18

F-FDG-PET/CT Imaging of Thoracic and

Extrathoracic Tuberculosis in Children
Matthieu Pelletier-Galarneau, MD, MSc,*,†,§ Patrick Martineau, MD, PhD,*,‡
Lionel S. Zuckier, MD,* Xuan Pham, MD,* Raymond Lambert, MD,§ and
Sophie Turpin, MD§

Tuberculosis (TB) remains a major health problem, affecting approximately one-third of the
world's population. The tubercle bacillus can affect virtually any organ of the human body and if
left untreated can lead to severe morbidity and death. Diagnosis of active TB is challenging,
especially in children. As a “great imitator,” the disease can mimic numerous other
pathologies, both clinically and at imaging. Although recognition of active TB is crucial to
initiate adequate treatment in a timely fashion, thereby preventing transmission of disease,
differentiation of active and quiescent disease is not always straightforward. Since the first
reports more than 20 years ago, FDG-PET/CT imaging has been shown to detect active
disease with accuracy equal or superior to other conventional imaging modalities. The role of
FDG-PET in evaluating patients with TB is rapidly expanding. FDG-PET/CT can effectively
identify foci of intrathoracic and extrathoracic TB, assess disease activity, differentiate between
active and latent disease, monitor response to therapy, identify potential biopsy targets, and
serve as a surrogate end point for new drug trials. Efficacy of FDG-PET/CT in the especially
challenging pediatric population will be the focus of this review.
Semin Nucl Med ]:]]]-]]] C 2016 Elsevier Inc. All rights reserved.

Introduction transmission are high concentration of organism in the air,

Tuberculosis (TB) is caused by Mycobacterium tuberculosis (M.
tuberculosis) bacilli. Bacilli are carried in small droplet particles
measuring between 1 and 5 mm, expelled when a person with
pulmonary or laryngeal TB coughs, sneezes, or even speaks.1
When inhaled, the particles reach the alveoli where the bacilli
proliferate, resulting in TB infection.1,2 These droplets are small
enough to stay suspended in the air for several hours,
promoting transmission of the infection, especially in indoor
spaces.3 The major factors increasing the likelihood of TB
*Division of Nuclear Medicine, The Ottawa Hospital, Ottawa, Ontario,
Canada.
†Department of Radiology and Nuclear Medicine, Montreal Heart Institute,
Montréal, Québec, Canada.
‡Department of Radiology, The Ottawa Hospital, Ottawa, Ontario, Canada.
§Division of Nuclear Medicine, CHU Sainte-Justine, Montréal, Québec,
Canada.
Address reprint requests to Matthieu Pelletier-Galarneau, MD, MSc, Nuclear
Medicine Department, Centre Hospitalier Universitaire Sainte-Justine, Uni-
versité de Montréal, 3175 Chemin de la Côte-Sainte-Catherine, Montréal,
Québec, Canada H3T 1C5. E-mail: matthieu.pelletier-galarneau@
icm-mhi.org
prolonged exposure to contaminated air, high bacterial viru-
lence, and host immunosuppression.1,3
TB remains a major international health problem, affecting
approximately one-third of the world's population. The World
Health Organization (WHO) reports that in 2015 alone, the
estimated incidence of TB was 10.5 million cases with
1.4 million deaths, the vast majority of which occurred in
low- and middle-income countries.4 The pediatric population
was not spared, with an estimated 550,000 children becoming
ill and 80,000 human immunodeficiency virus (HIV)-negative
children dying of TB annually.5 Spread of TB is closely
associated with the HIV epidemic and is a leading cause of
death among HIV-infected patients, particularly in low-income
countries.6 HIV and TB coinfection has altered the demo-
graphic and natural history of the disease, leading to an
increase in the absolute number of persons infected with TB,
principally in women of childbearing age and infants.6-9
In high-income countries, TB is closely linked to immigra-
tion, with a disproportionally high number of foreign-born
cases compared with those of local-born cases. In these
countries, approximately half of all cases affect migrants and,
with the incidence of foreign-born cases decreasing more

