1
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Wright WF, Kandiah S, Brady R, Shulkin BL, Palestro CJ, Jain SK. Nuclear Medicine Imaging Tools in Fever of Unknown Origin: Time for a Revisit and Appropriate Use Criteria. Clin Infect Dis 2024; 78:1148-1153. [PMID: 38441140 DOI: 10.1093/cid/ciae115] [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: 12/12/2023] [Revised: 02/01/2024] [Accepted: 02/27/2024] [Indexed: 03/28/2024] Open
Abstract
Fever of unknown origin (FUO) is a clinical conundrum for patients and clinicians alike, and imaging studies are often performed as part of the diagnostic workup of these patients. Recently, the Society of Nuclear Medicine and Molecular Imaging convened and approved a guideline on the use of nuclear medicine tools for FUO. The guidelines support the use of 2-18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) in adults and children with FUO. 18F-FDG PET/CT allows detection and localization of foci of hypermetabolic lesions with high sensitivity because of the 18F-FDG uptake in glycolytically active cells that may represent inflammation, infection, or neoplasia. Clinicians should consider and insurers should cover 18F-FDG PET/CT when evaluating patients with FUO, particularly when other clinical clues and preliminary studies are unrevealing.
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Affiliation(s)
- William F Wright
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sheetal Kandiah
- Department of Medicine, Division of Infectious Diseases, Emory University Hospital, Atlanta, Georgia, USA
| | - Rebecca Brady
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Barry L Shulkin
- Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Christopher J Palestro
- Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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2
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I 2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. Heart Rhythm 2024; 21:e1-e29. [PMID: 38466251 DOI: 10.1016/j.hrthm.2024.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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3
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I 2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. J Nucl Cardiol 2024; 34:101786. [PMID: 38472038 DOI: 10.1016/j.nuclcard.2023.101786] [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: 03/14/2024]
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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4
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. Clin Infect Dis 2024:ciae046. [PMID: 38466039 DOI: 10.1093/cid/ciae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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5
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Bourque JM, Birgersdotter-Green U, Bravo PE, Budde RPJ, Chen W, Chu VH, Dilsizian V, Erba PA, Gallegos Kattan C, Habib G, Hyafil F, Khor YM, Manlucu J, Mason PK, Miller EJ, Moon MR, Parker MW, Pettersson G, Schaller RD, Slart RHJA, Strom JB, Wilkoff BL, Williams A, Woolley AE, Zwischenberger BA, Dorbala S. 18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context: ASNC Imaging Indications (ASNC I 2) Series Expert Consensus Recommendations From ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS. JACC Cardiovasc Imaging 2024:S1936-878X(24)00036-6. [PMID: 38466252 DOI: 10.1016/j.jcmg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA, USA.
| | | | - Paco E Bravo
- Divisions of Nuclear Medicine, Cardiothoracic Imaging and Cardiovascular Medicine, Director, Nuclear Cardiology and Cardiovascular Molecular Imaging, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Wengen Chen
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Vasken Dilsizian
- University of Maryland School of Medicine, Department of Diagnostic Radiology and Nuclear Medicine, Baltimore, MD, USA
| | - Paola Anna Erba
- Department of Medicine and Surgery University of Milano Bicocca and Nuclear Medicine, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, Marseille, France
| | - Fabien Hyafil
- Nuclear Cardiology and Nuclear Medicine Department, DMU IMAGINA, Hôpital Européen Georges-Pompidou, University of Paris, Paris, France
| | - Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
| | - Jaimie Manlucu
- London Heart Rhythm Program, Western University, London Health Sciences Centre (University Hospital), London, Ontario, Canada
| | - Pamela Kay Mason
- Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Edward J Miller
- Nuclear Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew W Parker
- Echocardiography Laboratory, Division of Cardiovascular Medicine, University of Massachusetts T.H. Chan School of Medicine, Worcester, MA, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert D Schaller
- Department of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Riemer H J A Slart
- Medical Imaging Centre, Department of Nucleare, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, the Netherlands
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Harvard Medical School, Boston, MA, USA
| | - Bruce L Wilkoff
- Cardiac Pacing & Tachyarrhythmia Devices, Department of Cardiovascular Medicine, Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | | | - Ann E Woolley
- Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Betrains A, Mulders-Manders CM, Aarntzen EH, Vanderschueren S, Rovers CP. Update on imaging in fever and inflammation of unknown origin: focus on infectious disorders. Clin Microbiol Infect 2024; 30:288-295. [PMID: 37597617 DOI: 10.1016/j.cmi.2023.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Fever of unknown origin (FUO) and inflammation of unknown origin (IUO) are diagnostic challenges that often require an extensive work-up. When first-line tests do not provide any or only misleading clues, second-line investigations such as specialized imaging techniques are often warranted. OBJECTIVES To provide an overview of the diagnostic value of imaging techniques that are commonly used in patients with FUO/IUO. SOURCES MEDLINE database was searched to identify the most relevant studies, trials, reviews, or meta-analyses until 31 March 2023. CONTENT The most important types of second-line imaging tests for FUO and IUO are outlined, including [67Ga]-citrate single-photon emission computed tomography/computed tomography (CT), labelled leukocyte imaging, [18F]-fluorodeoxyglucose positron emission tomography CT ([18F]-FDG-PET), and whole-body magnetic resonance imaging. This review summarizes the diagnostic yield, extends on potential future imaging techniques (pathogen-specific bacterial imaging and [18F]-FDG-PET/magnetic resonance imaging), discusses cost-effectiveness, highlights practical implications and pitfalls, and addresses future perspectives. Where applicable, we provide additional data specifically for the infection subgroup. IMPLICATIONS Although many imaging examinations are proven to be useful in FUO and IUO, [18F]-FDG-PET/CT is the preferred second-line test when available as it provides a high diagnostic yield in a presumably cost-effective way.
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Affiliation(s)
- Albrecht Betrains
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium.
| | | | - Erik H Aarntzen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steven Vanderschueren
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Chantal P Rovers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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7
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Chen X, Gallagher F, Sellmyer MA, Ordonez AA, Kjaer A, Ohliger M, Wilson DM, Jain SK. Visualizing Bacterial Infections With Novel Targeted Molecular Imaging Approaches. J Infect Dis 2023; 228:S249-S258. [PMID: 37788506 PMCID: PMC10547462 DOI: 10.1093/infdis/jiad078] [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] [Indexed: 10/05/2023] Open
Abstract
Although nearly a century has elapsed since the discovery of penicillin, bacterial infections remain a major global threat. Global antibiotic use resulted in an astounding 42 billion doses of antibiotics administered in 2015 with 128 billion annual doses expected by 2030. This overuse of antibiotics has led to the selection of multidrug-resistant "super-bugs," resulting in increasing numbers of patients being susceptible to life-threatening infections with few available therapeutic options. New clinical tools are therefore urgently needed to identify bacterial infections and monitor response to antibiotics, thereby limiting overuse of antibiotics and improving overall health. Next-generation molecular imaging affords unique opportunities to target and identify bacterial infections, enabling spatial characterization as well as noninvasive, temporal monitoring of the natural course of the disease and response to therapy. These emerging noninvasive imaging approaches could overcome several limitations of current tools in infectious disease, such as the need for biological samples for testing with their associated sampling bias. Imaging of living bacteria can also reveal basic biological insights about their behavior in vivo.
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Affiliation(s)
- Xueyi Chen
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ferdia Gallagher
- Department of Radiology, University of Cambridge, Cambridge, United Kingdom
| | - Mark A Sellmyer
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alvaro A Ordonez
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andreas Kjaer
- Department of Clinical Physiology and Nuclear Medicine and Cluster for Molecular Imaging, Copenhagen University Hospital-Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Michael Ohliger
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - David M Wilson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Sanjay K Jain
- Center for Infection and Inflammation Imaging Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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8
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Rowe SP, Auwaerter PG, Sheikhbahaei S, Solnes LB, Wright WF. Molecular Imaging of Infections: Emerging Techniques for Pathogen-Specific Diagnosis and Guided Therapy. J Infect Dis 2023; 228:S241-S248. [PMID: 37788504 DOI: 10.1093/infdis/jiad092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Evaluation of patients that may be infected is challenging. Imaging to identify or localize a site of infection is often limited because of the nonspecific nature of the findings on conventional imaging modalities. Available imaging methods lack the ability to determine if antibiotics are reaching the site of infection and are not optimized to follow response to therapy. Positron emission tomography (PET) is a method by which radiolabeled molecules can be used to detect metabolic perturbations or levels of expression of specific targets. The most common PET agent is the glucose analog 2-deoxy-2-[18F]fluoro-D-glucose (18F-FDG). 18F-FDG has some applicability to localizing a site of infection, but its lack of specificity limits its usefulness. There is a need for the development of pathogen-specific PET radiotracers to address the imaging shortcomings noted above. Preclinical and clinical progress has been made, but significant challenges remain.
