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PET/CT features of extrapulmonary tuberculosis at first clinical presentation: a cross-sectional observational 18F-FDG imaging study across six countries

Jamshed Bomanji, Rajnish Sharma, Bhagwant R. Mittal, Sanjay Gambhir, Ahmad Qureshy, Shamim M.F. Begum, Diana Paez, Mike Sathekge, Mariza Vorster, Dragana Sobic Saranovic, Pawana Pusuwan, Vera Mann, Sobhan Vinjamuri, Alimuddin Zumla, Thomas N.B. Pascual for the International Atomic Energy Agency Extra-pulmonary TB Consortium
European Respiratory Journal 2020 55: 1901959; DOI: 10.1183/13993003.01959-2019
Jamshed Bomanji
1Institute of Nuclear Medicine, UCLH NHS Foundation Trust, London, UK
14All authors contributed equally
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  • ORCID record for Jamshed Bomanji
  • For correspondence: jamshed.bomanji@nhs.net
Rajnish Sharma
2Division of Nuclear Medicine and PET Imaging, Specialist in Nuclear Medicine and Thyroid Diseases, Molecular Imaging and Research Center (MIRC), INMAS, Delhi, India
14All authors contributed equally
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Bhagwant R. Mittal
3Dept of Nuclear Medicine and PET, Post Graduate Institute of Medical Education and Research, Chandigarh, India
14All authors contributed equally
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Sanjay Gambhir
4Dept of Nuclear Medicine, SGPGIMS, Lucknow, India
14All authors contributed equally
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Ahmad Qureshy
5Institute of Nuclear Medicine and Oncology (INMOL) Hospital, Lahore, Pakistan
14All authors contributed equally
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Shamim M.F. Begum
6National Institute of Nuclear Medicine and Allied Sciences (NINMAS), BSM Medical University Campus, Shahbag, Bangladesh
14All authors contributed equally
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Diana Paez
7Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, IAEA, Vienna, Austria
14All authors contributed equally
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Mike Sathekge
8Dept of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
14All authors contributed equally
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Mariza Vorster
8Dept of Nuclear Medicine, Steve Biko Academic Hospital, University of Pretoria, Pretoria, South Africa
14All authors contributed equally
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Dragana Sobic Saranovic
9Faculty of Medicine University of Belgrade, Center of Nuclear Medicine Clinical Center of Serbia, Belgrade, Serbia
14All authors contributed equally
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Pawana Pusuwan
10Division of Nuclear Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
14All authors contributed equally
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Vera Mann
1Institute of Nuclear Medicine, UCLH NHS Foundation Trust, London, UK
14All authors contributed equally
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Sobhan Vinjamuri
11Dept of Nuclear Medicine, Royal Liverpool University Hospital, Liverpool, UK
14All authors contributed equally
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Alimuddin Zumla
12Center for Clinical Microbiology, Division of Infection and Immunity, University College London, and the National Institute of Health Research Biomedical Research Centre at UCL Hospitals, London, UK
14All authors contributed equally
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Thomas N.B. Pascual
13Section of Nuclear Medicine and Diagnostic Imaging, Division of Human Health, Dept of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna International Centre, Vienna, Austria
14All authors contributed equally
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Abstract

Background A large proportion of the huge global burden of extrapulmonary tuberculosis (EPTB) cases are treated empirically without accurate definition of disease sites and extent of multi-organ disease involvement. Positron emission tomography (PET) imaging using 2-deoxy-2-(fluorine-18) fluoro-d-glucose (18F-FDG) in tuberculosis could be a useful imaging technique for localising disease sites and extent of disease.

Methods We conducted a study of HIV-negative adult patients with a new clinical diagnosis of EPTB across eight centres located in six countries: India, Pakistan, Thailand, South Africa, Serbia and Bangladesh, to assess the extent of disease and common sites involved at first presentation. 18F-FDG PET/computed tomography (CT) scans were performed within 2 weeks of presentation.

Findings 358 patients with EPTB (189 females; 169 males) were recruited over 45 months, with an age range of 18–83 years (females median 30 years; males median 38 years). 350 (98%) out of 358 patients (183 female, 167 male) had positive scans. 118 (33.7%) out of 350 had a single extrapulmonary site and 232 (66.3%) out of 350 had more than one site (organ) affected. Lymph nodes, skeleton, pleura and brain were common sites. 100 (28%) out of 358 EPTB patients had 18F-FDG PET/CT-positive sites in the lung. 110 patients were 18F-FDG PET/CT-positive in more body sites than were noted clinically at first presentation and 160 patients had the same number of positive body sites.