http://dx.doi.org/10.1053/j.semnuclmed.2016.12.003 1
0001-2998/& 2016 Elsevier Inc. All rights reserved.
2 M. Pelletier-Galarneau et al.
slowly than the incidence of local-born cases, this disparity is
expected to grow.10 The situation is similar in children residing
in high-income countries; TB rates per 100,000 population are
estimated to be 24 for foreign-born children, 5 for local-born
children of foreign-born parents, and only 0.75 for local-born
children of local-born parents.11,12
Classically, TB is classified as primary or postprimary
(reactivation) disease where primary TB refers to disease
following recent infection, and postprimary TB refers to
endogenous reactivation of a latent infection.1 This concept
has been criticized as confusing and misleading.13 First of all,
the terminology implies a clear pathologic, clinical, and radio-
logical distinction between primary and postprimary TB while
in fact distinction between the two modes is not always
possible. It has been shown that many cases of “postprimary
disease” actually represent a new infection rather than reac-
tivation of a latent prior infection,14,15 and it may be clinically
impossible to differentiate between reactivation and reinfec-
tion. Secondly, primary and postprimary disease can have
overlapping presentations, and features strongly associated
with postprimary infection, such as cavitation, may also be
seen in primary disease. In this article, we use the term
“primary TB” to denote an initial TB infection, whereas
“postprimary TB” refers to either reactivation or reinfection.
FDG-PET/CT plays several useful roles in patients with
confirmed or suspected TB.16-19 In addition, owing to its high
prevalence, findings of TB may be encountered when performing
FDG-PET/CT for other indications, such as fever of unknown
origin. As such, physicians must be able to recognize the various
presentations of TB to limit contagion and to ensure that the
patient receives appropriate therapy. In this article, we review the
FDG-PET/CT and correlative-imaging findings of thoracic and
extrathoracic TB in the pediatric population, address the roles of
FDG-PET/CT, and provide insights regarding the strengths and
limitations of FDG-PET/CT for the assessment of this disease.
Thoracic TB
In children, most cases of TB represent primary infection.
Infants younger than 5 years are especially at risk of contracting
the disease.20 Most children infected with TB present with
thoracic manifestations. Investigating a child with suspected
TB is very similar to investigating an adult, relying on clinical
history, with emphasis on TB contact and HIV status, clinical
examination, tuberculin skin testing, and chest X-ray.9 In
children, bacteriologic confirmation is particularly difficult to
obtain,21 making imaging crucial in the work-up. Chest
radiography remains the recommended first-line imaging
modality, although it can be normal in 15% of patients with
confirmed TB.22 There are four main presentations of primary
thoracic TB in children: parenchymal disease, lymphadenop-
athy, miliary disease, and pleural effusion (Table 1).23
Parenchymal Disease
Parenchymal disease is seen in 60%-80% of pediatric cases,
with prevalence of lung involvement increasing with age.24-26
Table 1 Four Main Presentations of Primary Thoracic Tubercu-
losis in the Pediatric Population, With Relative Frequencies for
Different Age Groups
Infant Children Adolescent
(0-3 y) (3-10 y) (10-18 y)
Parenchymal þþ þþþ þþþ
disease
Consolidation þþþ þþþ þþ
Disseminated þ þ 
nodules
Cavitation   þþ
Fibrosis  þ þþ
Lymphadenopathy þþþ þþþ þþ
Miliary disease þ  
Pleural effusion þ þþ þþ
, Rare; þ, infrequent;þþ, somewhat frequent;þþþ, very frequent.
On chest X-ray, air-space consolidation is identified in up to
80% of children.2 On CT, parenchymal disease can take many
forms, including consolidation (40%-100%), disseminated
nodules (17%-54%), cavitation (27%-29%), and fibrosis
(17%).2,24,26,27 Parenchymal lesions, often referred to as
tuberculomas, are more frequently seen in the mid or lower
right lung,24-26 and bilateral lung involvement is present in
10%-50% of cases.2,28 Healing of primary TB lesions can lead
to fibrosis and is more frequent in postprimary TB infection.
Fibrosis is relatively rare in children, present in 15%-20% of
cases, and usually detected 46 months after primary infec-
tion.2,24 There are multiple classic eponymous sequelae of
primary pulmonary TB: Ghon lesion granulomas, which
typically occur at the site of the primary infection; Ranke
complexes, which are the combination of a Ghon lesion with
calcified hilar or mediastinal lymphadenopathy; and Simon
foci, which represent granulomas present at the lung apices.29
Identification of active TB lung lesions is crucial to provide
appropriate treatment, and FDG-PET/CT has been used to
differentiate between active and inactive pulmonary tuber-
culomas. Active tuberculomas are FDG avid, with SUVmax
typically 42.5, whereas inactive disease is associated with low
uptake, usually SUVmax o1.5 (Fig. 1).30-33 Postprimary TB is
almost exclusively seen in adolescents and adults, and is
characterized by upper lobe predominance, cavitation, and
absence of lymphadenopathy (Fig. 2).23,34,35
Lymphadenopathy
Lymphatic involvement is the hallmark of primary TB in
children; 83%-97% of children with thoracic TB present with
mediastinal adenopathy, typically affecting the paratracheal
and subcarinal lymph nodes (Fig. 1).25,27,36 Nodal involve-
ment is normally more extensive in infants and younger
children compared with adolescents and adults.24 On FDG-
PET/CT, the increased FDG uptake associated with active TB
can be indistinguishable from other causes of FDG-avid
lymphadenopathy, such as lymphoma (Fig. 3) or sarcoido-
sis.37,38 On CT, centrally hypodense lymphadenopathy larger
than 2 cm is indicative of active disease.2,23,27
FDG-PET/CT in pediatric TB 3

