肝囊性病变和嗜酸粒细胞增多症的影像学诊断

Jakob Begun, HMS 3 Gillian Lieberman, MD Cystic liver lesion and Cystic liver lesion and eosinophiliaeosinophilia JakobJakob Begun, Harvard medical School Year IIIBegun, Harvard medical School Year III Gillian Lieberman, MD Gillian Lieberman, MD November, 2005 Jakob Begun, HMS 3 Gillian Lieberman, MD 2 Patient PresentationPatient Presentation  55 year old Cape Verde female presented to her 55 year old Cape Verde female presented to her PCP with 6 month history of variable RUQ pain PCP with 6 month history of variable RUQ pain (up to 9/10), intermittent fever and 15 kg weight (up to 9/10), intermittent fever and 15 kg weight loss.loss.  Patient denied nausea, vomiting, diarrhea, Patient denied nausea, vomiting, diarrhea, hematocheziahematochezia or or melenamelena, and had no GU , and had no GU symptoms.symptoms. http://www.cia.gov/cia/publications/factbook/geos/cv.html Jakob Begun, HMS 3 Gillian Lieberman, MD 3 Physical ExamPhysical Exam  VSVS-- 98.0, 98, 141/81, 100%(RA)98.0, 98, 141/81, 100%(RA)  The abdomen was soft and The abdomen was soft and nondistendednondistended with with epigastricepigastric and RUQ tenderness. Patient had and RUQ tenderness. Patient had rebound tenderness without guarding and no rebound tenderness without guarding and no other peritoneal signs.other peritoneal signs.  There was no There was no hepatomegalyhepatomegaly, , scleralscleral icterusicterus or or jaundice notedjaundice noted  The remainder of the physical exam was The remainder of the physical exam was unremarkableunremarkable Jakob Begun, HMS 3 Gillian Lieberman, MD 4 Pertinent admission laboratory Pertinent admission laboratory resultsresults  CBC CBC –– WBC 6.0, WBC 6.0, HgbHgb 11.9, 11.9, PltPlt 281281  Diff Diff –– 32.1%Neuts, 0%Bands, 35.7%Lymphs, 32.1%Neuts, 0%Bands, 35.7%Lymphs, 4.7%Monos, 4.7%Monos, 26.5%Eos26.5%Eos, 1.0%Baso, 1.0%Baso  ESR 92ESR 92  Amylase and Amylase and LFTLFT’’ss –– WNLWNL  ElectrolytesElectrolytes-- WNLWNL http://www.microscopyu.com/galleries/pathology/eosinophilia.html Jakob Begun, HMS 3 Gillian Lieberman, MD 5 Initial findingsInitial findings  6 month history of RUQ and intermittent fever6 month history of RUQ and intermittent fever Radiology  Travel history/Exposure Travel history/Exposure –– Cape VerdeCape Verde  Elevated ESR Elevated ESR  EosinophiliaEosinophilia  Normal liver and pancreas enzymeNormal liver and pancreas enzyme Jakob Begun, HMS 3 Gillian Lieberman, MD 6 Admission CT with contrastAdmission CT with contrast Cystic lesion of the liver with multiple septations Subcapsular fluid accumulation Images from PACS, BIDMC Jakob Begun, HMS 3 Gillian Lieberman, MD 7 Reformatted viewsReformatted views Coronal Sagital Contiguous area of enhancing inflammation near the hepatic flexure of the ascending colon Images from PACS, BIDMC Jakob Begun, HMS 3 Gillian Lieberman, MD 8 Ultrasound imagingUltrasound imaging Images from PACS, BIDMC Jakob Begun, HMS 3 Gillian Lieberman, MD 9 Our patient: Radiographic FindingsOur patient: Radiographic Findings  Cystic liver lesion with Cystic liver lesion with multiple tubular multiple tubular septationseptation  DiverticulosisDiverticulosis  Contiguous inflammation Contiguous inflammation surrounding the ascending surrounding the ascending colon near the hepatic flexurecolon near the hepatic flexure  Origin of these findings:Origin of these findings:  Liver abscess?Liver abscess?  