In routine practice, oncologic workup is responsible for the majority of referrals for whole-body FDG-PET/CT. The indications in oncology include staging, restaging, assessment of therapy response, and detection of recurrence. In spite of the great success achieved by FDG-PET imaging in the evaluation of malignant disorders, the modality is not specific for the diagnosis of cancer.[1] It has been noted that processes such as infection and inflammation, and particularly granulomatous diseases, also cause increased FDG uptake in the affected tissues.[2–6]
Tuberculosis (TB) is a chronic granulomatous inflammation caused by Mycobacterium tuberculosis. India accounts for nearly a third of the global burden of tuberculosis, with approximately 1.8 million new cases of tuberculosis reported every year.[7] Although it involves the thorax most frequently, any organ system in the body can be infected. The clinical and radiological features of tuberculosis are known to mimic those of many other diseases. The role of FDG PET and PET/CT in TB and other inflammatory diseases is evolving and is not as yet clearly defined.
At the same time, there is a considerable increase in PET/CT referrals for patients with fever of unknown origin (FUO), generalized lymph node (LN) enlargement, and mediastinal or abdominal lymphadenopathy, especially when other investigations are inconclusive. The aim of such referrals is generally to rule out an underlying malignant disease or to detect an inflammatory pathology. Infections remain the most frequent cause of FUO, followed by neoplasms and noninfectious inflammatory diseases.[8,9] In India, TB is known to be the commonest infection to present as FUO.[10] ′The high sensitivity of FDG PET in detecting malignant lesions, infections, and other inflammatory processes alike, makes it an important tool that has the potential to play a role in the diagnostic protocol and management of patients with FUO.′[11,12]
While performing FDG PET/CT for oncologic workup, we found TB to be a common cancer mimic, producing uptake patterns that are indistinguishable from that of cancer. Many studies have documented increased FDG uptake in active TB in diverse anatomical locations, mimicking malignant processes.[5,6,13–17] Though a high standardized uptake value (SUV), greater than 2.5, is attributed to malignant lesions,[18] we have encountered high values of peak SUV, upto 21.0 (range 2.2-21.0), in tuberculous lesions Figures [1–7].
Figure 1 (A-E).
Mediastinal lymphadenopathy in a patient of carcinoma colon who, post-hemicolectomy and post-chemotherapy was detected to have raised tumor marker (CEA) levels. Coronal plain CT (A), PET (B), PET/CT (C) with axial plain CT (D), and PET/CT (E) images of the thorax show FDG-avid mediastinal nodes (SUV 6.7) (arrows). No pulmonary lesion was detected on the CT images. The patient underwent mediastinoscopy and lymph node biopsy, which revealed tuberculosis
Figure 7 (A-D).
Disseminated TB with multifocal hepatic and diffuse splenic uptake. Coronal plain CT (A) and PET (B) with axial PET/CT (C, D) images in a patient with FUO show diffuse increased FDG uptake in an enlarged spleen and multifocal uptake in the liver, mediastinal nodes, and patchy lung lesions (arrows). Transbronchial sampling from the subcarinal nodes revealed tuberculosis. PET in this case guided the tissue sampling from an active lesion in an accessible site, using the least invasive route
Figure 6 (A-D).
Repeat axial CT (A), PET/CT (B) images of the thorax, and axial (C) and coronal (D) PET/CT abdomen images of the same patient described in Figure 5 show complete resolution of the liver lesion and a considerable reduction in the size of the left hilar mass and the intensity of the FDG uptake (arrow) (SUVmax 3.4). PET was useful in assessing response to therapy
Case Material
All studies were performed on an integrated PET/CT scanner (Biograph 2, Siemens Medical Solutions, Erlangen, Germany). A whole-body PET/CT study, from the skull base to the mid-thigh level, was performed 1 h after intravenous injection of 370 MBq of FDG. Nonenhanced CT scan images were obtained, using 130 KV and 100 mAs. CT-based attenuation correction was done. Images were reconstructed using a standard iterative algorithm and reformatted into transaxial, coronal, and sagittal views. Fusion images of PET and CT were obtained. The PET/CT images were evaluated by one radiologist and one nuclear medicine physician in all cases. Focal accumulation of FDG above the background muscle uptake in an abnormal location was considered a positive finding. Areas of increased uptake were evaluated qualitatively and quantitatively using standard methods.[19] The peak SUV (SUVmax) of the abnormal areas was noted.