Figure 1 Whole-body maximum intensity projection (MIP) FDG-PET (A) of a 3-year-old boy investigated for a persistent
left upper lobe mass shows abnormal parenchymal lung uptake (arrows) and increased uptake in mediastinal lymph nodes
(arrowhead), with faint hypermetabolic left inguinal and intra-abdominal lymph nodes. Axial fused PET/CT images (B and
C) demonstrate increased uptake corresponding to parenchymal consolidation on CT with SUVmax reaching 2.0 as well as
(D) FDG-avid subcarinal lymphadenopathy with SUVmax of 2.3 (arrowhead). Subsequent cultures confirmed
mycobacterium infection.

Miliary Disease
Miliary TB is defined as lymphohematogenous dissemination of
M. tuberculosis bacillus. The diagnosis is established in the
presence of diffuse miliary lung infiltrates on imaging, typically
smaller than 2 mm, and it may be associated with miliary lesions
in other organs.39 Miliary TB is estimated to represent 1%-2% of
all TB cases, though higher in younger and immunosuppressed
children.2,40,41 On FDG-PET/CT, miliary disease appears as
diffuse increased uptake in both lungs (Fig. 4).42

Figure 2 Axial CT (A) and PET/CT image (B) of a 44-year-old man with
bilateral postprimary pulmonary TB with right upper lobe cavitation
(arrowhead). Pulmonary lesions are associated with moderately
increased FDG uptake with SUVmax between 3.0 and 4.0.
Pleural Effusion
Pleural effusion secondary to TB infection represents an early
complication of primary TB in 8%-22% of cases and is
considered extrapulmonary disease.43,44 Pleural involvement
most frequently represents a hypersensitivity response after
spread from adjacent subpleural infection or hematogenous
spread.26,45 Pleural effusions related to TB are typically
unilateral, with accompanying ipsilateral parenchymal lesions,
and most frequently affect older children and adolescents.26,43
In cases of pleural involvement, moderate-to-high FDG uptake
is often seen in the pleura, whereas the effusion itself exhibits
4 M. Pelletier-Galarneau et al.

Figure 3 Whole-body maximum intensity projection (MIP) FDG-PET (A) of a 12-year-old boy with positive interferon
gamma release assays (QuantiFERON) investigated for enlarged cervical and axillary lymph nodes. Axial CT (B) and
corresponding PET/CT (C) images of the neck and axial CT (D) and corresponding PET/CT (E) images of the thorax
demonstrate FDG-avid lymphadenopathy (arrowheads) with SUVmax ranging between 5.0 and 10.0. Additionally, inguinal
lymphadenopathy (SUVmax ¼ 3.5) was also identified (white arrow, A). The diffuse marrow and splenic uptake is
consistent with marrow activation, likely related to the patient's pancytopenia. Paravertebral (black arrows (A) and white
arrows (D) and supraclavicular uptake was attributed to brown fat uptake. Biopsy of cervical lymphadenopathy revealed
necrotizing granulomatous lymphadenitis and it was negative for neoplasia.