Diverticulitis?Diverticulitis? Image from PACS, BIDMCImages from PACS, BIDMC Jakob Begun, HMS 3 Gillian Lieberman, MD 10 Differential diagnosis of cystic Differential diagnosis of cystic hepatic lesionhepatic lesion  Abscess (Abscess (pyogenicpyogenic, fungal, or , fungal, or parasiticparasitic))  Cyst, congenital or acquiredCyst, congenital or acquired  Cystic metastasis (Cystic metastasis (mucinousmucinous adenocarcinomaadenocarcinoma, , cystadenocarcinomacystadenocarcinoma, , melanoma, melanoma, carcinoidcarcinoid, or sarcoma with , or sarcoma with necrosis)necrosis)  Acute hematomaAcute hematoma  HydatidHydatid disease (disease (EchinococcusEchinococcus)) Maurice Reeder and Felson’s Gamuts in Radiology Jakob Begun, HMS 3 Gillian Lieberman, MD 11 Companion patient #1: Companion patient #1: PyogenicPyogenic liver abscessliver abscess http://sprojects.mmi.mcgill.ca/icm_c/Chest/case10/page3.html Jakob Begun, HMS 3 Gillian Lieberman, MD 12 Companion patient #2:Companion patient #2: EntamoebaEntamoeba histolyticahistolytica liver abscessliver abscess Haque, R. et al. (2003) Amebiasis. N Engl J Med, 348(16):1565-73. Jakob Begun, HMS 3 Gillian Lieberman, MD 13 Companion patient #3:Companion patient #3: HydatidHydatid EchinococcalEchinococcal cystcyst Proietti et al. (2004) Echinococcal cyst. Radiographics, 24(3):861-5. Jakob Begun, HMS 3 Gillian Lieberman, MD 14 Companion patient #4:Companion patient #4: FasciolaFasciola hepaticahepatica MacLean, J.D. and F.M. Graeme-Cook (2002) Case 12-2002 – A 50-year-old man with eosinophilia and fluctuating hepatic lesions. N Engl J Med, 346(16):1232-9. Jakob Begun, HMS 3 Gillian Lieberman, MD 15 Hospital courseHospital course  Patient was made NPO and treated with IV Patient was made NPO and treated with IV levofloxacinlevofloxacin and and metronidazolemetronidazole for presumed for presumed diverticulitisdiverticulitis  Patient spiked a fever to 100.5 for one day but Patient spiked a fever to 100.5 for one day but was otherwise stablewas otherwise stable  Diet was advanced and patient was discharged Diet was advanced and patient was discharged on hospital day 5 on on hospital day 5 on p.op.o. . levofloxacinlevofloxacin and and metronidazolemetronidazole Jakob Begun, HMS 3 Gillian Lieberman, MD 16 Infectious disease followInfectious disease follow--upup  Serum samples were sent for parasite serology:Serum samples were sent for parasite serology:  FasciolaFasciola hepaticahepatica AbAb positivepositive  EchinococcusEchinococcus AbAb negativenegative  EntamoebaEntamoeba histolyticahistolytica AbAb negativenegative  StrongyloidesStrongyloides IgGIgG positivepositive Jakob Begun, HMS 3 Gillian Lieberman, MD 17 FasciolaFasciola hepaticahepatica morphologymorphology http://www.yamagiku.co.jp/pathology/case/case051.htm Excretory/Genital pore oral sucker Ventral sucker Jakob Begun, HMS 3 Gillian Lieberman, MD 18 FasciolaFasciola hepatica hepatica life cyclelife cycle http://www.dpd.cdc.gov/dpdx/HTML/Fascioliasis.htm Jakob Begun, HMS 3 Gillian Lieberman, MD 19 Human Human fascioliasisfascioliasis  Acute phaseAcute phase  Migration of parasites through intestinal wall and liver Migration of parasites through intestinal wall and liver parenchymaparenchyma  Symptoms (fever, RUQ pain, Symptoms (fever, RUQ pain, hepatomegalyhepatomegaly) usually begin ) usually begin within 6within 6--12 weeks of parasite ingestion and last an average of 12 weeks of parasite ingestion and last an average of 6 weeks.6 weeks.  EosinophiliaEosinophilia noted at this stagenoted at this stage  Chronic phaseChronic phase  Maturation of the parasites that reach the Maturation of the parasites that reach the billiarybilliary tree and tree and subsequent egg productionsubsequent egg production  Usually asymptomatic but can cause Usually asymptomatic but can cause cholangitischolangitis, , cholelithiasischolelithiasis and obstructive jaundice, as well as RUQ/and obstructive jaundice, as well as RUQ/epigastricepigastric pain, pain, nausea, diarrhea, and wasting.nausea, diarrhea, and wasting. Jakob Begun, HMS 3 Gillian Lieberman, MD 20 Imaging tests for human Imaging tests for human fascioliasisfascioliasis  UltrasoundUltrasound  Computed tomographyComputed tomography  Magnetic resonance Magnetic resonance Axial Axial postcontrastpostcontrast fat saturated gradient echo MR image (TR 140 ms/ TE 4.1 ms)fat saturated gradient echo MR image (TR 140 ms/ TE 4.1 ms) Cevikol, C. et al. (2003) Human fascioliasis: MR imaging findings of hepatic lesions. Eur Radiol. 