Nuklearmedizinische Diagnostik prolongierter Fieberzustände

Zusammenfassung

Fieber (> 38,2 °C) bei immunkompetenten und nicht neutropenischen Patienten, das über mindestens 2-3 Wochen persistiert und dessen Ursache sich trotz einwöchiger adäquater Diagnostik nicht eruieren lässt, wird als „klassisches Fieber unbekannter Ursache” (oder englisch: FUO = „fever of unknown origin”) bezeichnet. Die meisten dieser Patienten (50-60 %) weisen autoimmune Erkrankungen, Kollagenosen oder Malignome auf. Lediglich bei 20-40 % der Fälle finden sich Entzündungen und Infektionserkrankungen. Somit unterscheiden sich Patienten mit klassischem FUO deutlich von Patienten mit neutropenischen, nosokomialen und postoperativen Fieberzuständen, die in der Regel auf akute entzündliche Prozesse zurückzuführen sind. In vitro oder in vivo radioaktiv markierte Leukozyten weisen eine hohe Sensitivität und Spezifität bei der Diagnostik einer granulozytären Entzündung auf. Da bei FUO-Patienten die Prävalenz solcher Entzündungen aber gering ist, tragen markierte Leukozyten nur selten zur Abklärung der endgültigen Fieberursache bei. Ihr Einsatz ist daher eher bei Patienten mit neutropenischen, nosokomialen und postoperativen Fieberzuständen indiziert. ⁶⁷Ga-Zitrat ist gegenwärtig das einzige kommerziell verfügbare Radiopharmakon, das sowohl eine Anzahl von Tumoren aber auch granulozytäre, autoimmune und granulomatöse Entzündungen darzustellen vermag. Die Anzahl diagnostischer Szintigrafien bei dieser Methode liegt bei FUO-Patienten höher als beim Einsatz markierter Leukozyten. Der Positronenstrahler [¹⁸F]-2-Fluor-2′-Deoxyglukose (FDG) wird seit ca. 5 Jahren bei der Diagnostik von FUO systematisch evaluiert. Die hierbei gewonnenen Daten lassen schon jetzt den Schluss zu, dass die FDG-PET zumindest beim klassischen FUO die bisherigen szintigrafische Techniken ersetzen wird. Verglichen mit markierten Leukozyten und mit ⁶⁷Ga-Zitrat kann mittels FDG ein breiteres Krankheitsspektrum in einer wesentlich kürzeren Zeit bei gleichzeitig geringerer Strahlenexposition diagnostiziert werden. Es ist zu erwarten, dass der Einsatz der PET / CT-Technologie zu einer weiteren Verbesserung der klinischen Ergebnisse, vor allem durch eine bessere anatomische Zuordnung der Befunde, führen wird.

Abstract

Fever of unknown origin (FUO) was originally defined as recurrent fever of 38.2 °C or higher, lasting 2-3 weeks or longer, and undiagnosed after 1 week of hospital evaluation. The last criterion has undergone modification and is now generally interpreted as no diagnosis after appropriate inpatient or outpatient evaluation. The three major categories that account for the majority of fever of unknown origin (FUO) are infections, malignancies and non infectious inflammatory diseases. In this respect FOU in its original definition is clearly separated from nosocomial, postoperative and neutropenic fever, where acute infection is more common. Although in-vitro- or in-vivo-labelled white blood cells (WBCs) have a high diagnostic accuracy in the detection and exclusion of granulocytic pathology, these methods are only of limited value in patients with “classic” FUO in establishing the final diagnosis due to the low prevalence of acute infection in this group. Labelled WBCs therefore seem to be more useful in patients with nosocomial, postoperative and neutropenic fever. ⁶⁷Ga citrate is the only commercially available gamma emitter in imaging acute, chronic, granulomatous and autoimmune inflammation and also various malignant diseases. Therefore ⁶⁷Ga citrate was for a long time considered to be the tracer of choice in the diagnostic work-up of FUO. The number of ⁶⁷Ga scans contributing to the final diagnosis was found to be higher than it has been reported for labelled WBCs. The positron emitter [¹⁸F]-2-fluoro-2′-deoxy-D-glucose (FDG) have been systematically evaluated in the context of classic FUO by several groups within last 5 years. This data, although limited, indicate that FDG-imaging should considered as the most promising procedure in patients with undetermined fever. FDG-PET seems to be more sensitive than other techniques, offers a more rapid diagnosis without an increase of the patients radioactive burden. It is expected that the PET / CT technology will improve the diagnostic impact of FDG-PET further, as already shown in the oncological context, mainly by improving the specificity of the method.

Schlüsselwörter

prolongiertes Fieber - Sepsis - postoperatives Fieber - Szintigrafie - FDG-PET - Infektion - Entzündung

Key words

fever of unknown origin - occult sepsis - postoperative fever - scintigraphy - FDG-PET - infection - inflammation

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