variable levels of uptake.46-49 In a study comparing the
intensity of pleural effusions from various malignant and
benign causes, 17 of 30 patients with TB-related pleural
effusion demonstrated elevated FDG uptake, with SUVmax
ranging from 2.2-11.8.46 Pleural involvement in TB is some-
times associated with pleural nodularity, making the distinc-
tion between malignancy and TB challenging.46-49
Extrathoracic TB
TB is primarily a disease of the lungs, transmitted by inhalation
of droplets containing M. tuberculosis; however, TB can affect
virtually any organ of the body, particularly in immunocom-
promised patients. Extrathoracic TB occurs in approximately
one-fifth of all immunocompetent patients and in more than
half of all immunocompromised patients with TB.50 The most
frequently affected sites include the bones, the central nervous
system (CNS), and the abdomen.
Skeletal TB
The musculoskeletal system is one of the most frequently
affected extrapulmonary sites.50 In children, the most common
skeletal TB manifestations are spondylitis, arthritis, and
osteomyelitis.51
TB Spondylitis
Approximately one-half of cases of skeletal TB involve the
spine.52 In infants from the developing world, the thoracic
spine is most commonly affected; whereas in North America
and Europe, spinal disease is more commonly seen affecting
the lumbar spine.53,54 TB spondylitis, also referred to as Pott
disease, is often secondary to hematogenous spread of the
bacillus via the perivertebral arterial plexus or venous plexus.
The infections typically starts in the anterior vertebral body
near the end plates and spread through the subchondral plate
or behind the anterior ligaments.55 The infection tracks along
the anterior longitudinal ligament leading to the involvement
of multiple contiguous vertebral levels with early sparing of the
intervertebral disks.56 Osseous erosion can then result in an
anterior compression deformity of the vertebral bodies—the
so-called gibbous deformity—occurring as a late complica-
tion.57 Although not typical, imaging findings of spondylitis
with involvement of the posterior elements should raise the
suspicion of TB infection as it is not a characteristic finding of
pyogenic infections.58
On FDG-PET/CT imaging, sclerosis and bony destruction
can be demonstrated with associated increased FDG uptake,
FDG-PET/CT in pediatric TB 5

Figure 4 Whole-body maximum intensity projection (MIP) FDG-PET (A) with selected CT (B) and corresponding FDG-
PET (C) images of a 15 year old girl with known miliary TB of the lungs undergoing FDG PET/CT to assess disease extent.
CT image demonstrate numerous small (o2 mm) pulmonary nodules in both lungs. On PET images, there is diffuse
increased FDG uptake in both lungs, with SUVmax ranging between 2.7 and 3.5, and small hypermetabolic mediastinal
lymph nodes (black arrow). Also noted on this study is splenomegaly with diffusely increased splenic uptake (SUVmax 3.7)
with one area of more intense uptake (arrowhead), compatible with splenic TB. Furthermore, there is a focus of increased
uptake in the liver (white arrow) with SUVmax of 3.3, suspicious for an active liver lesion.