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Affiliation(s)
- Steven P Rowe
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara Sheikhbahaei
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lilja B Solnes
- Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William F Wright
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Chen J, Xu D, Sun WJ, Wang WX, Xie NN, Ruan QR, Song JX. Differential diagnosis of lymphoma with 18F-FDG PET/CT in patients with fever of unknown origin accompanied by lymphadenopathy. J Cancer Res Clin Oncol 2023; 149:7187-7196. [PMID: 36884116 PMCID: PMC10374793 DOI: 10.1007/s00432-023-04665-7] [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: 01/04/2023] [Accepted: 02/22/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE To investigate the value of 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) in the differential diagnosis of lymphoma in patients with fever of unknown origin (FUO) accompanied by lymphadenopathy and to develop a simple scoring system to distinguish lymphoma from other etiologies. METHODS A prospective study was conducted on patients with classic FUO accompanied by lymphadenopathy. After standard diagnostic procedures, including PET/CT scan and lymph-node biopsy, 163 patients were enrolled and divided into lymphoma and benign groups according to the etiology. The diagnostic utility of PET/CT imaging was evaluated, and beneficial parameters that could improve diagnostic effectiveness were identified. RESULTS The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of PET/CT in diagnosing lymphoma in patients with FUO accompanied by lymphadenopathy were 81.0, 47.6, 59.3, and 72.7%, respectively. The lymphoma prediction model combining high SUVmax of the "hottest" lesion, high SUVmax of the retroperitoneal lymph nodes, old age, low platelet count, and low ESR had an area under the curve of 0.93 (0.89-0.97), a sensitivity of 84.8%, a specificity of 92.9%, a PPV of 91.8%, and an NPV of 86.7%. There was a lower probability of lymphoma for patients with a score < 4 points. CONCLUSIONS PET/CT scans show moderate sensitivity and low specificity in diagnosing lymphoma in patients with FUO accompanied by lymphadenopathy. The scoring system based on PET/CT and clinical parameters performs well in differentiating lymphoma and benign causes and can be used as a reliable noninvasive tool. REGISTRATION NUMBER This study on FUO was registered on http://www. CLINICALTRIALS gov on January 14, 2014, with registration number NCT02035670.
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Affiliation(s)
- Jia Chen
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Dong Xu
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Wen-Jin Sun
- Department of Infectious Diseases, Ezhou Central Hospital, Ezhou, 436099, China
| | - Wen-Xia Wang
- Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, 528406, China
| | - Na-Na Xie
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China
| | - Qiu-Rong Ruan
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
| | - Jian-Xin Song
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, China.
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10
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Chen J, Xing M, Xu D, Xie N, Zhang W, Ruan Q, Song J. Diagnostic models for fever of unknown origin based on 18F-FDG PET/CT: a prospective study in China. EJNMMI Res 2022; 12:69. [DOI: 10.1186/s13550-022-00937-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This study aims to analyze the 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) characteristics of different causes of fever of unknown origin (FUO) and identify independent predictors to develop a suitable diagnostic model for distinguishing between these causes. A total of 524 patients with classical FUO who underwent standard diagnostic procedures and PET/CT were prospectively studied. The diagnostic performance of PET/CT imaging was analyzed, and relevant clinical parameters that could improve diagnostic efficacy were identified. The model was established using the data of 369 patients and the other 155 patients comprised the validation cohort for verifying the diagnostic performance of the model.
Results
The metabolic characteristics of the “hottest” lesion, the spleen, bone marrow, and lymph nodes varied for various causes. PET/CT combined with clinical parameters achieved better discrimination in the differential diagnosis of FUO. The etiological diagnostic models included the following factors: multisite metabolic characteristics, blood cell counts, inflammatory indicators (erythrocyte sedimentation rate, C-reactive protein, serum ferritin, and lactate dehydrogenase), immunological indicators (interferon gamma release assay, antinuclear antibody, and anti-neutrophil cytoplasm antibody), specific signs (weight loss, rash, and splenomegaly), and age. In the testing cohort, the AUCs of the infection prediction model, the malignancy diagnostic model, and the noninfectious inflammatory disease prediction model were 0.89 (95% CI 0.86–0.92), 0.94 (95% CI 0.92–0.97), and 0.95 (95% CI 0.93–0.97), respectively. The corresponding AUCs for the validation cohort were 0.88 (95% CI 0.82–0.93), 0.93 (95% CI 0.89–0.98), and 0.95 (95% CI 0.92–0.99), respectively.
