Volume 82 - 2019 - Fasc.4 - Clinical images
A not-so-innocent kiss
A 64-year-old man was admitted to the hospital with a 3-day history of fever. Two months earlier, he had experienced a similar ten-day episode of fever and nightly sweating during a trip to Hungary. Apart from tiredness and subtle weight loss over the last year, the patient was symptom-free. Relevant medical history included gout and a past infection with Epstein-Barr virus (EBV). The patient was febrile, 38°C, but further clinical examination was completely normal. Laboratory findings showed an elevated white blood cell count of 13.250/µL [4200 - 9800/µL] and a CRP of 190mg/L [0 - 3.2mg/L]. On CT scanning of the abdomen, a 5 cm long pathological wall thickening of the terminal ileum was noted [Figure A, arrow]. Colonoscopy confirmed the abnormal mucosal lining of the terminal ileum, showing a whitish polypoid nodularity [Figure B]. Biopsies were taken for histopathological examination [Figure C, Hematoxylin-eosin staining; Figure D, CD30 staining; Figure E, EBER staining].
What happened to my liver lesion (Hepatic Sclerosed Hemangioma)? Let's not forget (radiological) history
A 68-year-old man with a medical history of hyper- tension, dyslipidemia, ischemic stroke, benign prostatic hyperplasia and hepatic steatosis underwent liver magnetic resonance imaging (MRI) in our Institution. Laboratory tests showed increased cholesterol levels and normal liver function.
Six months before, an abdominal ultrasound (US), in a context of hepatomegaly and hepatosteatosis, demonstrated a hypoechoic 2 cm lesion in liver segment VII, with regular margins. Contrast-enhanced US showed slight peripheral enhancement during the entire acquisition time. Due to its features not pathognomonic for a typical lesion, the patient underwent liver MRI performed with gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA), a hepatobiliary contrast agent. On MRI, the 2-cm lesion in liver segment VII showed heterogeneous signal intensity in both T1- and in T2- weighted images. In particular, strongly hyperintensity on heavily T2-weighted sequence typical of hemangioma (Fig. 1A), and diffuse and homogenous signal dropout on opposed-phase T1-weighted images (Fig. 1B) compared to in-phase T1-weighted images (Fig. 1C), pathognomonic for steatotic adenoma were absent. After administration of the contrast agent, a slight rim enhancement (Fig. 1D) and the EOB cloud sign on the hepatobiliary phase (Fig. 1E) were identified. Moreover, the lesion demonstrated hyperintensity in the diffusion- weighted image (Fig. 1F). Is it possible to reach diagnosis without previous imaging examinations?
