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Buchrits S, McNeil R, Avni T, Fredman D, Guz D, Gafter-Gvili A. The Contribution of 18F FDG PET-CT for the Investigation of Fever of Unknown Origin and Inflammation of Unknown Origin. Am J Med 2024:S0002-9343(24)00174-8. [PMID: 38499136 DOI: 10.1016/j.amjmed.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Fever of unknown origin and inflammation of unknown origin are highly challenging diagnostic conditions. The current practice for evaluating patients is to conduct a positron emission tomography-computed tomography (PET-CT) scan as either a first- or a second-line modality. We aimed to assess the contributory effect of PET-CT to the diagnosis and compare it with the contributory effect of CT alone. METHODS We performed a systematic review and meta-analysis. We included all cohorts that examined the contribution of PET-CT to the investigation of classical fever of unknown origin and inflammation of unknown origin. The primary outcome was the contribution of PET-CT to the final diagnosis. Secondary outcomes were sensitivity and specificity of PET-CT and CT scans, and contribution of a CT scan. We pooled the results of all studies and calculated the pooled contributory effect of PET-CT. RESULT Thirty-six studies (3516 patients) were included in the systematic review. The pooled contribution of PET-CT was 75.4%. The compiled sensitivity and specificity values for all studies were 85.9% and 59.5%, respectively. Five studies (405 patients) compared between the PET-CT component and the total body CT component. The pooled contribution of a CT scan was 68%. The summed sensitivity and specificity values of a CT scan for all studies were 63.1% and 84.4%, respectively. CONCLUSIONS PET-CT has a contributory effect of 75% for the diagnosis of fever of unknown origin and inflammation of unknown origin. PET-CT had superior sensitivity and inferior specificity vs the CT scan.
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Affiliation(s)
- Shira Buchrits
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Rotem McNeil
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Tomer Avni
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Danielle Fredman
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dmitri Guz
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Anat Gafter-Gvili
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel
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Wright WF, Betrains A, Stelmash L, Mulders-Manders CM, Rovers CP, Vanderschueren S, Auwaerter PG. Development of a Consensus-Based List of Potential Quality Indicators for Fever and Inflammation of Unknown Origin. Open Forum Infect Dis 2024; 11:ofad671. [PMID: 38333881 PMCID: PMC10853001 DOI: 10.1093/ofid/ofad671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/22/2023] [Indexed: 02/10/2024] Open
Abstract
With a growing emphasis on value-based reimbursement, developing quality indicators for infectious diseases has gained attention. Quality indicators for fever of unknown origin and inflammation of unknown origin are lacking. An assembled group of international experts developed 12 quality measures for these conditions, which could be validated with additional study.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Albrecht Betrains
- General Internal Medicine Department, University Hospitals Leuven, Leuven, Belgium
| | - Lauren Stelmash
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Catharina M Mulders-Manders
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Chantal P Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Steven Vanderschueren
- General Internal Medicine Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, Laboratory of Clinical Infectious and Inflammatory Disorders, KU Leuven, Leuven, Belgium
| | - Paul G Auwaerter
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Palestro CJ, Brandon DC, Dibble EH, Keidar Z, Kwak JJ. FDG PET in Evaluation of Patients With Fever of Unknown Origin: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023; 221:151-162. [PMID: 36722759 DOI: 10.2214/ajr.22.28726] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fever of unknown origin (FUO) is a diagnostic challenge, with its cause remaining undiagnosed in approximately half of patients. Nuclear medicine tests typically are performed after a negative or inconclusive initial workup. Gallium-67 citrate and labeled leukocytes were previous mainstays of radionuclide imaging for FUO, although they had limited diagnostic performance. FDG PET/CT has subsequently emerged as the nuclear medicine imaging test of choice, supported by a growing volume of evidence. A positive FDG PET/CT result contributes useful information by identifying potential causes of fever, localizing sites for further evaluation, and guiding further management; a negative result contributes useful information by excluding focal disease as the cause of fever and predicts a favorable prognosis. In 2021, CMS rescinded a prior national noncoverage determination for FDG PET for infection and inflammation, leading to increasing national utilization of FDG PET/CT for FUO workup. This article reviews the current status of the role of FDG PET/CT in the evaluation of patients with FUO. The literature reporting the diagnostic performance and yield of FDG PET/CT in FUO workup is summarized, with comparison with historically used nuclear medicine tests included. Attention is also given to the test's clinical impact; protocol, cost, and radiation considerations; and application in children.
