Presentation
Extreme weakness, diminished appetite, unintended weight loss. History remarkable for Waldenström macroglobulinemia and hypertrophic obstructive cardiomyopathy
Patient Data
Liver - normal size, coarse echotexture. 2 hypoechoic lesions in right lobe - approximately 4.7 cm and 2.8 cm across, possibly metastases or abscesses.
The gallbladder contains many stones but does not appear inflamed.
Intra- and extrahepatic bile ducts not distended.
Spleen - normal size. Large cystic structure measuring 7.2 cm across with internal sediment.
Recommended characterization of liver lesions and splenic cystic lesion with multiphasic liver CT.
Cardiac chambers enlarged. Pleural effusion - right minimal, left moderate, both accompanied by passive atelectasis in lung bases.
Liver of normal density, its border serrated, small right lobe. Several tiny hypodense (cystic?) foci in left lobe, most of which appear on previous CT exam two years prior (not shown). Between segments 6 and 7 are two hypodense subcapsular structures measuring ~20 HU with thin wall and septa isoenhancing to liver; the smaller measures 2.4 x 3.2 x 3.2 cm and abuts the right hepatic border, the larger measures 4.8 x 5.2 x 4.4 cm and bulges from the left hepatic border.
The gallbladder contains small stones.
Intra- and extrahepatic bile ducts not distended.
The spleen is enlarged, (15.7 cm in length), of normal density. At its inferior part, homogeneous hypodense structure measuring 7.3 x 8.9 x 10.2 cm and 22 HU in density, has a smooth thin wall, and displaced the splenic capsule. Fat stranding between spleen and diaphragm. Perisplenic varices. Minimal amount of free fluid in left paracolic gutter.
Tiny cysts in both kidneys.
In summary:
- liver with serrated border and small right lobe; enlarged spleen (also cf. previous exam 2 years prior), surrounded by varices - findings compatible with liver cirrhosis
- 2 septated cystic hepatic lesions and single large cystic splenic lesion, neither of which appears on previous CT exam and all of which probably represent the same entity, most probably abscesses
- minimal amount of pleural fluid on right and moderate amount on left
Case Discussion
The smaller, more superficial hepatic lesion was aspirated, as was the large splenic lesion, both yielding thick pus. The pus was cultured and grew S. viridans.
The patient underwent splenectomy but deteriorated rapidly in the course of several weeks, and died of septic shock.
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