Conclusions
18F-FDG PET/CT has a certain level of sensitivity and accuracy in diagnosing FUO, which can be further improved by combining it with clinical parameters. Diagnostic models based on PET/CT show excellent performance and can be used as reliable tools to discriminate the cause of FUO.
Trial registration This study (a two-step method apparently improved the physicians’ level of diagnosis decision-making for adult patients with FUO) was registered on the website http://www.clinical-trials.gov on January 14, 2014, with registration number NCT02035670.
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12
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Li Q, Tian R, Wang H, Li L, Wu T, Ren Y, Su M, Zou K, Sun X. Quantifying the contribution of 18F-FDG PET to the diagnostic assessment of pediatric patients with fever of unknown origin: a systematic review and meta-analysis. Pediatr Radiol 2022; 52:1500-1511. [PMID: 35348809 DOI: 10.1007/s00247-022-05333-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/18/2021] [Accepted: 02/23/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The value of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) in the diagnostic assessment of pediatric fever of unknown origin is not known, and evidence from adults is not applicable. OBJECTIVE To quantify the contribution of 18F-FDG PET to pediatric fever of unknown origin, considering its diagnostic limitations. MATERIALS AND METHODS We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials up to Feb. 18, 2021. We included studies on patients with pediatric fever of unknown origin presenting sufficient data to calculate the likelihood of achieving definite diagnosis (based on pathology or clinical follow-up) between those with abnormal PET findings versus those with normal PET findings. We assessed the risk of bias using a modified Newcastle-Ottawa quality assessment scale and quantified the value of PET by pooling the likelihood of achieving definite diagnosis using a random-effects model. RESULTS We included 6 studies and found that pediatric patients with abnormal PET findings were about 17 times more likely to achieve definite diagnoses than those with normal PET findings (odds ratio [OR]: 16.75, 95% confidence interval [CI] 8.0-35, P < 0.00001). Sensitivity analyses using a fixed-effect model (OR 16.91, 95% CI 8.1-35, P < 0.0001) or removing one study at a time (OR 12-20, 95% CI lower bound 3.8-8.6, 95% CI upper bound 33-45, P < 0.0001) did not significantly alter the results. Sample size (interaction P = 0.75), imaging modality (interaction P = 0.29), length of follow-up (interaction P = 0.37), fever of unknown origin subclasses (interaction P = 0.89) and geographical areas (interaction P = 0.74) of studies showed no statistically significant influence on the results. CONCLUSION 18F-FDG PET is a promising approach in the diagnostic work-up of pediatric fever of unknown origin. Further studies are warranted to support routine use in clinical care.
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Affiliation(s)
- Qianrui Li
- Department of Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Chinese Evidence-Based Medicine Centre, Cochrane China Centre, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, China.,National Medical Products Administration (NMPA) Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, China
| | - Rong Tian
- Department of Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hongxi Wang
- Department of Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ling Li
- Chinese Evidence-Based Medicine Centre, Cochrane China Centre, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, China.,National Medical Products Administration (NMPA) Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, China
| | - Tian Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yan Ren
- Chinese Evidence-Based Medicine Centre, Cochrane China Centre, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, China.,National Medical Products Administration (NMPA) Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, China
| | - Minggang Su
- Department of Nuclear Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Centre, Cochrane China Centre, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, China.,National Medical Products Administration (NMPA) Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Centre, Cochrane China Centre, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, China. .,National Medical Products Administration (NMPA) Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, Sichuan, China.
