 18, 3011, Bern, Switzerland.
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Espígol-Frigolé G, Dejaco C, Mackie SL, Salvarani C, Matteson EL, Cid MC. Polymyalgia rheumatica. Lancet 2023; 402:1459-1472. [PMID: 37832573 DOI: 10.1016/s0140-6736(23)01310-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 06/04/2023] [Accepted: 06/22/2023] [Indexed: 10/15/2023]
Abstract
Polymyalgia rheumatica is an inflammatory disease producing pain and stiffness, mainly in the shoulders and pelvic girdle, in people older than 50 years. Elevation of acute phase reactants is common due to the inflammatory nature of the disease. Since there are no specific diagnostic tests, diagnosis requires the exclusion of other diseases with similar presentations. Imaging has helped to identify the pathological substrate of polymyalgia rheumatica and it is increasingly used to support clinical diagnosis or to detect coexistent giant cell arteritis. Although polymyalgia rheumatica does not clearly impair survival or organ function, it can have a detrimental effect on quality of life. Glucocorticoids at 12·5-25·0 mg prednisone per day are effective in inducing remission in most individuals but, when tapered, relapses occur in 40-60% of those affected and side-effects are common. Assessment of disease activity can be difficult because pain related to common comorbidities such as osteoarthritis and tendinopathies, can return when glucocorticoids are reduced, and acute phase reactants are increased less during flares in individuals undergoing treatment or might increase for other reasons. The role of imaging in assessing disease activity is not yet completely defined. In the search for more efficient and safer therapies, tocilizumab and sarilumab have shown efficacy in randomised controlled trials and additional targeted therapies are emerging. However, judicious risk-benefit balance is essential in applying therapeutic innovations to people with polymyalgia rheumatica.
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Affiliation(s)
- Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Christian Dejaco
- Department of Rheumatology, Medical University Graz, Graz, Austria; Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy; Azienda Ospedaliera-Universitaria di Modena, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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