背景:结核病(TB)由结核分枝杆菌(Mtb)引起,通常会感染肺部。然而,肺外形式的结核病可以在大约20%的病例中发现。有人建议,高达10%的肺外结核会影响肌肉骨骼系统,其中脊柱元素(脊柱结核,大约50%的病例涉及STB)。STB是一种具有非特异性症状的衰弱性疾病,诊断通常会延迟数月至数年。在我们的脊髓结核X队列中,我们的目标是使用全身18F-脱氧葡萄糖正电子发射断层扫描计算机断层扫描(PET/CT)描述STB的临床表型,并在PET/CT上确定不同播散阶段的特定基因表达谱。在这里,我们报告了招募到我们队列中的第一位患者,在治疗开始之前接受了PET/CT检查,在6个月和12个月时-TB治疗完成时。
方法:一名27岁的免疫功能正常的男性,表现为严重的胸腰椎背痛,持续9个月,伴有严重的止痛步态和盗汗。整个脊柱的磁共振成像(MRI)显示与STB一致的多级脊柱疾病(T5/6,T11/12,L3/4)。在知情同意并招募到脊髓结核X队列后,患者根据方案接受了PET/CT检查,显示孤立的多水平STB(T4-7,T11/12,L3/4),没有合并的肺部或泌尿生殖系统病变。然而,痰和尿液为XpertMTB/RIFUltra阳性,从尿液样品中培养Mtb。T11/12病变的CT引导活检证实了对XpertMTB/RIFUltra的药物敏感性Mtb,并根据当地指南开始对患者进行12个月的TB治疗。6个月的随访PET/CT显示,尽管临床特征和实验室标志物得到了显着改善,但新的和现有的脊柱病变的FDG摄取增加。经过9个月的治疗,病人出现了急性尿道狭窄,很可能是由于泌尿生殖系统结核,插入耻骨上导管。12个月的PET/CT显示所有病灶的PET/CT值明显下降,然而,在TB治疗结束时存在显著的持续性脊髓炎症.临床上,结核病控制计划认为患者治愈,目前正在等待尿道成形术.
结论:在我们的案例中,PET/CT作为初步评估的一种有价值的成像方式出现,通过揭示更全面的广泛疾病来超越MRI。随后6个月的PET/CT扫描发现了新的病变,并在现有的病变中增加了炎症,而在结核病治疗结束时,所有病变均表现出改善。然而,FDG贪婪的解释仍然模棱两可,是否与活动性感染和存活的Mtb相关。或表明愈合过程的纤维和成骨细胞活性。此外,尽管痰和尿液微生物学呈阳性,但PET/CT上没有脊柱外TB病变可能是由细菌减少引起的,脊柱外器官的亚临床感染。脊髓结核X队列在诊断时努力揭示全身成像模式,他们在结核病治疗的中途发展,治疗完成后。最终,这项研究旨在提高我们对这种复杂疾病的生物学理解。
BACKGROUND: Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb) and typically infects the lungs. However, extrapulmonary forms of TB can be found in approximately 20% of cases. It is suggested, that up to 10% of extrapulmonary TB affects the musculoskeletal system, in which spinal elements (spinal tuberculosis, STB) are involved in approximately 50% of the cases. STB is a debilitating disease with nonspecific symptoms and diagnosis is often delayed for months to years. In our Spinal TB X Cohort, we aim to describe the clinical phenotype of STB using whole-body 18 F-fluorodeoxyglucose positron emission tomography computed tomography (PET/CT) and to identify a specific gene expression profile for the different stages of dissemination on PET/CT. Here we report on the first patient recruited into our cohort who underwent PET/CT before treatment initiation, at 6-months and at 12-months - time of TB treatment completion.
METHODS: A 27-year-old immunocompetent male presented with severe thoracolumbar back pain for 9 months with severe antalgic gait and night sweats. Magnetic resonance imaging (MRI) of the whole spine revealed multilevel spinal disease (T5/6, T11/12, L3/4) in keeping with STB. After informed consent and recruitment into the Spinal TB X Cohort, the patient underwent PET/CT as per protocol, which revealed isolated multilevel STB (T4-7, T11/12, L3/4) with no concomitant lung or urogenital lesion. However, sputum and urine were Xpert MTB/RIF Ultra positive and Mtb was cultured from the urine sample. CT-guided biopsy of the T11/12 lesion confirmed drug-sensitive Mtb on Xpert MTB/RIF Ultra and the patient was started on TB treatment according to local guidelines for 12 months. The 6-month follow-up PET/CT revealed new and existing spinal lesions with increased FDG-uptake despite significant improvement of clinical features and laboratory markers. After 9 months of treatment, the patient developed an acute urethral stricture, most likely due to urogenital TB, and a suprapubic catheter was inserted. The 12-month PET/CT showed significantly decreased PET/CT values of all lesions, however, significant persistent spinal inflammation was present at the end of TB treatment. Clinically, the patient was considered cured by the TB control program and currently awaits urethroplasty.
CONCLUSIONS: In our case, PET/CT emerged as a valuable imaging modality for the initial assessment, surpassing MRI by revealing more comprehensive extensive disease. Subsequent PET/CT scans at 6-month uncovered new lesions and increased inflammation in existing ones, while by the end of TB treatment, all lesions exhibited improvement. However, the interpretation of FDG avidity remains ambiguous, whether it correlates with active infection and viable Mtb. or fibro- and osteoblast activity indicative of the healing process. Additionally, the absence of extraspinal TB lesions on PET/CT despite positive microbiology from sputum and urine maybe explained by paucibacillary, subclinical infection of extraspinal organs. The Spinal TB X Cohort endeavours to shed light on whole-body imaging patterns at diagnosis, their evolution midway through TB treatment, and upon treatment completion. Ultimately, this study aims to advance our understanding of the biology of this complex disease.