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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PD Dr. J. Meller
Abteilung Nuklearmedizin
Robert Koch-Str. 40
37075 Göttingen
Phone: +49 / 5 51 / 39 85 12
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Email: jmeller@med.uni-goettingen.de