Patients with a diagnosis of tuberculosis were identified from the database. A large number of these were referred for workup of FUO or lymphadenopathy [Figures 5–9]. Others included suspected cases of malignancy that turned out to have tuberculosis [Figures 2 and 10–12] and follow-up cases of cancer found to have associated TB [Figure 1]. A few patients had established TB and were referred for evaluation of the extent of disease or to monitor response to treatment [Figures 3 and 13]. Table 1 lists all the cases described here.
Figure 5 (A-F).
Tuberculous hilar lymphadenopathy associated with a solitary focal hepatic lesion. A chest radiograph in a 14-year-old girl with cough revealed a left-sided hilar mass. Axial CT thorax with lung (A) and mediastinal (B), axial PET/CT (C), axial abdominal CT (D) and PET/CT(E), and coronal PET/CT (F) images show intense FDG uptake in the enlarged left hilar nodes (SUV 9.7) and focal uptake in the liver, subdiaphragmmatic in location (arrows). The Mantoux test was strongly positive, along with the TB polymerase chain reaction test. The patient was started on antituberculous therapy
Figure 9 (A-D).
Pulmonary and spinal tuberculosis. Axial CT chest (A), axial PET/CT (B), sagittal reconstructed spine (C), and sagittal PET/ CT (D) images in a patient with FUO show FDG-avid reticulonodular lesions in the left lung with associated FDG-avid foci in two dorsal vertebrae (arrows), with no bony lesion seen in the corresponding CT images. The patient responded well to empirical antituberculous therapy
Figure 2 (A-C).
Cerebral tuberculous abscess. A 70-year-old diabetic with acute-onset hemiparesis. Axial plain CT (A), PET (B), and PET/CT (C) images show hypodense lesions in the right basal ganglia and thalamus (arrows) with a mass effect. PET shows two ′doughnut lesions,′ with peripheral FDG concentration and central cold areas. The pattern is suggestive of, though not specific for, tuberculous abscesses. Stereotactic biopsy revealed tuberculosis
Figure 10 (A-F).
Tuberculosis of the esophagus. Endoscopy in a 42-year-old man with dysphagia revealed a mid-esophageal stricture. Sagittal (A) and coronal (B) PET, sagittal plain CT (C), coronal PET/CT (D), axial PET/CT (E), and axial CT (F) images of the thorax show increased FDG uptake in the mildly thickened walls of the mid-esophagus (arrows), with multiple FDG-avid nodes in the mediastinum and supraclavicular regions. Carcinoma of the esophagus was suspected. Biopsy from the esophagus and the supraclavicular lymph nodes revealed tuberculosis
Figure 12 (A-F).
Tuberculosis of chest wall and adrenal gland. Axial (A) and coronal (D) plain CT, PET (B, E), and axial PET/CT (C, F) images in a 57-year-old man with an anterior right chest wall swelling shows intense subcutaneous FDG uptake within a soft tissue mass involving the fi fth costochondral junction, associated with increased FDG uptake in an enlarged left adrenal gland (arrows). A soft tissue chest wall sarcoma with adrenal metastasis was suspected. Biopsy of the chest wall lesion revealed TB. The lesions regressed following anti-tuberculous therapy
Figure 3 (A-D).
