Skip to main content
SpringerLink
Log in

Fever of unknown origin: large vessel vasculitis diagnosed by PET/CT

  • Short Communication
  • Published:
Rheumatology International Aims and scope Submit manuscript

Abstract

PET/CT is starting to play an important role in evaluating fever of unknown origin (FUO), due to its ability to localize and delineate areas of high metabolic activity, such as neoplastic proliferation and inflammation, including vasculitis. We present a case of giant cell arteritis (GCA) in a 72-year-old female patient admitted to our department with a 4-month history of FUO, weight loss and fatigue, without specific symptoms or signs. Laboratory investigations suggested acute phase response, with a pronounced erythrocyte sedimentation rate, high CRP level and microcytic anemia. A thorough diagnostic evaluation was performed to exclude an unknown primary tumor, which was initially suspected due to a positive family history of cancer. Surprisingly, PET/CT revealed large vessel vasculitis affecting the ascending, descending and abdominal aorta, as well as subclavian, proximal brachial and carotid arteries bilaterally. Biopsy of the superficial temporal artery confirmed the diagnosis of GCA. Treatment with methylprednisolone and azathioprine led to resolution of clinical symptoms and normalization of laboratory parameters. In addition to the use of PET/CT in the evaluation of FUO, its value as a method complementary to temporal artery biopsy is also discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Abbreviations

FUO:

Fever of unknown origin

ESR:

Erythrocyte sedimentation rate

CRP:

C-reactive protein

GCA:

Giant cell arteritis

PMR:

Polymyalgia rheumatica

PET:

Positron emission tomography

FDG:

2-Deoxy-2-[18F]fluoro-d-glucose

CT:

Computed tomography

MSCT:

Multislice CT

SUVmax:

Maximum standard uptake value

SUVs:

Standard uptake values

References

  1. Durack DT, Street AC (1991) Fever of unknown origin–reexamined and redefined. Curr Clin Top Infect Dis 11:35–51

    PubMed  CAS  Google Scholar 

  2. Ergönül O, Willke A, Azap A, Tekeli E (2005) Revised definition of “fever of unknown origin”: limitations and opportunities. J Infect 50(1):1–5

    Article  PubMed  Google Scholar 

  3. Vanderschueren S, Knockaert D, Adriaenssens T, Demey W, Durnez A, Blockmans D, Bobbaers H (2003) From prolonged febrile illness to fever of unknown origin: the challenge continues. Arch Intern Med 163(9):1033–1041

    Article  PubMed  Google Scholar 

  4. Knockaert DC, Vanderschueren S, Blockmans D (2003) Fever of unknown origin in adults: 40 years on. J Intern Med 253(3):263–275

    Article  PubMed  CAS  Google Scholar 

  5. Bijlsma J (2009) EULAR Compendium on rheumatic diseases. BMJ Publishing Group Ltd., London

    Google Scholar 

  6. Langford CA (2010) Vasculitis. J Allergy Clin Immunol 125(2):S216–S225

    Article  PubMed  Google Scholar 

  7. Salvarani C, Cantini F, Hunder GG (2008) Polymyalgia rheumatica and giant-cell arteritis. Lancet 372(9634):234–245

    Article  PubMed  Google Scholar 

  8. Meller J, Sahlmann C-O, Scheel AK (2007) 18F-FDG PET and PET/CT in fever of unknown origin. J Nucl Med 48(1):35–45

    PubMed  CAS  Google Scholar 

  9. Ferda J, Ferdová E, Záhlava J, Matejovic M, Kreuzberg B (2010) Fever of unknown origin: a value of (18)F-FDG-PET/CT with integrated full diagnostic isotropic CT imaging. Eur J Radiol 73(3):518–525

    Article  PubMed  Google Scholar 

  10. Mourad O, Palda V, Detsky AS (2003) A comprehensive evidence-based approach to fever of unknown origin. Arch Intern Med 163(5):545–551

    Article  PubMed  Google Scholar 

  11. Brodmann M, Lipp RW, Passath A, Seinost G, Pabst E, Pilger E (2004) The role of 2–18F-fluoro-2-deoxy-d-glucose positron emission tomography in the diagnosis of giant cell arteritis of the temporal arteries. Rheumatology 43:241–242