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Wright WF, Betz JF, Auwaerter PG. Prospective Studies Comparing Structured vs Nonstructured Diagnostic Protocol Evaluations Among Patients With Fever of Unknown Origin: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2215000. [PMID: 35653154 PMCID: PMC9164007 DOI: 10.1001/jamanetworkopen.2022.15000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/14/2022] [Indexed: 11/14/2022] Open
Abstract
Importance Patients meeting the criteria for fever of unknown origin (FUO) can be evaluated with structured or nonstructured approaches, but the optimal diagnostic method is unresolved. Objective To analyze differences in diagnostic outcomes among patients undergoing structured or nonstructured diagnostic methods applied to prospective clinical studies. Data Sources PubMed, Embase, Scopus, and Web of Science databases with librarian-generated query strings for FUO, PUO, fever or pyrexia of unknown origin, clinical trial, and prospective studies identified from January 1, 1997, to March 31, 2021. Study Selection Prospective studies meeting any adult FUO definition were included. Articles were excluded if patients did not precisely fit any existing adult FUO definition or studies were not classified as prospective. Data Extraction and Synthesis Abstracted data included years of publication and study period, country, setting (eg, university vs community hospital), defining criteria and category outcome, structured or nonstructured diagnostic protocol evaluation, sex, temperature threshold and measurement, duration of fever and hospitalization before final diagnoses, and contribution of potential diagnostic clues, biochemical and immunological serologic studies, microbiology cultures, histologic analysis, and imaging studies. Structured protocols compared with nonstructured diagnostic methods were analyzed using regression models. Main Outcomes and Measures Overall diagnostic yield was the primary outcome. Results Among the 19 prospective trials with 2627 unique patients included in the analysis (range of patient ages, 10-94 years; 21.0%-55.3% female), diagnoses among FUO series varied across and within World Health Organization (WHO) geographic regions. Use of a structured diagnostic protocol was not significantly associated with higher odds of yielding a diagnosis compared with nonstructured protocols in aggregate (odds ratio [OR], 0.98; 95% CI, 0.65-1.49) or between Western Europe (Belgium, France, the Netherlands, and Spain) (OR, 0.95; 95% CI, 0.49-1.86) and Eastern Europe (Turkey and Romania) (OR, 0.83; 95% CI, 0.41-1.69). Despite the limited number of studies in some regions, analyses based on the 6 WHO geographic areas found differences in the diagnostic yield. Western European studies had the lowest percentage of achieving a diagnosis. Southeast Asia led with infections at 49.0%. Noninfectious inflammatory conditions were most prevalent in the Western Pacific region (34.0%), whereas the Eastern Mediterranean region had the highest proportion of oncologic explanations (24.0%). Conclusions and Relevance In this systematic review and meta-analysis, diagnostic yield varied among WHO regions. Available evidence from prospective studies did not support that structured diagnostic protocols had a significantly better rate of achieving a diagnosis than nonstructured protocols. Clinicians worldwide should incorporate geographical disease prevalence in their evaluation of patients with FUO.
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Affiliation(s)
- William F. Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua F. Betz
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul G. Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Wright WF, Yenokyan G, Simner PJ, Carroll KC, Auwaerter PG. Geographic Variation of Infectious Disease Diagnoses Among Patients with Fever of Unknown Origin (FUO) – A Systematic Review and Meta-analysis. Open Forum Infect Dis 2022; 9:ofac151. [PMID: 35450085 PMCID: PMC9017373 DOI: 10.1093/ofid/ofac151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
Abstract
Background Fever of unknown origin (FUO) investigations yield a substantial number of patients with infectious diseases. This systematic review and meta-analysis aimed to quantify more common FUO infectious diseases etiologies and to underscore geographic variation. Methods Four databases (PubMed, Embase, Scopus, and Web of Science) were searched for prospective studies reporting FUO rates among adult patients from 1 January 1997 to 31 March 2021. The pooled proportion for infectious diseases etiology was estimated using the random-effects meta-analysis model. Results Nineteen prospective studies were included with 2667 total cases. No studies were available for Africa or the Americas. Overall, 37.0% (95.0% confidence interval [CI], 30.0%–44.0%) of FUO patients had an infectious disease etiology. Infections were more likely from Southeastern Asia (pooled proportion, 0.49 [95% CI, .43–.55]) than from Europe (pooled proportion, 0.31 [95% CI, .22–.41]). Among specifically reported infectious diseases (n = 832), Mycobacterium tuberculosis complex predominated across all geographic regions (n = 285 [34.3%]), followed by brucellosis (n = 81 [9.7%]), endocarditis (n = 62 [7.5%]), abscesses (n = 61 [7.3%]), herpesvirus (eg, cytomegalovirus and Epstein-Barr virus) infections (n = 60 [7.2%]), pneumonia (n = 54 [6.5%]), urinary tract infections (n = 54 [6.5%]), and enteric fever (n = 40 [4.8%]). Conclusions FUO patients from Southeastern Asia were more likely to have an infectious diseases etiology when compared to other regions. The predominant factor for this finding appears to be differences in disease prevalence among various geographical locations or other factors such as access to timely care and diagnosis. Noting epidemiological disease factors in FUO investigations could improve diagnostic yields and clinical outcomes.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patricia J Simner