Pulmonary tuberculosis. A sputum positive case of pulmonary TB with clinically poor response to 2 months of antituberculous therapy. Coronal plain CT (A) and PET/CT (B) with axial plain CT (C) and PET/CT (D) images reveal extensive FDG-avid pulmonary parenchymal lesions. The superior segment of the left lower lobe shows consolidation with central cavitation (arrows) with an SUVmax of 10.1. These fi ndings suggest active disease, indicating an inadequate response to therapy
Figure 13 (A-E).
Tuberculosis of the spine. A coronal plain CT reconstruction (A) in a 42-year-old man with upper back pain shows osteolytic lesions involving multiple contiguous mid-dorsal vertebrae (arrows), with a paravertebral cold abscess and a left-sided pleural effusion, suggesting tuberculosis. Coronal (B) and sagittal (C) PET with axial plain CT (D), and corresponding PET/CT (E) images acquired to evaluate the extent of the disease show intense FDG uptake in the affected thoracic vertebrae. No other FDG-avid lesion is detected. The patient responded well to anti-tuberculous therapy
Table 1.
Case details
| Fig. no | Organ System | Location of lesion on PET/CT | Indication for PET/CT | Original diagnosis | Method of confirming diagnosis | Uptake intensity (SUVmax) | CT features |
|---|---|---|---|---|---|---|---|
| 1 | Lymphoreticular | Mediastinum | Ca. colon follow-up | Mediastinal nodal metastases | Mediastinoscopy and LN biopsy | 7.9 | Discrete 10-18 mm sized mediastinal nodes |
| 2 | Brain | Basal ganglia and thalamus (right) | Mass lesion - brain | Glioma | Stereotactic biopsy | 9.4 | Hypodense lesion with mass effect. No calcification. |
| 3 | Thorax | Lungs (bilateral parenchymal lesions) | To assess response to ATT | Tuberculosis | Sputum AFB (+) | 10.1 | Bilateral reticulonodular opacities, consolidation with cavitation |
| 4 | Thorax | Lung (SPN) | To assess nature (benign vs malignant) | ? Carcinoma lung | Wedge resection and biopsy | 19.0 | Soft tissue density lung nodule with enlarged parabronchial node (right) |
| 5,6 | Lymphoreticular | Hilar adenopathy | To assess nature (benign vs malignant) | ? Tuberculosis ? Lymphoma | Tuberculosis PCR, Mantoux, response to ATT | 9.7 | Hilar lymph node mass (left) |
| 7 | Multisystem | Liver, spleen, lung parenchyma, mediastinal nodes | FUO | ? Tuberculosis ? Lymphoma | Transbronchial sampling of mediastinal nodes | 6.1-12.4 | Hepatosplenomegaly, patchy lung consolidation |
| 8 | Multisystem | Spleen, abdominal and supraclavicular nodes | FUO | ? Tuberculosis ? Lymphoma | Supraclavicular lymphnode biopsy | 14.3 | Retroperitoneal lymphadenopathy, hypodense lesions in spleen |
| 9 | Skeletal | Dorsal spine, lung | FUO | ? Tuberculosis | Response to empirical ATT | 6.4 | Reticulonodular lung lesions. Bones normal. |
| 10 | GIT | Esophagus, mediastinal nodes | Esophageal stricture | ? Ca. Esophagus | Esophageal biopsy | 3.6-10.1 | Mediastinal lymphadenopathy |
| 11 | GIT | Caecum, abdominal and supraclavicular nodes | Generalized lymphadenopathy. Lump in Rt. iliac fossa | ? Ca. caecum | Cecal and LN biopsy | 16.3 | Caecal mass, abdominal and supraclavicular nodes |
| 12 | Multisystem | Chest wall, adrenal gland | Chest wall swelling; to assess nature (benign vs malignant) | ? Soft tissue sarcoma | Biopsy from the chest wall mass. Response to ATT. | 8.6 | Soft tissue mass fifth costochondral junction (right). Enlarged left adrenal gland. |
| 13 | Skeletal | Dorsal spine | To assess disease extent | Caries spine | Response to empirical ATT | 7.8 | Osteolytic lesions in mid-dorsal spine, paravertebral cold abscess, and pleural effusion |
Role of Accompanying CT Scans
CT images of PET/CT were helpful in characterizing the lesions morphologically and in some instances, especially in lung and bone lesions, were indicative of a tuberculous etiology. We did not use intravenous contrast enhancement for our CT scans. However, the use of intravenous contrast may increase the specificity of diagnosis in some instances, by more accurately demonstrating the presence of necrosis in enlarged lymph nodes or the presence of typical focal lesions in the liver and spleen.