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Affiliation(s)
- Christopher J Palestro
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
- Division of Nuclear Medicine & Molecular Imaging, Northwell Health, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040
| | - David C Brandon
- Department of Radiology, Division of Nuclear Medicine, Emory University School of Medicine, Atlanta VA Medical Center, Atlanta, GA
| | - Elizabeth H Dibble
- Department of Diagnostic Imaging, The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Jennifer J Kwak
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, University of Colorado Anschutz Medical Campus, Aurora, CO
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Holubar J, Broner J, Arnaud E, Hallé O, Mura T, Chambert B, Sotto A, Roubille C, Gaujoux-Viala C, Goulabchand R. Diagnostic performance of 18 F-FDG-PET/CT in inflammation of unknown origin: A clinical series of 317 patients. J Intern Med 2022; 291:856-863. [PMID: 35018669 DOI: 10.1111/joim.13452] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Inflammation of unknown origin (IUO) is a challenging situation in internal medicine. OBJECTIVES To describe the final diagnoses in IUO and assess the helpfulness of 18 F-fluorodesoxyglucose positron emission tomography with computerized tomography (18 F-FDG-PET/CT) in the diagnosis strategy. RESULTS A total of 317 IUO patients with 18 F-FDG-PET/CT were enrolled. A diagnosis was reached in 228 patients: noninfectious inflammatory diseases (NIID) (37.5%), infectious diseases (18.6%), malignancies (7.9%), and non-systemic-inflammatory miscellaneous diseases (7.9%). The two leading causes of NIID were polymyalgia rheumatica and giant cell arteritis. 18 F-FDG-PET/CT results were classified as true positive in 49.8% of patients and contributory in 75.1% of overall IUO patients (after the complete investigation set and a prolonged follow-up). In multivariate analysis, only C-reactive protein minimum level (≥50 mg/L) was associated with the contributory status of 18 F-FDG-PET/CT. CONCLUSION Within the wide spectrum of IUO underlying diseases, 18 F-FDG-PET/CT is helpful to make a diagnosis and to eliminate inflammatory diseases. Obese patients constitute a specific group needing further studies.
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Affiliation(s)
- Jan Holubar
- Internal Medicine Department, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Jonathan Broner
- Internal Medicine Department, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Erik Arnaud
- Internal Medicine Department, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Olivier Hallé
- Internal Medicine Department 2, CH Ales-Cevennes, Ales, France
| | - Thibault Mura
- Department of Biostatistics, Clinical Epidemiology, Public Health, and Innovation in Methodology, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Benjamin Chambert
- Department of Nuclear Medicine, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Albert Sotto
- Department of Infectious and Tropical Diseases, CHU Nîmes, University of Montpellier, Nîmes, France
| | - Camille Roubille
- Department of Internal Medicine, Lapeyronie Hospital, Montpellier University Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Cecile Gaujoux-Viala
- Department of Rheumatology, CHU Nîmes, Nîmes, France.,University of Montpellier, INSERM UA11 Institut Desbrest d'Épidémiologie et de Santé Publique, Montpellier, France
| | - Radjiv Goulabchand
- Internal Medicine Department, CHU Nîmes, University of Montpellier, Nîmes, France.,IRMB, University of Montpellier, INSERM, Montpellier, France
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Öğüt TS, Erbasan F, Terzioğlu ME, Tazegul G, Yazısız V. The Diagnostic Value of Fluoro-18 Fluorodeoxyglucose (F-18 FDG) PET/CT in Fever or Inflammation of Unknown Origin: A Retrospective Study at a Rheumatology Clinic. Cureus 2022; 14:e24192. [PMID: 35592192 PMCID: PMC9110075 DOI: 10.7759/cureus.24192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Further diagnostic procedures are necessary for patients with fever of unknown origin (FUO) and unknown cause of inflammation (inflammation of unknown origin - IUO) for the identification of the definitive diagnosis. The aim of this study was to evaluate the contribution and roles of F-18 FDG PET/CT (fluoro-18 fluorodeoxyglucose-positron emission tomography/computed tomography) in the diagnostic process of patients with FUO/IUO. Methods The data of 58 patients who had F-18 FDG PET/CT scans for FUO/IUO were re-evaluated retrospectively. The relationships between definitive diagnosis and fluorodeoxyglucose uptake and SUVmax (maximum standardized uptake value) were examined. Results Rheumatic disease was diagnosed in 26 patients (44.5%), malignancy in 20 patients (34.5%), and infectious diseases in six patients (10.3%). The most prevalent rheumatic disease in patients with FUO/IUO was systemic vasculitis (n:10, 17.2%), especially large vessel vasculitis. There were 37 patients (63.7%) with clinically significant true positive fluorodeoxyglucose uptake. True positive fluorodeoxyglucose uptake was significantly higher in patients diagnosed with malignancy (85%, 17/20 patients) compared to other diagnoses. Fluorodeoxyglucose uptake above physiological levels was determined in 15 of the 26 patients (57.6%) diagnosed with rheumatic diseases. Conclusion The results of this study showed that F-18 FDG PET/CT is a useful imaging modality in FUO/IUO patients, who present a challenging diagnostic process for clinicians. In addition to malignancies, the presence of chronic inflammatory diseases, especially early period systemic vasculitis, were diagnosed in these patients.