sometimes involving the posterior elements with soft tissue
extension (Fig. 5).51,59 FDG-PET/CT is superior to other nu-
clear medicine modalities such as bone and gallium scintig-
raphy and is particularly useful in excluding spondylitis, as a
negative study essentially precludes active disease (Fig. 6).60
TB Arthritis
Arthritis is the second most common presentation of skeletal
disease in TB and is one of the most frequent forms of
infectious arthritis in countries where TB is endemic.61 TB
arthritis is typically monoarticular and usually involves the hips
or knees, although it can affect any joint.51 In children, TB
arthritis is secondary to hematogenous dissemination through
the synovial vessels or through direct extension of a meta-
physeal lesion.61 Imaging findings are completely indistin-
guishable from other forms of synovitis.23,51 On ultrasound,
the synovium appears thickened and a joint effusion can be
present (Fig. 7).58 The presence of bone destruction, tract
formation, and a sequestrum can be established by CT.
On MRI, TB arthritis can manifest as synovitis with joint
effusion, associated with marrow changes as well as
rim-enhancing cartilaginous or osseous erosions (Fig. 7).51,62
On FDG-PET/CT, areas of inflammation demonstrate intense
increased uptake (Fig. 8).63
TB Osteomyelitis
TB osteomyelitis occurs less frequently than TB spondylitis or
arthritis. In children, TB osteomyelitis typically involves multi-
ple bones at presentation, due to hematogenous dissemination
of the bacillus from pulmonary, meningeal, or lymphatic
infection55; however, in cases of single site of osteomyelitis,
most children will demonstrate no lung involvement.51 TB
osteomyelitis usually involves the metaphysis of long bones,
more frequently of the lower limbs.64 Diagnosis of TB
osteomyelitis can be challenging. Indeed, patients often present
with nonspecific symptoms and can have normal erythrocyte
sedimentation rate and negative result for tuberculin skin
testing. In addition, imaging findings overlaps with those of
fungal and pyogenic infections. Finally, the lesions can have
different radiological presentations: cystic, infiltrative, focal
erosions, and dactylitis (spina ventosa), with the cystic pattern
occurring more frequently in children than in adults.23,64 For
these reasons, a biopsy is required to establish the diagnosis of
TB osteomyelitis. FDG-PET/CT cannot confidently distinguish
between TB osteomyelitis and other lesions such as bone
metastases or pyogenic osteomyelitis. Because of the relatively
frequent involvement of the hands and feet in the pediatric
population, whole-body imaging including the extremities
should be performed in cases of suspected TB osteomyelitis.
TB of the CNS
The CNS is affected in 5% of patients with TB and the pre-
valence is even greater in immunocompromised patients.65 TB
can affect the CNS in three different ways—tuberculous menin-
gitis, intracranial tuberculoma, and spinal tuberculous arach-
noiditis. Most pediatric cases involving the CNS are meningitis,
whereas intracranial tuberculomas and tuberculous arachnoidi-
tis are only very rarely seen in children.66 Avid meningeal FDG
uptake has been described in children with tubercular
6 M. Pelletier-Galarneau et al.

Figure 5 Axial FDG-PET/CT images of a 10-year-old girl with confirmed disseminated TB with decrease in size of numerous
intra-abdominal lesions following initiation of treatment. She was referred to confirm eradication of the disease. Fused PET/
CT (A) image demonstrates increased uptake in the vertebral body of L3 (arrowhead) with SUVmax of 3.6. Fused PET/CT
(B) image at the level of the thorax demonstrates focal increased uptake in the right posterior element of T6 (white arrow) as
well as extensive pulmonary TB with numerous hypermetabolic lymphadenopathy (white asterisks). These findings are
compatible with TB spondylitis. Axial fused PET/CT (C) image at the level of the pelvis shows two foci (black arrows) of
increased uptake (SUVmax ¼ 6.4), compatible with additional osseous TB lesions. On CT (D), there were no corresponding
identifiable lesions.

Figure 6 Posterior MIP images of FDG-PET/CT (A), posterior planar image of a 99mTc-methylene diphosphonate (MDP)
bone scintigraphy (B) and gallium scintigraphy (C) of the 10-year-old patient presented in Figure 5. The increased activity
in the sacrum and spine (arrowheads) on PET/CT is not visible on bone or gallium scintigraphy. Incidentally noted is
diffuse increased FDG and gallium uptake in the lungs, compatible with diffuse pulmonary TB. MIP, maximum intensity
projection.
FDG-PET/CT in pediatric TB 7

Figure 7 A 17-year-old boy who presented with long-standing left hip pain. He was initially investigated by MRI to rule out
inflammatory arthritis. Representative T1 (A), T2 fat-saturation (B), and T1 postgadolinium (C) coronal MRI images of the
pelvis demonstrate decreased T1 signal, increased T2 signal, and enhancement postgadolinium injection. Axial CT image
(D) demonstrates diffuse left hip osteopenia and a focal area of preserved density (arrow). Ultrasound of the left hip joint (E)
confirmed a joint effusion and synovial thickening (arrowhead).