Organs
Central nervous system
According to Kang et al., ′the possibility of a tuberculous brain abscess should be considered when FDG accumulates at the periphery of a ring-enhancing lesion in a chronically ill or immunocompromised patient.′[20] FDG-PET shows intense tracer uptake at the periphery of the lesion in a ring-like or ′doughnut′ pattern, with low uptake within the abscess cavity [Figure 2].
Thorax
Intense FDG uptake is usually noted in active tuberculous lesions involving the lung parenchyma[6,21] [Figure 3]. This is attributed to the presence of a large number of activated macrophages which have a high glycolytic rate. The CT images in PET/CT may add useful morphological information in defining the nature of the lung lesions. PET may help in determining the activity in the lesions, define the extent of disease, and aid in assessing the response to therapy. High FDG uptake has been reported in tuberculomas[16] [Figure 4].
Figure 4 (A-D).
Pulmonary tuberculoma. Axial lung (A) and mediastinal window (C) CT images show a soft tissue density nodule in the right upper lobe of the lung. Axial (B) and coronal (D) PET/CT images reveal intense FDG uptake in the nodule (SUVmax of 19.0) and an enlarged right parabronchial node (arrows), suggesting a malignant neoplasm. Wedge resection and histopathologic examination of this solitary pulmonary nodule revealed TB. In TB endemic countries like India, FDG-avid lung lesions need to be interpreted cautiously
A common dilemma faced during oncologic workup with FDG-PET/CT is the presence of FDG-avid mediastinal or hilar nodes in cases of extrathoracic malignancies (e.g., carcinoma colon, renal cell carcinoma, or carcinoma cervix). In these entities, isolated mediastinal nodal metastases are uncommon and tuberculosis may be the cause of FDG-avid mediastinal or hilar adenopathy [Figure 1].
Lymphoreticular system
In mediastinal, supraclavicular, and intra-abdominal tuberculous lymphadenitis, a high focal uptake of FDG has been reported.[21–23] We found FDG-avid tuberculous nodes in diverse locations [Figures 157 and 8]. Also, disseminated TB can variably involve the liver and spleen. In proven cases of disseminated TB, we found varied patterns of increased FDG uptake in the liver and spleen, some showing diffuse and others focal uptake [Figures 7 and 8].
Figure 8 (A-C).
Disseminated TB with focal splenic lesions, sparing of the liver and with extensive lymph node involvement. Coronal CT (A), PET (B), and PET/CT (C) images in a patient with cervical lymphadenopathy show large FDG-avid cervical, supraclavicular, and abdominal nodes. FDG-avid focal lesions are seen in the spleen (arrows). The differential diagnoses included lymphoreticular malignancy (lymphoma), metastases from an unknown primary, and tuberculosis. A supraclavicular lymph node biopsy confi rmed tuberculosis. Note the relative sparing of the liver
Skeletal system
Osteomyelitis: Tuberculous osteomyelitis is a common entity in Asian countries, with frequent involvement of the spinal column. This entity classically involves contiguous dorsal or lumbar vertebral bodies and the intervening discs, often associated with abscess formation and granulation tissue. FDG-PET has a high sensitivity for the detection of chronic osteomyelitis.[24] Tuberculous lesions are found to have increased FDG uptake in the active regions of granulomatous inflammation, with cold areas that represent necrosed tissue (pus)[25] [Figures 9 and 13].