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karen C Carroll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Diagnostic value of F-18 FDG PET/CT in fever or inflammation of unknown origin in a large single-center retrospective study. Sci Rep 2022; 12:1883. [PMID: 35115619 PMCID: PMC8813902 DOI: 10.1038/s41598-022-05911-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
Cause determination is challenging in fever or inflammation of unknown origin (FUO/IUO) despite today’s diagnostic modalities. We evaluated the value of F-18 FDG PET/CT in an unselected patient collective. This retrospective nonrandomized single-center study enrolled 300 male and female patients with FUO/IUO. PET/CT findings were compared with final clinical outcomes to determine the sensitivity, specificity, clinical significance, etiological distribution of final diagnoses, impact on treatment, role of white-blood cell count (WBC), and C-reactive protein (CRP). In 54.0% (162/300) PET/CT was the decisive exanimation for establishing the final diagnosis, in 13.3% (40/300) the findings were equivocal and indecisive, in 3.3% (10/300) PET/CT findings were false positive, while in 29.3% (88/300) a normal F-18 FDG pattern was present. Statistical analysis showed a sensitivity of 80.2% and a specificity of 89.8% for the contribution of PET/CT to the final diagnosis. CRP levels and WBC were not associated with PET/CT outcome. PET/CT let to new treatment in 24.0% (72/300), treatment change in 18.0% (54/300), no treatment change in 49.6% (149/300), and in 8.3% (25/300) no data was available. Our study demonstrates the utility of F-18 FDG PET/CT for source finding in FUO/IUO if other diagnostic tools fail.
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Wright WF, Mulders-Manders CM, Auwaerter PG, Bleeker-Rovers CP. Fever of Unknown Origin (FUO) - A Call for New Research Standards and Updated Clinical Management. Am J Med 2022; 135:173-178. [PMID: 34437835 DOI: 10.1016/j.amjmed.2021.07.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 02/06/2023]
Abstract
Prolonged fever of 38.3°C or higher for at least 3 weeks' duration has been termed fever of unknown origin if unexplained after preliminary investigations. Initially codified in 1961, classification with subgroups was revised in 1991. Additional changes to the definition were proposed in 1997, recommending a set of standardized initial investigations. Advances in diagnosis and management and diagnostic testing over the last 3 decades have prompted a needed update to the definition and approaches. While a 3-week fever duration remains part of the criteria, a lower temperature threshold of 38°C and revised minimum testing criteria will assist clinicians and their patients, setting a solid foundation for future research.
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Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Catharina M Mulders-Manders
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul G Auwaerter
- The Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Chantal P Bleeker-Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Fisher RE, Drews AL, Palmer EL. Lack of Clinical Utility of Labeled White Blood Cell Scintigraphy in Patients with Fever of Unknown Origin. Open Forum Infect Dis 2022; 9:ofac015. [PMID: 35146051 PMCID: PMC8825748 DOI: 10.1093/ofid/ofac015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/07/2022] [Indexed: 11/12/2022] Open
Abstract
Background Labeled white blood cell scintigraphy (WBCS) has been used for over 40 years to localize an infection source in patients with fever of unknown origin (FUO). It continues to be in widespread use for such patients in modern times, despite the tremendous advances in modern radiological imaging and laboratory medicine. Methods We critically evaluated the clinical contribution of WBCS performed in 132 patients with FUO at 7 hospitals from mid-2015 to the end of 2019. For each patient, all radiographic and laboratory results and all electronic clinical notes were carefully evaluated as many days before and after the scan as necessary to arrive at a final diagnosis. Results Although 50 WBCS (38%) showed positive findings, the majority of these were false positive (FP). Of the 19 true-positive (TP) scans, most were already known or about to become known by tests already ordered at the time of the scan. Only 2 TP scans (1.5%) contributed to the final diagnosis, and these did so only indirectly. FP scans led to 7 unnecessary procedures. Conclusions In FUO patients for whom an infection source is not discovered following an appropriate radiographic and laboratory workup, WBCS is not a useful procedure.
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Affiliation(s)
- Ronald E Fisher
- Dept of Radiology, Baylor College of Medicine, Houston, Texas, USA
- Dept of Radiology, Houston Methodist Hospital, USA
| | - Ashley L Drews
- Dept of Medicine, Section of Infectious Disease, Houston Methodist Hospital, USA
- Houston Methodist Academic Institute, Houston, Texas, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Edwin L Palmer
- Dept of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Ordoñez AA, Jain SK. Imaging of Bacterial Infections. Mol Imaging 2021. [DOI: 10.1016/b978-0-12-816386-3.00089-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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