13(1):141-8. Jakob Begun, HMS 3 Gillian Lieberman, MD 21 Radiologic Radiologic –– Pathologic correlationPathologic correlation Coronal CT Companion patient #5 Gross pathology specimen Image from PACS, BIDMC http://www.yamagiku.co.jp/pathology/case/case051.htm Jakob Begun, HMS 3 Gillian Lieberman, MD 22 F. hepatica F. hepatica in a liver abscessin a liver abscess http://www.yamagiku.co.jp/pathology/case/case051.htm H&E stain of a F. hepatic abscess Jakob Begun, HMS 3 Gillian Lieberman, MD 23 F. hepatica F. hepatica ovaova Foreign body granuloma reaction to F. hepatica ovum in the gallbladder wall. F. Hepatica ovum on O&P. http://www.yamagiku.co.jp/pathology/case/case051.htm Jakob Begun, HMS 3 Gillian Lieberman, MD 24 Our patientOur patient’’s clinical courses clinical course  Patient followed up with ID as an outpatient and was Patient followed up with ID as an outpatient and was treated with a 2 day course of treated with a 2 day course of triclabendazoletriclabendazole for for presumptive presumptive F. hepatica F. hepatica liverliver abscess 6 weeks after abscess 6 weeks after discharge.discharge.  48 hours after treatment patient felt nauseous and 48 hours after treatment patient felt nauseous and blood tests revealed elevated blood tests revealed elevated LFTsLFTs (AST 492, ALT 573, (AST 492, ALT 573, alkalk phosphos 416), which resolved after 4 weeks with no 416), which resolved after 4 weeks with no interventionintervention  Likely due to an inflammatory response to dying Likely due to an inflammatory response to dying parasitesparasites Jakob Begun, HMS 3 Gillian Lieberman, MD 25 Patient followPatient follow--up up –– 6 months6 months  All symptoms resolvedAll symptoms resolved  No No eosinophiliaeosinophilia Initial Follow-up Jakob Begun, HMS 3 Gillian Lieberman, MD 26 AcknowledgementsAcknowledgements  Jason Jason HandwerkerHandwerker, MD, MD  MervynMervyn Lobo, MDLobo, MD  Larry Larry BarbarasBarbaras  Pamela Pamela LepkowskiLepkowski  Gillian Lieberman, MDGillian Lieberman, MD Jakob Begun, HMS 3 Gillian Lieberman, MD 27 ReferencesReferences •http://www.cia.gov/cia/publications/factbook/geos/cv.html •http://www.microscopyu.com/galleries/pathology/eosinophilia.html •Maurice Reeder and Felson’s Gamuts in Radiology •http://sprojects.mmi.mcgill.ca/icm_c/Chest/case10/page3.html •Haque, R. et al. (2003) Amebiasis. N Engl J Med, 348(16):1565-73. •Proietti et al. (2004) Echinococcal cyst. Radiographics, 24(3):861-5. •MacLean, J.D. and F.M. Graeme-Cook (2002) Case 12-2002 – A 50-year- old man with eosinophilia and fluctuating hepatic lesions. N Engl J Med, 346(16):1232-9.•http://www.yamagiku.co.jp/pathology/case/case051.htm •http://www.dpd.cdc.gov/dpdx/HTML/Fascioliasis.htm •Cevikol, C. et al. (2003) Human fascioliasis: MR imaging findings of hepatic lesions. Eur Radiol. 13(1):141-8. Cystic liver lesion and eosinophilia Patient Presentation Physical Exam Pertinent admission laboratory results Initial findings Admission CT with contrast Reformatted views Ultrasound imaging Our patient: Radiographic Findings Differential diagnosis of cystic hepatic lesion Companion patient #1: �Pyogenic liver abscess Companion patient #2: �Entamoeba histolytica liver abscess Companion patient #3:�Hydatid Echinococcal cyst Companion patient #4:�Fasciola hepatica Hospital course Infectious disease follow-up Fasciola hepatica morphology Fasciola hepatica life cycle Human fascioliasis Imaging tests for human fascioliasis Radiologic – Pathologic correlation F. hepatica in a liver abscess F. hepatica ova Our patient’s clinical course Patient follow-up – 6 months Acknowledgements References