    Article  PubMed  CAS  Google Scholar 

  12. Blockmans D, de Ceuninck L, Vanderschueren S, Knockaert D, Mortelmans L, Bobbaers H (2006) Repetitive 18F-fluorodeoxyglucose positron emission tomography in giant cell arteritis: a prospective study of 35 patients. Arthritis Rheum 55:131–137

    Article  PubMed  Google Scholar 

  13. Bleeker-Rovers CP, Bredie SJ, van der Meer JW, Corstens FH, Oyen WJ (2003) F-18-fluorodeoxyglucose positron emission tomography in diagnosis and follow-up of patients with different types of vasculitis. Neth J Med 61(10):323–329

    PubMed  CAS  Google Scholar 

  14. Bural GG, Torigian DA, Chamroonrat W, Houseni M, Chen W, Basu S, Kumar R, Alavi A (2008) FDG-PET is an effective imaging modality to detect and quantify age-related atherosclerosis in large arteries. Eur J Nucl Med Mol Imaging 35:562–569

    Article  PubMed  Google Scholar 

  15. Belhocine T, Blockmans D, Hustinx R, Vandevivere J, Mortelmans L (2003) Imaging of large vessel vasculitis with (18)FDG PET: illusion or reality? A critical review of the literature data. Eur J Nucl Med Mol Imaging 30(9):1305–1313

    Article  PubMed  Google Scholar 

  16. Hunder GG, Arend WP, Bloch DA, Calabrese LH, Fauci AS, Fries JF, Leavitt RY, Lie JT, Lightfoot RW Jr, Masi AT et al (1990) The American College of Rheumatology 1990 criteria for the classification of vasculitis. Introduction. Arthritis Rheum 33(8):1065–1067

    Article  PubMed  CAS  Google Scholar 

  17. Jennette JC, Falk RJ, Andrassy K, Bacon PA, Churg J, Gross WL, Hagen EC, Hoffman GS, Hunder GG, Kallenberg CG et al (1994) Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum 37(2):187–192

    Article  PubMed  CAS  Google Scholar 

  18. Ball EL, Walsh SR, Tang TY, Gohil R, Clarke JM (2010) Role of ultrasonography in the diagnosis of temporal arteritis. Br J Surg 97(12):1765–1771

    Article  PubMed  CAS  Google Scholar 

  19. Bley TA, Reinhard M, Hauenstein C, Markl M, Warnatz K, Hetzel A, Uhl M, Vaith P, Langer M (2008) Comparison of duplex sonography and high-resolution magnetic resonance imaging in the diagnosis of giant cell (temporal) arteritis. Arthritis Rheum 58(8):2574–2578

    Article  PubMed  CAS  Google Scholar 

  20. Buchbinder R, Detsky AS (1992) Management of suspected giant cell arteritis: a decision analysis. J Rheumatol 19(8):1220–1228

    PubMed  CAS  Google Scholar 

  21. Brack A, Martinez-Taboada V, Stanson A, Goronzy JJ, Weyand CM (1999) Disease pattern in cranial and large-vessel giant cell arteritis. Arthritis Rheum 42(2):311–317

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Kispaticeva 12, Zagreb, Croatia

    Dubravka Bosnić, Marko Barešić, Ivan Padjen & Branimir Anić

  2. Medikol Polyclinic, PET/CT Centre, Vinogradska 29, Zagreb, Croatia

    Antonija Balenović

  3. Department of Pathology and Cytology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Kispaticeva 12, Zagreb, Croatia

    Kamelija Žarković

Authors
  1. Dubravka Bosnić
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marko Barešić
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ivan Padjen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Antonija Balenović
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kamelija Žarković
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Branimir Anić
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ivan Padjen.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bosnić, D., Barešić, M., Padjen, I. et al. Fever of unknown origin: large vessel vasculitis diagnosed by PET/CT. Rheumatol Int 33, 2417–2421 (2013). https://doi.org/10.1007/s00296-012-2425-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00296-012-2425-1

Keywords

Search

Navigation