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Affiliation(s)
| | | | | | - Gokhan Tazegul
- Internal Medicine, Ankara Polatlı Duatepe State Hospital, Ankara, TUR
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Béra S, Jamilloux Y, Gerfaud-Valentin M, Durupt S, Nove-Josserand R, Lega JC, Durieu I, Hot A, Sève P. Inflammation of Unknown Origin: Evaluation and Prognosis of 57 Cases. J Clin Med 2021; 11:jcm11010032. [PMID: 35011773 PMCID: PMC8745449 DOI: 10.3390/jcm11010032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/07/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022] Open
Abstract
(1) Background: there are few studies on the inflammation of unknown origin (IUO). We sought to determine the etiologies and prognosis of IUO, as well as the contribution of complementary examinations. (2) Methods: this retrospective study analyzed patients meeting the Vanderschueren’s criteria in the Hospices Civils de Lyon from 2005 to 2020. (3) Results: a total of 57 patients (mean age: 67 years; interquartile range: 55–79) were included. Final diagnoses were made for 26 (46%) patients. Non-infectious inflammatory diseases were the most common diagnoses (13/26, 50%), followed by neoplasms (10/26, 38%; 8/10 hematological malignancies), infections (2/26, 8%), and miscellaneous causes (1/26, 4%). Moreover, 18-FDG-PET/CT was contributory in 12/42 cases. Anti-neutrophil cytoplasmic antibodies, serology, temporal biopsies, and bone marrow aspirates were contributory in 3/41, 1/57, 5/23, and 3/19 cases, respectively. At last follow-up (mean follow-up duration: 48 months), 8/31 undiagnosed patients were cured (five received an empirical treatment), and 5/31 died (one death was related to the empirical treatment). (4) Conclusion: more than half of the IUO remained undiagnosed. Non-infectious inflammatory diseases and hematological malignancies were the most common etiologies. Moreover, 18-FDG-PET/CT had the highest diagnostic value. Most IUO without final diagnosis persisted. The role of empirical treatments remains to be explored.
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Affiliation(s)
- Suzanne Béra
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (S.B.); (Y.J.); (M.G.-V.)
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (S.B.); (Y.J.); (M.G.-V.)
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Lyon Immunology Federation (LIFE), 69000 Lyon, France
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (S.B.); (Y.J.); (M.G.-V.)
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
| | - Stéphane Durupt
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Department of Internal Medicine, Hôpital Lyon-Sud, Hospices Civils de Lyon, 69310 Pierre-Benite, France
| | - Raphaèle Nove-Josserand
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Department of Internal Medicine, Hôpital Lyon-Sud, Hospices Civils de Lyon, 69310 Pierre-Benite, France
| | - Jean-Christophe Lega
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Department of Internal Medicine, Hôpital Lyon-Sud, Hospices Civils de Lyon, 69310 Pierre-Benite, France
| | - Isabelle Durieu
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Department of Internal Medicine, Hôpital Lyon-Sud, Hospices Civils de Lyon, 69310 Pierre-Benite, France
| | - Arnaud Hot
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Department of Internal Medicine, Hôpital Edouard-Herriot, Hospices Civils de Lyon, 69003 Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 69004 Lyon, France; (S.B.); (Y.J.); (M.G.-V.)
- Université Claude Bernard Lyon 1, 69000 Lyon, France; (S.D.); (R.N.-J.); (J.-C.L.); (I.D.); (A.H.)