Figure 8 Whole-body maximum intensity projection (MIP) FDG-PET/CT image (A) of the 17-year-old patient presented in
Figure 7 demonstrating abnormal uptake in the left hip area (arrowhead), with small hypermetabolic left inguinal and intra-
abdominal lymph nodes (arrows). Axial PET images (B) with corresponding CT (C) and fused images (D) as well as coronal
fused image (E) demonstrate intense uptake in the left hip joint space with SUVmax reaching 16.8. Joint aspiration
subsequently confirmed TB arthritis.
8 M. Pelletier-Galarneau et al.

meningitis.67 Intracranial tuberculomas, on the other hand,
demonstrate focal increased parenchymal FDG uptake (Fig. 9).
On nonenhanced CT, the presence of central calcification with
surrounding hypoattenuation is suggestive, but not specific, of
TB.23 On MRI, the lesions may vary in appearance depending
on whether the tuberculoma is liquid or solid, caseating or
noncaseating, and if there is adjacent edema or not.23
peripancreatic region.23 On FDG-PET/CT, affected lymph
nodes will demonstrate intense uptake (Fig. 10). Intensity of
uptake cannot be used to differentiate between TB infection
and other causes of hypermetabolic lymph nodes in children
such as lymphoma or histiocytosis19; however, tuberculous
lymph nodes classically exhibit hypoattenuating centers and
enhancing rims on CT.23

Abdominal TB Tuberculous Peritonitis

Abdominal TB is uncommon in healthy children without
predisposing conditions such as cirrhosis, chronic renal failure,
or peritoneal dialysis, and it is usually the result of hematog-
enous or lymphatic dissemination.68 Less frequently, it can be
due to ingestion of sputum containing bacillus in patients with
active pulmonary TB.69 Mycobacterium bovis infection, fre-
quently resulting from ingestion of contaminated nonpasteur-
ized milk, should also be considered in the differential
diagnosis of patient suspected of abdominal TB.
Lymph Nodes
Intra-abdominal lymphadenopathy and peritonitis are two of
the most common presentations of abdominal TB.68 Lympha-
denopathy occurs typically in clusters and is located in the
Tuberculous peritonitis is relatively rare and typically affects
sicker patients with comorbidities such as cirrhosis, renal
failure, diabetes mellitus, and malignancy.70,71 Symptoms of
tuberculous peritonitis are nonspecific and most patients
have ascites at presentation.72 The gold standard for the
diagnosis of tuberculous peritonitis is a positive culture of M.
tuberculosis from ascitic fluid or peritoneal biopsy.70 Radio-
logical findings include omental caking, hepatomegaly,
thickened mesentery with adherent small bowel loops,
splenomegaly, lymphadenopathy, and thickening of the ileal
wall.73 On FDG-PET/CT, the findings of diffuse peritoneal
uptake are indistinguishable from other causes of peritonitis
(Fig. 11).74 On CT, the ascites has high attenuation and the
peritoneum can appear nodular and thickened.70

Figure 9 FDG-PET/CT of an 11-month-old girl with pulmonary and abdominal lesions, suspicious for TB. Whole-body
MIP image (A) shows extensive lymph node involvement (arrows) as well as a large hypermetabolic right pulmonary lesion
(asterisk). Noncontrast CT (B), FDG-PET (C) and fused (D) transaxial brain images reveals the presence of multiple foci of
mildly increased uptake in the brain parenchyma (arrowheads), compatible with tuberculomas in the context of
disseminated disease. On brain MRI (E), the lesions also demonstrate significant enhancement after administration of
gadolinium. MIP, maximum intensity projection.
FDG-PET/CT in pediatric TB 9

Figure 10 Abdominal ultrasound of a 14-year-old female (A) shows multiple hypoechoic retroperitoneal lymph nodes. On
contrast-enhanced CT (B), these lymph nodes appear necrotic (arrow). On FDG-PET (C) and fused PET/CT (D) axial
images, these lymph nodes demonstrate intense increased FDG uptake (arrow), compatible with active TB. Additionally, a
small liver hypodensity was noted on CT (arrowhead), without corresponding increased FDG uptake, compatible with a
benign liver cyst.

Figure 11 Tuberculous peritonitis in a 17-year-old boy with acute abdominal pain and mycobacterium growth on ascites
culture. MIP images from FDG-PET/CT (A) and representative axial CT (B) and fused PET/CT (C) images show diffuse
increased uptake in the thickened peritoneum, without evidence of extra-abdominal active TB. MIP, maximum intensity
projection.
10 M. Pelletier-Galarneau et al.