Interpretation 18F-FDG PET/CT scan has potential for further elucidating the spectrum of disease, pathogenesis of EPTB and monitoring the effects of treatment on active lesions over time, and requires longitudinal cohort studies, twinned with biopsy and molecular studies.

Abstract

18F-FDG PET/CT can localise EPTB disease sites not clinically detected. It may serve a useful tool for research studies defining pathogenetic mechanisms and cure, relapse and recurrence. http://bit.ly/2CKSH9a

Footnotes

  • Author contributions: J. Bomanji, T.N.B Pascual and A. Zumla developed the concept and initiated discussions which led to the formation of the consortium. All authors developed and helped finalise the study protocols. R. Sharma, B.R. Mittal, S. Gambhir, A. Qureshy, S.M.F. Begum, M. Sathekge, M. Vorster, D. Sobic Saranovic and P. Pusuwan led the study sites. S. Vinjamuri conducted quality assessment of imaging data. V. Mann performed the data analyses. J. Bomanji led the imaging studies, and with A. Zumla, D. Paez and T.N.B Pascual developed the first and subsequent drafts of the manuscript. All authors contributed to data interpretation and writing of the manuscript.

  • Conflict of interest: J. Bomanji was the PI and received non-financial support from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: R. Sharma reports grants and non-financial support for research from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: B.R. Mittal reports grants and non-financial support for research from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: S. Gambhir reports grants and non-financial support from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: A. Qureshy reports grants and non-financial support for research from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: S.M.F. Begum reports grants and non-financial support for research from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: D. Paez has nothing to disclose.

  • Conflict of interest: M. Sathekge reports grants from International Atomic Energy association (IAEA), during the conduct of the study.

  • Conflict of interest: M. Vorster reports grants from International Atomic Energy Association (IAEA), during the conduct of the study.

  • Conflict of interest: D. Sobic Saranovic reports grants and non-financial support from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: P. Pusuwan reports grants and non-financial support for research from IAEA, Vienna, during the conduct of the study.

  • Conflict of interest: V. Mann reports payment for statistical software purchase from UCLH, during the conduct of the study.

  • Conflict of interest: S. Vinjamuri has nothing to disclose.

  • Conflict of interest: A. Zumla has nothing to disclose.

  • Conflict of interest: T.N.B. Pascual has nothing to disclose.

  • Support statement: The International Atomic Energy Agency (IAEA) assisted in selection of recruitment centres with optimal 18F-FDG PET/CT imaging facilities and provided support for 18F-FDG PET/CT scans, consortium meetings and centralised facilities for data storage. A. Zumla and J. Bomanji acknowledge support from the NIHR Biomedical Centre at UCL Hospitals Foundation NHS Trust. A. Zumla is a member of the Pan-African network for Rapid research, Response and Preparedness for Infectious Diseases Epidemics (PANDORA-ID-NET consortium (www.pandora-id.net/)) and acknowledges support from the PANDORA-ID-NET, EDCTP CANTAM2, TESA2 and EACCR2 grants from the European and Developing Countries Clinical Trials Partnership (EDCTP2) programme. A. Zumla is in receipt of a National Institutes of Health Research (NIHR) senior investigator award. Funding information for this article has been deposited with the Crossref Funder Registry.

  • Received October 8, 2019.
  • Accepted November 11, 2019.
  • Copyright ©ERS 2020
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PET/CT features of extrapulmonary tuberculosis at first clinical presentation: a cross-sectional observational 18F-FDG imaging study across six countries
Jamshed Bomanji, Rajnish Sharma, Bhagwant R. Mittal, Sanjay Gambhir, Ahmad Qureshy, Shamim M.F. Begum, Diana Paez, Mike Sathekge, Mariza Vorster, Dragana Sobic Saranovic, Pawana Pusuwan, Vera Mann, Sobhan Vinjamuri, Alimuddin Zumla, Thomas N.B. Pascual
European Respiratory Journal Feb 2020, 55 (2) 1901959; DOI: 10.1183/13993003.01959-2019

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PET/CT features of extrapulmonary tuberculosis at first clinical presentation: a cross-sectional observational 18F-FDG imaging study across six countries
Jamshed Bomanji, Rajnish Sharma, Bhagwant R. Mittal, Sanjay Gambhir, Ahmad Qureshy, Shamim M.F. Begum, Diana Paez, Mike Sathekge, Mariza Vorster, Dragana Sobic Saranovic, Pawana Pusuwan, Vera Mann, Sobhan Vinjamuri, Alimuddin Zumla, Thomas N.B. Pascual
European Respiratory Journal Feb 2020, 55 (2) 1901959; DOI: 10.1183/13993003.01959-2019
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