- Research on Healthcare Performance (RESHAPE), Université Claude Bernard Lyon 1, INSERM U1290, 69003 Lyon, France
- Correspondence:
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Kan Y, Wang W, Liu J, Yang J, Wang Z. Contribution of 18F-FDG PET/CT in a case-mix of fever of unknown origin and inflammation of unknown origin: a meta-analysis. Acta Radiol 2019; 60:716-725. [PMID: 30205705 DOI: 10.1177/0284185118799512] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are challenging medical problems. Previous studies have shown that 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) plays an important role in the diagnosis of FUO, but few studies have explored this diagnostic technique in relation to IUO. PURPOSE To systematically review and perform a meta-analysis of published data on the diagnostic performance of PET/CT in the diagnosis of FUO and IUO. MATERIAL AND METHODS A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines published in March 2018. Meta-analysis of diagnostic performance was performed using STATA 12.0 software. Subgroup analysis was performed by stratification based on study design, number of patients, geographic area, and final diagnosis based on 18F-FDG PET/CT. Meta-regression analyses were performed to recognize heterogeneity. RESULTS Our meta-analysis included 23 studies, comprising a total sample size of 1927 patients. The pooled diagnosis performance was calculated with a per-patient-based analysis: sensitivity = 0.84 (95% confidence interval [CI] = 0.79-0.89), specificity = 0.63 (95% CI = 0.49-0.75), positive likelihood ratio = 2.3 (95% CI = 1.5-3.4), negative likelihood ratio = 0.25 (95% CI = 0.16-0.38), diagnostic odds ratio = 9 (95% CI = 4.0-20), and AUC = 0.84 (95% CI = 0.81-0.87). CONCLUSION In patients with non-specific symptoms and signs, 18F-FDG PET/CT is very helpful for recognizing and excluding diseases, directing further diagnostic decisions, and avoiding unnecessary invasive examinations. We recommend that 18F-FDG PET/CT should be considered among the first-line diagnostic tools for patients with FUO and IUO.
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Affiliation(s)
- Ying Kan
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Wei Wang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Jie Liu
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
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Kan Y, Wang W, Liu J, Yang J, Wang Z. Contribution of 18F-FDG PET/CT in a case-mix of fever of unknown origin and inflammation of unknown origin: a meta-analysis. Acta Radiol 2019; 60:716-725. [PMID: 30205705 DOI: 10.1177/028418511879951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are challenging medical problems. Previous studies have shown that 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) plays an important role in the diagnosis of FUO, but few studies have explored this diagnostic technique in relation to IUO. PURPOSE To systematically review and perform a meta-analysis of published data on the diagnostic performance of PET/CT in the diagnosis of FUO and IUO. MATERIAL AND METHODS A comprehensive literature search was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines published in March 2018. Meta-analysis of diagnostic performance was performed using STATA 12.0 software. Subgroup analysis was performed by stratification based on study design, number of patients, geographic area, and final diagnosis based on 18F-FDG PET/CT. Meta-regression analyses were performed to recognize heterogeneity. RESULTS Our meta-analysis included 23 studies, comprising a total sample size of 1927 patients. The pooled diagnosis performance was calculated with a per-patient-based analysis: sensitivity = 0.84 (95% confidence interval [CI] = 0.79-0.89), specificity = 0.63 (95% CI = 0.49-0.75), positive likelihood ratio = 2.3 (95% CI = 1.5-3.4), negative likelihood ratio = 0.25 (95% CI = 0.16-0.38), diagnostic odds ratio = 9 (95% CI = 4.0-20), and AUC = 0.84 (95% CI = 0.81-0.87). CONCLUSION In patients with non-specific symptoms and signs, 18F-FDG PET/CT is very helpful for recognizing and excluding diseases, directing further diagnostic decisions, and avoiding unnecessary invasive examinations. We recommend that 18F-FDG PET/CT should be considered among the first-line diagnostic tools for patients with FUO and IUO.
