Hepatic alveolar echinococcosis
Severe abdominal pain, nausea and vomitting. Rule out diverticulitis or occlusive lesion.
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There is a large, heterogeneous, multiseptate, poorly marginated mass measuring 13 x 10 x 9 cm involving nearly all the right liver. It has different internal densities, some of which are certainly cystic. On the hepatic window images, there seems to be images of "cyst within a cyst". Small 6 mm calcification within the mass.
There is an element of chronicity of the mass seeing as the right liver is atrophic with polylobular, angular deformity of its margins and compensatory hypertrophy of the left liver. Occlusive compression (and likely invasion) of the right portal vein and right hepatic vein. The mass causes tight stenosis of the intrahepatic and suprahepatic inferior vena cava (IVC). The infrahepatic IVC is tortuous, probably because of chronic stenosis.
Small amount of peri-hepatic fluid of intermediate density, suggesting that there might have been partial rupture of the mass, although this might just be inflammatory.
There are also two subcapsular hypodensities of unknown etiology in segments III.
Dilatation of the common bile duct up to 13 mm with portions of the large mass abutting the common bile duct and also causing distention of some intra-hepatic bile ducts.
Thickening of the pleura above the mass with reticulations in the adjacent lung parenchyma, which could be either reactive or because of invasion by the mass itself.
Large right hepatic mass of mixed attenuation with some cystic parts and perhaps solid components as well. There is an element of chronicity as evidenced by the hepatic parenchymal atrophy and compression (possible invasion) of vascular structures. The appearance of "cysts within cysts", most visible at the superior portion of the mass, is suggestive of hepatic echinococcosis. Because of the infiltrating appearance of the mass, one should consider hepatic alveolar echinococcosis, a rarer but more aggressive form of hepatic hydatid infection caused by Echinococcus multilocularis. It is unclear if there had been a recent rupture of part of the mass to explain more acute symptoms.
Complete blood count showed no leukocytosis or eosinophilia. Liver function tests and enzymes were normal.
Differential diagnosis in this case included:
Upon further questioning by the clinical team, the patient who lived in a North African country was presently on vacation. Her travel insurance opted to repatriate her and therefore diagnostic confirmation was unavailable to us.