British Journal of Radiology (2005) 78, 1116-1117
© 2005 British Institute of Radiology
doi: 10.1259/bjr/55612039
Multiple hepatosplenic nodules
A N Hegde, MD
1 and
A Kohli, MD, DNB
2
1 Jaslok Hospital and Research Center, Mumbai and 2 Breach Candy Hospital and Research Center, Mumbai, India
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Introduction
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A 50-year-old female with complaints of vague pain in epigastric region of the abdomen for 2 weeks and mild dyspnoea for 2–3 years was referred for an ultrasound examination of the abdomen.
Ultrasound revealed multiple round to oval heterogeneous, predominantly hyperechoic, lesions in both lobes of the liver (Figure 1
).
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Figure 1. Ultrasound image shows a heterogeneous, predominantly hyperechoic lesion in right lobe of liver.
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For further evaluation, a contrast enhanced CT (CECT) scan of the abdomen (Figure 2) was performed which revealed multiple discrete hypodense nodules varying in size between 0.5 cm and 2 cm scattered in the liver and spleen. The lesions did not enhance on administration of intravenous non-ionic contrast. Liver and spleen were normal in size. In view of the possibility of these representing metastatic deposits, a CT scan of the chest (Figure 3) was performed to look for other metastatic lesions/primary in the lungs. However, the high resolution CT (HRCT) images showed characteristic nodular peribronchovascular interstitial thickening and small nodules in relation to the pleural surfaces, interlobular septa and centrilobular structures. Additionally, areas of bronchiectasis, septal thickening and fibrosis were noted. What is the diagnosis? What further tests should be carried out to confirm this?
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Figure 2. Contrast enhanced CT shows multiple hypodense non-enhancing nodular lesions in liver and spleen.
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Figure 3. Nodular lesions at subpleural (along the major fissure) and peribronchovascular locations, and changes of fibrosis.
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Figure 4. Hyperechoic nodule in spleen without any posterior acoustic shadowing. This was observed on a retrospective viewing of the ultrasound images.
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On the basis of the HRCT, a diagnosis of sarcoidosis was made. The nodules in the liver and spleen were attributed to sarcoid granulomas.
A core biopsy of one of the hepatic lesions was then performed which revealed characteristic non-caseating granulomas, thus confirming the diagnosis of sarcoidosis.
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Discussion
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Sarcoidosis is a common granulomatous disease of unknown aetiology, which involves the thorax in more than 90% of cases. However, extrathoracic manifestations, particularly infradiaphragmatic involvement are also common and may be the sole or predominant feature [1]. At CT, the liver and spleen may be normal or enlarged without any obvious focal lesions. In 5–15% of cases, however, sarcoidosis manifests as multiple, low attenuation nodules. It can then be easily mistaken for lymphoma, metastatic disease, or infection [2]. The age of onset is usually in the third decade. Common presentations include fatigue, malaise, weakness and weight loss. Respiratory involvement presents as cough, dyspnoea and rarely with haemoptysis. Abdominal symptoms include pain, nausea and vomiting. Hepatosplenomegaly may be present.
Ultrasound may demonstrate hepatomegaly and/or splenomegaly. This may be associated with a diffuse or inhomogeneous increase in the parenchymal echogenicity. The liver may have a nodular surface. The granulomas in the spleen appear as focal bright echogenic foci with or without acoustic shadowing [3].
On CT, findings of hepatomegaly, splenomegaly, lymphadenopathy and focal lesions in the liver and spleen have been described [2]. Low attenuation nodules in the liver and spleen are infrequent manifestations of sarcoidosis. In a series of 59 patients with sarcoidosis who underwent abdominal CT, low attenuation nodules were seen in liver of 3 patients and in spleen of 8 patients [4]. On CT, the hepatic nodules are small, of low attenuation and vary in size between 0.2 cm and 1.9 cm. Splenic nodules are described as being multiple, of low attenuation and varying in size between 0.3 cm and 2 cm. The nodules are discrete and scattered throughout the liver and spleen. With increasing size, however, nodules tend to become confluent. Hepatosplenomegaly and adenopathy involving porta hepatis, para-aortic region, coeliac axis, superior mesenteric artery, gastrohepatic ligament and retrocrural region have been described [5]. However, no strong relationship has been found between presence of nodules and liver or spleen size [2]. A study by Warhauser et al demonstrated striking elevations in angiotensin converting enzyme (ACE) levels in patients with nodular sarcoidosis in liver and spleen with a mean elevation of 2.6 times the upper limit of normal [5]. This level suggests both a clinically important disease and a large total body burden of disease. The pathological significance of the hepatosplenic nodules is unclear. In one series, partial or complete resolution of the nodules occurred with steroid therapy in a few patients who were followed up on CT [5]. There is no correlation between nodular hepatosplenic sarcoidosis and advanced pulmonary sarcoidosis [5]. It is important to recognize the nodular appearance of hepatosplenic sarcoidosis to distinguish it from more common causes of low attenuation nodules in liver and spleen, which include infection, metastatic disease and lymphoma [5]. Liver lesions may simulate disseminated hepatic micro abscesses such as those seen in Candida, Staphylococcus and Aspergillus infections. More significant is the close resemblance between sarcoidosis and lymphoma, both clinically and radiologically. Both present with similar symptoms and can be associated with adenopathy and hepatosplenomegaly. On CT, both show nodular lesions in liver and spleen, hepatosplenomegaly and adenopathy. Retrocrural adenopathy, however, was found to be less common in sarcoidosis than in lymphoma. Lymph nodes were also smaller and more discrete in sarcoidosis than in lymphoma (mean 2.6 cm in sarcoid as compared with 8 cm in lymphoma) [5].
In conclusion, when unexplained focal hepatic and splenic lesions are encountered on imaging, sinister causes like metastasis and lymphoma must be ruled out first and a possibility of sarcoidosis must be kept in mind. Differentiation between focal lesions of sarcoidosis and those of other causes on imaging is difficult. Other findings like organomegaly and adenopathy should be sought. If adenopathy is present, its size, presence of conglomeration and involvement of retrocrural lymph nodes can help to differentiate between sarcoid and lymphoma. A chest radiograph or HRCT of the chest is worthwhile as it may show the characteristic changes of sarcoidosis. This may spare the patient an invasive confirmatory biopsy.
Received for publication December 29, 2004.
Revision received April 10, 2005.
Accepted for publication April 26, 2005.
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References
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- Lynch JP III. Extrapulmonary manifestations of sarcoidosis. J Intern Med Specialist 1984;5:163–89.
- Warhauser DM, Dumbleton SA, Molina PL, Yankaskas BC, Parker LA, Woosley JT. Abdominal CT findings in sarcoidosis: radiologic and clinical correlation. Radiology 1994;192:93–8.[Abstract/Free Full Text]
- Mathieson JR, Cooperberg PL. Spleen. In: Rumack CM, Wilson SR, Charboneau JW, editors. Diagnostic ultrasound. Missouri, USA: Mosby, 1997:155–74.
- Mayock RL, Bertrand P, Morrison CE, Scott JH. Manifestations of sarcoidosis: analysis of 145 patients with a review of nine series elected in the literature. Am J Med 1963;35:67–9.[CrossRef][Medline]
- Warhauser DM, Molina PL, Hamman SM, Koehler RE, Paulson HK, et al. Nodular sarcoidosis of the liver and spleen: analysis of 32 cases. Radiology 1995;195:757–62.[Abstract/Free Full Text]
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Introduction
Discussion