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Affiliation(s)
- Ying Kan
- 1 Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Wei Wang
- 1 Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Jie Liu
- 1 Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Jigang Yang
- 1 Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Zhenchang Wang
- 2 Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
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Schönau V, Vogel K, Englbrecht M, Wacker J, Schmidt D, Manger B, Kuwert T, Schett G. The value of 18F-FDG-PET/CT in identifying the cause of fever of unknown origin (FUO) and inflammation of unknown origin (IUO): data from a prospective study. Ann Rheum Dis 2017; 77:70-77. [PMID: 28928271 DOI: 10.1136/annrheumdis-2017-211687] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 08/24/2017] [Accepted: 09/08/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are diagnostically challenging conditions. Diagnosis of underlying disease may be improved by 18F-fluorodesoxyglucose positron emission tomography (18F-FDG-PET). METHODS Prospective study to test diagnostic utility of 18F-FDG-PET/CT in a large cohort of patients with FUO or IUO and to define parameters that increase the likelihood of diagnostic 18F-FDG-PET/CT. Patients with FUO or IUO received 18F-FDG-PET/CT scanning in addition to standard diagnostic work-up. 18F-FDG-PET/CT results were classified as helpful or non-helpful in establishing final diagnosis. Binary logistic regression was used to identify clinical parameters associated with a diagnostic 18F-FDG-PET/CT. RESULTS 240 patients were enrolled, 72 with FUO, 142 with IUO and 26 had FUO or IUO previously (exFUO/IUO). Diagnosis was established in 190 patients (79.2%). The leading diagnoses were adult-onset Still's disease (15.3%) in the FUO group, large vessel vasculitis (21.1%) and polymyalgia rheumatica (18.3%) in the IUO group and IgG4-related disease (15.4%) in the exFUO/IUO group. In 136 patients (56.7% of all patients and 71.6% of patients with a diagnosis), 18F-FDG-PET/CT was positive and helpful in finding the diagnosis. Predictive markers for a diagnostic 18F-FDG-PET/CT were age over 50 years (p=0.019), C-reactive protein (CRP) level over 30 mg/L (p=0.002) and absence of fever (p=0.001). CONCLUSION 18F-FDG-PET/CT scanning is helpful in ascertaining the correct diagnosis in more than 50% of the cases presenting with FUO and IUO. Absence of intermittent fever, higher age and elevated CRP level increase the likelihood for a diagnostic 18F-FDG-PET/CT.
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Affiliation(s)
- Verena Schönau
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Kristin Vogel
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Jochen Wacker
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Daniela Schmidt
- Clinic of Nuclear Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Bernhard Manger
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Torsten Kuwert
- Clinic of Nuclear Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany
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Bouter C, Braune I, Meller B, Sahlmann C, Ritter C, Meller J. 18F-FDG-PET/CT in unexplained elevated inflammatory markers. Joining entities. Nuklearmedizin 2016; 55:242-249. [PMID: 27617327 DOI: 10.3413/nukmed-0798-16-02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 08/29/2016] [Indexed: 11/20/2022]
Abstract
The diagnostic strategy in patients with fever or inflammation of unknown origin remains a major clinical challenge. The aim of this study was to evaluate the role of 18F-FDG-PET/CT in patients with unexplained elevated C-reactive protein with or without fever. Contribution of 18F-FDG-PET/CT to the final diagnosis was evaluated. In addition we determined whether a differentiation between patients with or without fever is clinically reasonable. PATIENTS, METHODS We retrospectively analysed 72 consecutive patients with unexplained elevated C-reactive protein levels (above 8mg/l) that underwent 18F-FDG-PET/CT in our facility between 10/2009 and 11/2012. 18F-FDG-PET/CT was considered a so-called diagnostic scan when results decisively led to a final diagnosis and adequate therapy with a response of symptoms was initiated due to the PET/CT result. RESULTS In 60/72 patients (83%) a final diagnosis was established. Diagnoses included infections (58%), non-infectious inflammatory diseases (29%) and malignancies (8%). 18F-FDG-PET/CT was true positive in 47 cases (65%) and the diagnostic scan in 29 patients (40%). Sensitivity of 18F-FDG-PET/CT was 81% and specificity was 86%. Diagnostics, final diagnoses, 18F-FDG-PET/CT results, SUVmax, C-reactive protein levels and the diagnostic scan did not differ significantly between patients with fever and patients without fever. CONCLUSION 18F-FDG-PET/CT is a useful method in the diagnostic workup of patients with inflammation of unknown origin. In our series there was no significant difference between patients with or without fever. Regarding 18F-FDG-PET/CT-imaging inflammation of unknown origin and unexplained fever can be joined to one entity.
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Affiliation(s)
- Caroline Bouter
- Caroline Bouter, Department of Nuclear Medicine, Georg-August-University Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany, E-Mail:
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