Usefulness of PET/CT in ANCA associated renal vasculitis

Feng, Yaqi; Wang, Peng; Cui, Bangping

doi:10.1016/j.medcli.2019.05.038

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After treatment, MIP image showing decreased renal cortex uptake and the renal pyramids were regular in arrangement (arrows) (D), axial PET (E), and axial fused PET/CT (F)." ] ] ] "textoCompleto" => "Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are a group of systemic autoimmune disease characterized by inflammation of small blood vessels with multi-organ involvement, including the kidney, lung, joints, nerves, and so on, the kidney is most commonly involved. The clinical manifestations of some AAV patients are acute fatal pulmonary hemorrhage and/or irreversible nephritis in the early stage of the disease course, with rapid progress but short effective treatment time. Therefore, early diagnosis and treatment of the disease is of great significance.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> The definite diagnosis mainly depends on biopsy.We report the case of a 58-year-old woman with a fever of unknown origin. Serum MPO-ANCA was elevated, no obvious abnormalities were found in lungs and abdomen CT, she subsequently underwent FDG PET/CT. The 18F-FDG PET/CT showed bilateral renal enlargement and diffuse increase of FDG uptake in renal parenchyma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). During examination for etiology her creatinine increased from 57.4μmoI/L to 300.7μmoI/L within 20 days. Then renal biopsies combined with clinical diagnosis of AAV. After 3 plasma exchange treatments and multiple immunotherapy, PET/CT showed the kidneys returning to normal uptake and size (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), blood tests showed MPO-ANCA was negative and creatinine returned to normal as well.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>According to the staining site of indirect immunofluorescence, ANCA can be divided into cytoplasmic type (C-ANCA) and pericyclic type (P-ANCA). The two main antigens that these antibodies are directed against are proteinase 3 (anti-PR3) and myeloperoxidase (anti-MPO).<a class="elsevierStyleCrossRef" href="#bib0035">2</a> AAV is a collective term for three diseases: granuloma with polyvasculitis (GPA), microscopically polyvasculitis (MPA), and eosinophilic GPA (EGPA).<a class="elsevierStyleCrossRef" href="#bib0040">3</a> This case is MPO-AAV which is common in China and mainly affects the elderly. The most common manifestation is glomerulonephritis and pulmonary capillaritis.The present case is of interest because this patient has been suffering a persistent fever, and no abnormalities were found in the lung and abdomen CT. FDG PET/CT suggested diffuse metabolism increase in both kidneys, combined with creatinine and ANCA antibodies, the cause of the fever was ultimately located in the kidney. 18F-FDG has been routinely used to detect various types of cancer as well as infections and inflammation. A study showed that FDG PET/CT had a higher negative predictive value (93%) in the diagnosis of AAV and was effective in excluding cancer and infection.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> Diffuse renal parenchymal FDG uptake is nonspecific and can be seen in lymphoma, sarcoidosis, IgG4-related disease and so on.<a class="elsevierStyleCrossRef" href="#bib0050">5</a> Careful investigation of the renal cortex may reveal lesions and diffuse uptake of both renal parenchyma usually indicates abnormalities. When glomerulonephritis is gone, renal cortical FGD uptake reduced. This case was mainly renal damage without morphological changes. PET functional imaging can detect early target lesions by increasing metabolism, at the same time, the therapeutic effect can be evaluated by metabolic changes." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "These authors contributed equally to this work." "identificador" => "fn0005" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 734 "Ancho" => 1750 "Tamanyo" => 113027 ] ] "descripcion" => array:1 [ "en" => "Maximum intensity projection (MIP) image showing bilateral renal enlargement and diffuse increase of FDG uptake in renal parenchyma (arrows) (A), axial PET (B), and axial fused PET/CT (C). After treatment, MIP image showing decreased renal cortex uptake and the renal pyramids were regular in arrangement (arrows) (D), axial PET (E), and axial fused PET/CT (F)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical analysis of patients with myeloperoxidase antineutrophil cytoplasmic antibody-associated vasculitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Z.W. Shuai" 1 => "Y.F. Lv" 2 => "M.M. Zhang" 3 => "Z.Y. 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Chowdhury" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/RLU.0000000000001960" "Revista" => array:6 [ "tituloSerie" => "Clin Nucl Med" "fecha" => "2018" "volumen" => "43" "paginaInicial" => "e96" "paginaFinal" => "e97" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29293138" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00257753/0000015500000004/v1_202008110620/S0025775319304944/v1_202008110620/en/main.assets" "Apartado" => array:4 [ "identificador" => "66430" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas al Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00257753/0000015500000004/v1_202008110620/S0025775319304944/v1_202008110620/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775319304944?idApp=UINPBA00004N"]

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