Presentation
Young male hospitalized for perimyocarditis in ICCU. Blood tests were significant for eosinophilia (9,000/μL). Patient history includes working on a farm, with exposure for sheep and dogs. The patient underwent an extensive serological evaluation for parasitic infections with borderline results of serology for echinococcal infection. The patient was referred for abdominal sonography for further evaluation.
Patient Data
Liver sonographic examination showed a well defined hypoechoic lesion of about 3 x 2.4 cm, with a cystic component, in the area between segments 6 and 7.
The cystic component of the lesion in the border between segments 6 and 7 is clearly shown during all phases of the multiphasic liver CT scan. On the portal and delayed phases, an extensive well-demarcated wedge-shaped subcapsular hypodense area is evident in the posterior part of segment 6, as well as an additional, smaller lesion in the inferior part of segment 6, of about a diameter of 1 cm with ill-defined borders.
The imaging appearance, combined with the clinical findings raised a differential diagnosis that included focal eosinophilic infiltration, echinococcal, or another parasitic abscess. Due to inconclusive echinococcal serology, the patient was referred for imaging-guided biopsy.
The tissue was sent to histopathological examination, culture, and PCR testing. Histopathology showed eosinophilic abscess. No remnants of parasites were found. The culture was also negative. However, the PCR test of the tissue confirmed echinococcal infection.
The patient received Albendazole treatment with clinical improvement.
Case Discussion
This case shows an echinococcal liver abscess with imaging features of a complex liver lesion that has a cystic component, without characteristic imaging features of an echinococcal cyst (like daughter cysts or water lily sign). The patient history of exposure for sheep and dogs was suggestive for the diagnosis. However, due to borderline serology and lack of specific imaging findings, the diagnosis was done based on tissue sampling.
Courtesy of Shady Kasis.
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