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Revised: 11 January 2023
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Accepted: 25 January 2023
DOI: 10.1111/liv.15530
CLINICAL IMAGE
The utility of F-­18 FDG PET/CT for diagnosis and response
evaluation of hepatosplenic tuberculosis
Dae-­Weung Kim | Soon-­Ah Park | Myoung Hyoun Kim
Department of Nuclear Medicine and
Institute of Wonkwang Medical Science,
Wonkwang University School of Medicine,
Iksan, South Korea
Correspondence
Myoung Hyoun Kim, Department of
Nuclear Medicine and Institute of
Wonkwang Medical Science, Wonkwang
University School of Medicine, 895,
Muwang-­ro, Iksan 54538, Republic of
Korea.
Email: yarn1004@wku.ac.kr
Abstract
A 77-­year-­old woman underwent F-­18 FDG PET/CT for evaluation of fever focus.
Diffuse and intense hepatosplenic uptake was noted and lymphoma or tuberculosis was proposed. Liver biopsy revealed chronic granulomatous inflammation with
Langerhans-­t ype giant cells and necrosis. A follow-­up PET/CT after anti-­tuberculosis
treatment revealed that the hepatosplenic uptake had resolved.
KEYWORDS
F-­18 FDG, fever of unknown origin, hepatosplenic tuberculosis, PET/CT
Funding information
Wonkwang University
A 77-­year-­old woman with a history of hypertension presented with
lymphatic uptake newly observed in post-­therapy images is thought
a fever lasting 3 weeks despite antibiotic treatment. There were also
to be due to the normalization of FDG biodistribution in post-­therapy
symptoms of nausea, vomiting and abdominal pain. Laboratory tests
images, which was suppressed by hepatic superscan in pre-­therapy
9
revealed leukopenia (white blood cell count, 2.8 × 10 /L), raised C-­
images. Since all of the patient's symptoms and laboratory findings
reactive protein (138.4 mg/L), aspartate transaminase (799 IU/L),
improved, anti-­tuberculosis treatment could be stopped after a total
alanine aminotransferase (471 IU/L), alkaline phosphatase (205 U/L),
of 8 months.
lactate dehydrogenase (1149 IU/L), gamma-­glutamyl transferase
Fever of unknown origin (FUO) can be caused by a variety of
(234 IU/L) and normal bilirubin levels. Blood, sputum, stool and urine
conditions, including infections, non-­infectious inflammatory dis-
cultures were negative. Tests for hepatitis B surface antigen, anti-­
ease, neoplasm and miscellaneous others. Among bacterial infec-
hepatitis C virus antibody, anti-­human immunodeficiency virus an-
tions, tuberculosis is the most common infectious cause of FUO.1
tibody, anti-­Rickettsial antibody and PCR testing for SARS-­CoV-­2
Extrapulmonary tuberculosis constitutes 15%–­20% of all tubercu-
were all negative. Mild hepatomegaly and decreased liver paren-
losis cases, 2 and radiological evaluations are critical for diagnosis
chymal attenuation were observed; however, no febrile foci were
and crucial in planning the treatment and follow-­up. F-­18 FDG is a
identified on chest and abdominal CT. F-­18 fluorodeoxyglucose
highly influential radiotracer that provides valuable information for
(FDG) PET/CT was subsequently acquired for further evaluation.
many cancer types, as well as inflammatory disease. Although it is
Maximal intensity projections (MIP) view (Figure 1A) and axial fu-
usually caused by neoplastic lesions, hepatic tuberculosis can be a
sion view (Figure 1C) showed diffuse increased hepatic and splenic
rare cause of FDG hepatic superscan.3 Our case once again demon-
uptake. Diffuse inflammation or lymphoma involving the liver and
strated that F-­18 FDG PET/CT is very useful in monitoring the ther-
spleen was suspected, and a liver biopsy was performed. The biopsy
apeutical response of patients with hepatosplenic tuberculosis.4,5
showed chronic granulomatous inflammation with Langerhans-­t ype
In addition, unlike the focal uptake of spleen in the previous cases,
giant cells and necrosis. Also, interferon gamma releasing assay was
both the liver and spleen show diffuse intense uptake, indicating the
positive. These results led to the suspicion of hepatosplenic tuber-
need for a differential diagnosis from diseases such as lymphoma.6
culosis, and the patient began anti-­tuberculosis medication. On the
6-­month follow-­up FDG PET/CT images (Figure 1B,D), increased up-
AC K N O​W L E​D G E​M E N T S
take of the liver and spleen was normalized. Mediastinal and hilar
This study was supported by Wonkwang University in 2021.
© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Liver International. 2023;43:733–734.
wileyonlinelibrary.com/journal/liv
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14783231, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/liv.15530 by Wonkwang University, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Received: 19 November 2022
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KIM et al.
F I G U R E 1 Pre-­therapy and post-­therapy F-­18 FDG PET/CT images of hepatosplenic tuberculosis. These two scans were acquired with
similar FDG dose (0.15 mCi per kg) and same acquisition parameters according to a standard FDG PET protocol. Serial MIP (A,B) and fusion
(C,D) images acquired at 6-­month intervals revealed the remarkable resolution of diffuse hepatosplenic uptake. The SUVmax of liver and
spleen decreased from 7.4 to 2.6 and from 7.2 to 2.1, respectively.
C O N F L I C T O F I N T E R E S T S TAT E M E N T
Dae-­Weung Kim, Soon-­Ah Park and Myoung Hyoun Kim declare
that they have no conflict of interest.
E T H I C S S TAT E M E N T
All procedures performed in studies involving human participants
were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
I N FO R M E D C O N S E N T
The institutional review board of our institute approved this retrospective study, and the requirement to obtain informed consent was
2. Baykan AH, Sayiner HS, Aydin E, Koc M, Inan I, Erturk SM.
Extrapulmonary tuberculosis: an old but resurgent problem.
Insights Imaging. 2022;13:39.
3. Wong SS, Yuen HY, Ahuja AT. Hepatic tuberculosis: a rare cause
of fluorodeoxyglucose hepatic superscan with background suppression on positron emission tomography. Singapore Med J.
2014;55:e101-­e103.
4. Jeong YJ, Sohn MH, Lim ST, et al. ‘Hot liver’ on 18F-­FDG PET/CT
imaging in a patient with hepatosplenic tuberculosis. Eur J Nucl Med
Mol Imaging. 2010;37:1618-­1619.
5. Jin X, Huo L, Wang T, Liu Y, Li F. Hepatosplenic tuberculosis
on pretherapy and posttherapy FDG PET/CT. Clin Nucl Med.
2020;45:174-­176.
6. Quak E, Salaun V, Le Naoures C, Fruchart C. 18F-­FDG PET/CT
in hepatosplenic gamma-­delta T-­cell lymphoma. Clin Nucl Med.
2015;40:730-­731.
waived.
ORCID
Myoung Hyoun Kim
https://orcid.org/0000-0002-4541-8019
REFERENCES
1. Haidar G, Singh N. Fever of unknown origin. N Engl J Med.
2022;386:463-­477.
How to cite this article: Kim D-W, Park S-A, Kim MH. The
utility of F-18 FDG PET/CT for diagnosis and response
evaluation of hepatosplenic tuberculosis. Liver Int.
2023;43:733-734. doi:10.1111/liv.15530
14783231, 2023, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/liv.15530 by Wonkwang University, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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