Figure 12 FDG-PET (A) and fused (B) axial images of a 13-year-old boy with known pulmonary TB. These images
demonstrate intense uptake in the periphery of hepatic lesions with central photopenia. Doppler ultrasound (C) shows
multiple poorly vascularized hepatic lesions, with hypoechoic periphery and hyperechoic center. Contrast-enhanced CT
(D) shows hypodense lesions with central calcifications.

Figure 13 Abdominal FDG-PET image of a 10-year-old girl with confirmed pulmonary TB infection demonstrating (A)
heterogeneous and increased splenic uptake of FDG (arrowheads), without significant abnormality on noncontrast CT (B),
compatible with splenic TB. On a follow-up study performed 1.5 years later, following therapy, the abnormal splenic
uptake has resolved (B) and splenic calcifications (arrow) are seen on noncontrast CT (D). Note that there was also
resolution of the previously noted retroperitoneal lymph node involvement (asterisk).
FDG-PET/CT in pediatric TB 11

Table 2 Roles for FDG-PET Imaging in Mycobacterium tubercu- Renal TB

losis Infection
Detection of TB lesions
Assessment of disease activity
Differentiation between active and latent disease
Assessment of disease extent
Monitoring response to treatment
Identification of potential biopsy target
Surrogate end point for new drug trials
Differentiation between peritoneal carcinomatosis and tuber-
culous peritonitis can be difficult and final diagnosis should
rely on correlation with other imaging findings and ascites
culture.75,76
Hepatosplenic TB
Hepatosplenic TB is an infrequent presentation of
gastrointestinal TB, representing less than 1% of TB
cases. 77 It is usually seen in disseminated infection and
patients very rarely present with isolated hepatic TB. 68
Macronodular lesions will demonstrate FDG uptake
greater than the surrounding liver parenchyma
(Fig. 12).78,79 On CT, these lesions are hypoattenuating
with central enhancement, calcifications, or both. Early
lesions can be difficult to identify and may present as
small hypoattenuating lesions with mildly increased
FDG uptake. On MRI and ultrasound, TB lesions are
almost impossible to distinguish from those of meta-
stases or abscess.23,80 Splenic involvement may be
suspected when there is focal increased or heteroge-
neous splenic FDG uptake (Fig. 13). 81
Renal TB is rare in children and arises from hematogenous dis-
semination to the glomerulus.82 Focal increased uptake corre-
sponding to a renal nodule can be identified on FDG-PET/CT in
cases of renal TB83,84; however, this finding is nonspecific and
FDG-PET/CT demonstrates poor sensitivity for renal lesions due
to physiological excretion of the tracer by the kidneys. Indeed,
small lesions or lesions deep in the cortex are easily missed.
Hence, FDG-PET/CT has no significant role in investigating re-
nal TB, though these findings may be incidentally encountered.
Dual-Time-Point Imaging
Dual-time-point imaging (DTPI) has been applied in diverse
circumstances to differentiate benign from malignant proc-
esses.85 DTPI relies on the premise that nonmalignant lesions
tend to have early peak uptake, whereas malignant lesions,
with increased cell proliferation and enhanced hexokinase and
GLUT expression, have late peak uptake.86,87 Although some
reports suggest that DTPI could be useful in identifying TB,88
in most cases DTPI does not allow accurate differentiation
between active TB and malignancy.89 In a case series of 15 TB
patients, most lesions did not show reduction in uptake
between 45 and 120 minutes. Some lesions demonstrated
modest reduction of up to 20%, whereas others demonstrated
increase in uptake by 10%-40%.90 Kim et al30 studied the use
of DTPI at 60 and 120 minutes to differentiate active and
inactive pulmonary TB. The percentage change in SUVmax was
significantly greater in active lesions (8.07 ⫾ 7.77%) compared
with inactive lesions (3.83 ⫾ 6.59%). However, the diag-
nostic performance of DTPI was similar to qualitative visual

Figure 14 Whole-body MIP FDG-PET images of a 14-year-old girl with extensive cervical, thoracic, and abdominal
lymphadenopathy, initially referred for suspected lymphoma. On the initial study (A), several foci of increased uptake were
identified in thoracic and abdominal lymph nodes as well as a FDG-avid mesenteric mass (arrowhead) with SUVmax of 8.5.
These findings were interpreted as being consistent with lymphoma and a biopsy was performed, which revealed
Mycobacterium bovis infection. A follow-up study performed 18 months later (B), after completion of therapy, demonstrated
mild residual activity in the mesenteric mass with SUVmax of 5.3. These findings were felt to represent either residual disease
or persistent inflammation. On a second follow-up study performed 34 months after the initial scan (C), mild residual
uptake in the mesenteric mass is again seen, with SUVmax of 4.6 (arrowhead). In light of the fact that the patient did not
receive additional treatment after the first follow-up study, and the lesions remained unchanged, the diagnosis of aseptic
granulomatous inflammation was favored. MIP, maximum intensity projection.
12 M. Pelletier-Galarneau et al.