Abdomen
Although TB can involve any part of the gastrointestinal tract, from the esophagus to the anal canal, the most commonly involved regions are the distal ileum and cecum. The lesions may be ulcerative, proliferative, or ulceroproliferative. The latter type may present as a bowel mass, indistinguishable from bowel cancer on routine imaging modalities and may exhibit intense uptake on FDG-PET imaging[14] [Figures 10 and 11]. Involvement of the adrenal gland may also present with FDG avidity [Figure 12]. The role of FDG-PET in assessing the urinary system is limited because of the interference caused by the high concentration of the excreted FDG in urine, which masks FDG-avid lesions.
Figure 11 (A-E).
Tuberculosis of the cecum. Coronal PET/CT (A), sagittal plain CT reconstruction (B), sagittal PET/CT (C), axial plain CT (D), and axial PET/CT (E) images of the abdomen in a 36-year-old man with generalized lymphadenopathy shows increased FDG uptake in the cecum (arrows), with irregularly thickened walls (SUV 16.8) and multiple enlarged supraclavicular and abdominal lymph nodes. Disseminated carcinoma of the cecum was suspected. Colonoscopic biopsy of the cecal lesion and cervical lymph node biopsy, both revealed tuberculosis. The patient responded well to antituberculous therapy
Dual time point imaging
Studies have documented the value of additional delayed images, obtained 90-120 min after FDG injection, in differentiating benign from malignant lesions. On delayed images, inflammatory lesions show increased FDG washout, whereas cancerous lesions usually exhibit further accumulation of tracer.[26,27] However, in our experience, in 15 TB patients, we found equivocal results with dual time point imaging at 45 and 120 min post-FDG injection; a majority of the tuberculous lesions showed no reduction, a few showed mild reduction (up to 20%), and many showed an increase (varying from 10-40%), in peak SUV.
The future
FDG-PET has a high sensitivity for infection and inflammation but poor specificity. One approach that may increase the diagnostic accuracy of PET for tuberculosis includes the combined use of F-18 FDG and C-11 acetate, as the latter accumulates in tumors but not in inflammatory lesion.[28] Thus, C-11 acetate may help differentiate inflammation from neoplasms. In the future, labeling antituberculous drugs like isoniazid and rifampicin with positron emitting isotopes may culminate in the development of TB-specific PET radiopharmaceuticals.
Conclusion
Due to the high prevalence of tuberculosis in India, false positive cases during oncologic workup with FDG-PET are commonly encountered in practice. Though FDG PET/CT is not specific for tuberculosis, it plays an important role in the evaluation of known or suspected TB cases. FDG PET/CT can determine the activity of lesions, guide biopsy from active sites, assess disease extent, detect occult distant foci, and evaluate response to therapy. Active tuberculous lesions often exhibit a high degree of FDG uptake, though this can vary, depending upon the grade of inflammatory activity. No characteristic pattern has been identified as yet that will definitely differentiate them from cancerous lesions.
With FDG-PET imaging per se, based on semiquantitative analysis using SUV and the dual time point imaging technique, it is currently not possible to differentiate malignant lesions from active tuberculosis consistently. However, with an integrated PET/CT technique, the CT scan images may help differentiate tuberculosis from malignant lesions, using morphologic criteria. The use of intravenous contrast increases this ability. In future, new, more specific radiotracers, like positron-emitter labeled antituberculous drug molecules may help to differentiate TB from cancer and nontuberculous inflammatory processes.
