Comparing cardiac MRI and lung PET/CT after completion of tuberculosis treatment – preliminary findings of participants co-enrolled into the StatinTB trial and Cardiac Imaging After TB (CIA-TB) study

Introduction

Mortality rates after successful tuberculosis (TB) treatment remain elevated and healthy survival is impaired by chronic pulmonary disease and persistent inflammation. Inflammation leads to a complex cascade of events and has been associated with cardiovascular disease (CVD). Recent epidemiological work described an increased risk of CVD in persons with history of TB.

Aims and objectives

In our ongoing StatinTB trial (NCT04147286), we evaluate safety and efficacy of 40 mg atorvastatin to reduce persistent lung inflammation (PLI) after TB treatment in HIV−/HIV+ adults measured by 18F-FDG-PET/CT. Participants are co-enrolled into the Cardiac Imaging After Tuberculosis (CIA-TB) study. Here we report preliminary findings of participants enrolled into the StatinTB trial and CIA-TB study with the aim to correlate PLI with cardiac magnetic resonance imaging (CMR) parameters.

Methods

Participants with clinical response to TB treatment and a negative sputum culture at 16 weeks were screened at the end of a 24-week course of treatment for drug-sensitive TB. PET/CT was performed on a Philips Gemini TF scanner and analysed using MIM®Software. PLI was defined as total lung glycolysis (TLG) ≥50 SUV·mL (Figure 1). CMR was performed using a 3T Siemens Magnetom Skyra scanner and parameters were derived from the following acquisitions: SSFP cine imaging of the short and long axes, T1 mapping (MOLLI, 5 (3) 3), T2 mapping and late gadolinium enhancement (LGE) imaging. StatinTB trial is conducted according to ICH-GCP.

Results

26 participants (mean age 37.8±13.8 years, 38.5% women) underwent PET/CT and CMR. 23.1% were infected with HIV, 34.6% smokers, and 26.9% had a previous history of TB. Median BMI was 21.3 (IQR 19.7; 24.3). One participant reported hypertension. Common symptoms at enrollment were cough (26.9%), shortness of breath (11.5%), and chest pain (3.9%). On CT scan, 73.1% had pulmonary nodules, 57.7% scarring, 50.0% cavities, 42.3% bronchiectasis, 19.2% centrilobular disease, 19.2% distorted lung architecture, and 11.5% consolidations. On PET/CT, PLI was detected among 11 (42.3%) participants with a mean TLG of 216.0 (IQR 78.2; 384.0). In a multivariable regression analysis, left ventricular end systolic volume (LVESV) (−1.46; 95% CI: −2.89, −0.23; p=0.047) and distorted lung architecture (2.84; 95% CI: 1.17, 4.52; p=0.003) were significantly associated with TLG. Native T1 relaxation time showed a strong, but not significant association with TLG (15.01; 95% CI: −8.08, 38.10; p=184).

Conclusion

We present data of a young cohort at the end of TB treatment without significant cardiac risk factors. Structural lung disease is affecting at least half of participants, and many remain symptomatic. PLI is present in more than one-third of participants and our preliminary findings suggest an association with cardiac impairment. Further enrolment and ongoing laboratory studies will shed more light into post-TB cardio-pulmonary sequelae.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EDCTP

Efficacy of Single Fixed Dose of Radioiodine (I 131) Therapy in Patients Treated for Hyperthyroidism at Nuclear Medicine Department of Groote Schuur Hospital(GSH)

BACKGROUND

Failure of radioactive iodine therapy (RAI) in patients with hyperthyroidism is not uncommon. A Second dose is usually needed if the first one failed. The purpose of this audit was to determine the efficacy of RAI in patients with hyperthyroidism at Groote Schuur Hospital (GSH).

METHODS

This was a retrospective study. A single observer reviewed the records of all patients who received I131 therapy for hyperthyroidism between 23rd April, 2010 and 23rd November, 2017 in conjunction with their pre- and post-treatment thyroid function tests. Results of their thyroid ultrasound were retrieved and documented. The images of their Tc99m sodium per-technetate thyroid scans were also retrieved and reprocessed. Cure was determined by three consecutive thyroid function tests by euthyroid or hypothyroid status 6 months after therapy.

RESULTS

Of the 353 patients with complete records, 310 (88%) of our patients were females and 43 (12%) were male patients. Majority (200 patients) of the patients were older than 45 years of age, 148 patients were between 15 to 45 years and 5 patients were 5 years and below. 314 patients (89%) achieved cure at some stage after receiving one dose of RAI; 239(76%) achieved cure < 6 months of therapy and 75(24%) patients after 6 months. Patients who failed to achieve cure following the first RAI therapy appeared to be younger (median(interquartile range) age 39(16), p=0.03), had severe hyperthyroidism as demonstrated by higher pre-treatment FT4 (median(interquartile range) 27 pmol/L(30.6), p= 0.05) and high pertechnetate uptake (median(interquartile range) uptake 9.9%(14), p= 0.002) on thyroid scintigraphy.

CONCLUSION

Our audit showed cure rate was 68% at 6 month and 89% at a year. A second dose was indicated in 32% of patients. Patients presenting with severe thyrotoxicity are likely to require more than one RAI therapy. Further researches are suggested to find out if pre-treatment with antithyroid drugs would influence efficacy of RAI in patients with severe thyrotoxicity and would a one year follow up after radioiodine therapy be considered before second RAI.

The College of Nuclear Physicians of South Africa Practice Guidelines on Peptide Receptor Radionuclide Therapy in Neuroendocrine Tumours

BACKGROUND

Peptide receptor radionuclide therapy (PRRT) for metastatic or inoperable neuroendocrine tumours (NETs) is a systemic therapy which targets somatostatin receptors overexpressed by differentiated NETs for endoradiotherapy. This guideline has been compiled by the College of Nuclear Physicians of the Colleges of Medicine of South Africa, with endorsement by the South African Society of Nuclear Medicine and the Association of Nuclear Physicians to guide Nuclear Medicine Physicians in its application during the management of these patients.

RECOMMENDATIONS

Patients with well- to moderately-differentiated NETs should be comprehensively worked-up to determine their suitability for PRRT. Treatment should be administered by a Nuclear Medicine Physician in a licensed, appropriately equipped and fully staffed facility. Patient monitoring is mandatory during and after each therapy cycle to identify and treat therapy-related adverse events. Patients should also be followed-up after completion of therapy cycles for monitoring of long-term toxicities and response assessment.

CONCLUSION

PRRT is a safe and effective therapy option in patients with differentiated NETs. Its use in appropriate patients is associated with a survival benefit.

Pregnancy in systemic lupus erythematosus: a retrospective study from a developing community

Little data exists from the developing world on pregnancy in systemic lupus erythematosus (SLE). A 10-year review of pregnancies in lupus patients was conducted at a tertiary hospital in a developing country. Forty-seven pregnancies in 31 patients were identified. Eleven (23%) booked after 20 weeks gestation. There were no maternal deaths; six (13%) mothers experienced flares-all mild. Twelve women developed preeclampsia of which one experienced an intrauterine death. One patient was diagnosed with lupus and nephritis during pregnancy. She required an abortion to control the disease. Another with active nephritis delivered a normal but premature infant despite cyclophosphamide therapy. There was only minor deterioration in renal function. There were 36 (77%) live births, 8 first trimester abortions, 2 elective abortions and 1 still birth. Fourteen (39%) of live births were premature, and five (14%) experienced intrauterine growth retardation (IUGR). Two live-born babies experienced neonatal heartblock, and one, a neonatal lupus rash. We discuss these finding in relation to risk factors and to results from the developed world.