Figure 15 Whole-body MIP PET images of the 10-year-old girl presented in Figure 5. She was initially referred to confirm
eradication of TB after several months of treatment. On the initial study (A), several foci of increased uptake were identified
in the lungs, the spleen, the bones, and lymph nodes. A follow-up study performed 18 months later (B), after adjustment of
her therapy, reveals complete resolution of the hypermetabolic lesions. The foci of uptake in the left arm on the follow-up
study represents an injection site and the thoracic uptake, with an “inverted Y” shape, represents physiological uptake in the
thymus (arrow). MIP, maximum intensity projection.

assessment and quantitative analyses on early images alone.
Razak et al91 obtained similar results for extrapulmonary TB,
showing that early imaging was sufficient to differentiate
between active and inactive extrapulmonary TB lesions. The
exact role of DTPI in TB remains unclear and there is no
consensus about its effectiveness in differentiating between
malignancy and active TB lesions or between active and
latent TB.
Roles of FDG-PET/CT in Pediatric
TB
FDG-PET/CT is typically not the initial imaging modality used
to evaluate suspected TB; however, in children, as in adults, a
number of useful roles for FDG-PET/CT have been defined
(Table 2). FDG-PET/CT can detect TB lesions, assess disease
activity, and differentiate active from latent TB.16,31-33,92-94
This is of potentially great importance given that children are at
high risk of developing active TB after contact with an infected
person. Early identification of active TB facilitates prompt
initiation of treatment, minimizes transmission risk, and
improves patient outcomes.95 The accuracy of FDG-PET/CT
in detecting active TB lesions compares favorably to other
imaging modalities, with ionizing radiation exposure within
the range of diagnostic exposure encountered in pediatric
CT.96 Whole-body scanning enables detection of active disease
in most organs (with the possible exception of the kidneys, as
discussed earlier), which allows for accurate staging of TB in a
single imaging session.97,98 Whole-body assessment is
FDG-PET/CT in pediatric TB
important because more extensive disease is associated with
treatment failure.16 FDG-PET/CT can be used to monitor
treatment response, which can be especially useful in cases of
extrapulmonary TB16,31,32,92,93,97,99-103 as well as in other
forms of mycobacterial infection (Fig. 14).31,93 Indeed, extrap-
ulmonary lesions may be present for years on anatomical
modalities before any changes are detected. In the context of
drug-resistant TB, serial FDG-PET/CT scans allow evaluation
of disease activity following therapy and facilitate subsequent
adjustment of therapy as needed (Fig. 15). Significant reduc-
tion in uptake with residual faint activity indicates positive
response to therapy.31,100
Obtaining diagnostic confirmation in a child with suspected
TB can be difficult and sometimes requires a biopsy. FDG-PET/
CT can be helpful in identifying potential biopsy targets,
especially in cases of extrathoracic TB.17,90 Finally, Chen
et al103 showed that the results of early FDG-PET/CT,
performed as soon as 2 months after initiation of therapy,
correlate with long-term outcome. As a result, it has been
proposed that FDG-PET/CT could be used as a surrogate end
point for trials evaluating new TB drugs.103
Conclusion
For the foreseeable future, pediatric TB will remain a
persistent problem in the developed world, due to
population shifts from the developing world. FDG-PET/
CT represents an effective tool for the evaluation of TB,
sensitive for both thoracic and extrathoracic disease,
which allows for the rapid assessment of treatment
response. Understanding the typical manifestations of
this disease on FDG-PET/CT imaging can, therefore, lead
to rapid diagnosis of children infected with TB, resulting
in earlier and more effective treatment and in decreasing
the risk of contagion to family members and the general
population.
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