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
References
- 1.Rosenbaum SJ, Lind T, Antoch G, Bockisch A. False-positive FDG PET uptake the role of PET/CT. Eur Radiol. 2006;16:1054–65. doi: 10.1007/s00330-005-0088-y. [DOI] [PubMed] [Google Scholar]
- 2.Yamada S, Kubota K, Kubota R, Ido T, Tamahashi N. High accumulation of fluorine-18-fluorodeoxyglucose in turpentine-induced inflammatory tissue. J Nucl Med. 1995;36:1301–6. [PubMed] [Google Scholar]
- 3.Ichiya Y, Kuwabara Y, Sasaki M, Yoshida T, Akashi Y, Murayama S, et al. FDG-PET in infectious lesions: The detection and assessment of lesion activity. Ann Nucl Med. 1996;10:185–91. doi: 10.1007/BF03165391. [DOI] [PubMed] [Google Scholar]
- 4.Yago Y, Yukihiro M, Kuroki H, Katsuragawa Y, Kubota K. Cold tuberculous abscess identified by FDG PET. Ann Nucl Med. 2005;19:515–8. doi: 10.1007/BF02985581. [DOI] [PubMed] [Google Scholar]
- 5.Chen YK, Shen YY, Kao CH. Abnormal FDG PET imaging in tuberculosis appearing like lymphoma. Clin Nucl Med. 2004;29:124. doi: 10.1097/01.rlu.0000109300.89514.35. [DOI] [PubMed] [Google Scholar]
- 6.Yang CM, Hsu CH, Lee CM, Wang FC. Intense uptake of [F-18]-fluoro-2 deoxy-D-glucose in active pulmonary tuberculosis. Ann Nucl Med. 2003;17:407–10. doi: 10.1007/BF03006610. [DOI] [PubMed] [Google Scholar]
- 7.Park K. Park′s textbook of preventive and social medicine. 18th ed. Jabalpur: Banarsidas Bhanot; 2005. Epidemiology of communicable diseases: Tuberculosis; pp. 146–61. [Google Scholar]
- 8.Gelfand JA, Callahan MV. Fever of Unknown origin. In: Kasper DL, Fauci AS, Longo DL, editors. Harrisons Principles of Internal Medicine. 16th ed. New York: McGraw Hill; 2005. pp. 116–21. [Google Scholar]
- 9.Gaeta GB, Fusco FM, Nardiello S. Fever of unknown origin: A systematic review of the literature for 1995-2004. Nucl Med Commun. 2006;27:205–11. doi: 10.1097/00006231-200603000-00002. [DOI] [PubMed] [Google Scholar]
- 10.Kejariwal D, Sarkar N, Chakraborti SK, Agarwal V, Roy S. Pyrexia of unknown origin: A prospective study of 100 cases. J Postgrad Med. 2001;47:104–7. [PubMed] [Google Scholar]
- 11.Meller J, Altenvoerde G, Lehmann K, Sahlmann C, Meyer I, Behe M, et al. Fever of unknown origin - Prospective comparison of 18 FDG- imaging with a double head coincidence camera (DHCC) and Ga-67 citrate SPECT. Eur J Nucl Med. 2001;28:OS387. doi: 10.1007/s002590000341. [DOI] [PubMed] [Google Scholar]
- 12.Meller J, Sahlmann CO, Scheel AK. 18 F-FDG PET and PET/CT in fever of unknown origin. J Nucl Med. 2007;48:35–45. [PubMed] [Google Scholar]
- 13.Chang JM, Lee HJ, Goo JM, Lee HY, Lee JJ, Chung JK, et al. False positive and false negative FDG-PET scans in various thoracic diseases. Korean J Radiol. 2006;7:57–69. doi: 10.3348/kjr.2006.7.1.57. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Wang HY, Lin WY. Jejunal tuberculosis: Incidental finding on an FDG-PET scan. Kaohsiung J Med Sci. 2006;22:34–8. doi: 10.1016/S1607-551X(09)70218-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Takalkar AM, Bruno GL, Reddy M, Lilien DL. Intense FDG activity in peritoneal tuberculosis mimics peritoneal carcinomatosis. Clin Nucl Med. 2007;32:244. doi: 10.1097/01.rlu.0000255239.04475.c2. [DOI] [PubMed] [Google Scholar]
- 16.Goo JM, Im JG, Do KH, Yeo JS, Seo JB, Kim HY, et al. Pulmonary tuberculoma evaluated by means of FDG PET: Findings in 10 cases. Radiology. 2000;216:117–21. doi: 10.1148/radiology.216.1.r00jl19117. [DOI] [PubMed] [Google Scholar]
- 17.Fernandez P, Guyot M, Lazaro E, Viallard JF, Allard M, Ducassou D. Systemic tuberculosis presenting as an epiglottic mass detected on F-18 FDG PET/CT. Clin Nucl Med. 2007;32:719–24. doi: 10.1097/RLU.0b013e318123f7fb. [DOI] [PubMed] [Google Scholar]
- 18.Lowe VJ, Delbeke D, Coleman RE. Applications of PET in oncologic imaging. In: Colemen RE, Patton JA, Wackers FJ, Gotschalk A, editors. Diagnostic Nuclear Medicine. 4th ed. Lippincot: Philadelphia: 2003. pp. 987–1014. [Google Scholar]
- 19.Takalkar AM, El-Haddad G, Lilien DL. FDG-PET and PET/CT - Part I. Indian J Radiol Imaging. 2007;17:169–80. [Google Scholar]
- 20.Kang K, Lim I, Roh JK. Positron emission tomographic findings in a tuberculous abscess. Ann Nucl Med. 2007;21:303–6. doi: 10.1007/s12149-007-0023-1. [DOI] [PubMed] [Google Scholar]
- 21.Bakheet SM, Powe J, Ezzat A, Rostom A. F-18-FDG uptake in tuberculosis. Clin Nucl Med. 1998;23:739–42. doi: 10.1097/00003072-199811000-00003. [DOI] [PubMed] [Google Scholar]
- 22.Cook GJ, Fogelman I, Maisey MN. Normal physiological and benign pathological variants of 18-fluoro-2-deoxyglucose positron-emission-tomography scanning: Potential for error in interpretation. Semin Nucl Med. 1996;26:308–14. doi: 10.1016/s0001-2998(96)80006-7. [DOI] [PubMed] [Google Scholar]
- 23.Obama K, Kanai M, Taki Y, Nakamoto Y, Takabayashi A. Tuberculous lymphadenitis as a cause of obstructive jaundice: Report of a case. Surg Today. 2003;33:229–31. doi: 10.1007/s005950300051. [DOI] [PubMed] [Google Scholar]
- 24.Zhuang H, Duarte PS, Pourdehand M, Shnier D, Alavi A. Exclusion of chronic osteomyelitis with F-18 fluorodeoxyglucose positron emission tomographic imaging. Clin Nucl Med. 2000;25:281–4. doi: 10.1097/00003072-200004000-00009. [DOI] [PubMed] [Google Scholar]
- 25.James SL, Davies AM. Imaging of infectious spinal disorders in children and adults. Eur J Radiol. 2006;58:27–40. doi: 10.1016/j.ejrad.2005.12.002. [DOI] [PubMed] [Google Scholar]
- 26.Zhuang H, Pourdehnad M, Lambright ES, Yamamoto AJ, Lanuti M, Li P, et al. Dual time point 18F-FDG PET imaging for differentiating malignant from inflammatory processes. J Nucl Med. 2001;42:1412–7. [PubMed] [Google Scholar]
- 27.Matthies A, Hickeson M, Cuchiara A, Alavi A. Dual time point 18F-FDG PET for the evaluation of pulmonary nodules. J Nucl Med. 2002;43:871–5. [PubMed] [Google Scholar]
- 28.Liu RS, Shei HR, Feng CF. Combined 18F-FDG and 11C-acetate PET imaging in diagnosis of pulmonary tuberculosis. J Nucl Med. 2002;43:127. [Google Scholar]