Isolated splenic tuberculosis: A case report

We present a rare case of a 36 year old man who presented with recurrent fever but no other symptoms. Laboratory data provided no specific information for diagnosis. Abdominal ultrasonography revealed splenomegaly with multiple small hypoechoic lesions within the spleen. Computed tomography of abdomen showed a hypodense diffuse lesion. A diagnosis of isolated splenic tuberculosis was confirmed after a splenic puncture and histopathological examination.     

Tuberculous brain abscess in a patient with AIDS: case report and literature review

Tuberculous brain abscesses in AIDS patients are considered rare with only eight cases reported in the literature. We describe the case of a 34-year-old woman with AIDS and previous toxoplasmic encephalitis who was admitted due to headache and seizures. A brain computed tomography scan disclosed a frontal hypodense lesion with a contrast ring enhancement. Brain abscess was suspected and she underwent a lesion puncture through a trepanation. The material extracted was purulent and the acid-fast smear was markedly positive. Timely medical and surgical approaches allowed a good outcome. Tuberculous abscesses should be considered in the differential diagnosis of focal brain lesions in AIDS patients. Surgical excision or stereotactic aspiration, and antituberculous treatment are the mainstay in the management of these uncommon lesions.     

Pancreatic metastases of renal cell carcinoma: report of two cases

Two cases of renal cell carcinoma, metastatic to the pancreas, are presented. The lesions were hypoechoic with ultrasound examination, and were mixed iso- and hypodense with computed tomography. Angiography was performed in one case, and showed a typical hypervascular pattern of the metastatic tumor.     

Diagnosis of pancreatic tuberculosis by combined, contrast-enhanced sonography and endoscopic ultrasound-guided fine-needle aspiration

A 79-year-old woman complaining of epigastric pain was examined by her local physician, who found an abdominal mass and referred the patient to our department. Abdominal plain computed tomography revealed a mass, 50 mm in size, with slight calcification on the ventral side of the head of the pancreas. On abdominal ultrasound, the mass lesion consisted of an aggregation of hypoechoic masses, with a heterogeneous hyperechoic region at its center. On contrast ultrasonography, only the hyperechoic region was stained. ¹⁸F-Fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed FDG accumulation in the same region. It was difficult to differentiate between a malignant pancreatic tumor and an inflammatory disease on imaging, but since QuantiFERON TB2G testing was positive, pancreatic tuberculosis was suspected, and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) was performed to obtain a definitive diagnosis. Samples from the hypoechoic region consisted of necrotic tissue, while those from the hyperechoic region consisted of pancreatic tissue together with granulation tissue. BCG immunostaining was positive, and a diagnosis of pancreatic tuberculosis was made. If EUS-FNA is performed on stained areas seen on contrast ultrasonography, this will probably enable a more accurate diagnosis of pancreatic tuberculosis with low invasiveness.     

Tuberculous abscesses in patients with AIDS.

Five cases of large tuberculous abscesses in patients with AIDS were observed over a 2-year period at the New York Veterans Affairs Medical Center. These cases represent 11.6% of the 43 cases of tuberculosis diagnosed in patients with AIDS during that period. The abscesses were located in the liver, abdominal wall, psoas muscle, mediastinum, and peripancreatic area. All patients presented with localized pain or swelling, and four of five patients had fever. The diagnosis was made on the basis of detection of abscesses on computed tomography (CT) and the results of culture of abscess material obtained by CT-guided aspiration. CT-guided therapeutic drainage was performed in two cases. Despite administration of therapy, two of five patients died of tuberculous infection. Formation of tuberculous abscesses appears to be a common complication of tuberculosis in patients with AIDS. This diagnosis should be considered for patients with AIDS who have fever and localized pain or swelling.     

Bile-Duct Hamartomas Presenting as Multiple Focal Lesions on Hepatic Ultrasonography

Multiple bile-duct hamartomas are usually diagnosed at autopsy as an incidental finding. We report a case of a 50-yr-old male in whom multiple bile-duct hamartomas were suspected in an abdominal ultrasonography and confirmed by an echo-guided needle liver biopsy. The ultrasonography disclosed multiple scattered hyperechoic lesions with a diameter of up to 1 cm, associated with some anechoic lesions of a larger size and a cystic appearance. Computed tomography demonstrated multiple hypodense lesions that were not modified by the administration of contrast. Bile-duct hamartomas should be included in the differential diagnosis of multiple focal hepatic lesions at ultrasonography or computed tomography.     

Abdominal lymph node tuberculosis: diagnostic value of echography and x-ray computed tomography

The aspects of abdominal ultrasonography and computed tomography (CT) were studied in 4 patients (3 African and 1 Haitian) with abdominal tuberculosis. All were markedly debilitated and three patients had protracted fever. Tuberculosis was documented in all cases by demonstrating Mycobacterium tuberculosis in cultures of lymph nodes taken during laparotomy and/or cultures of products of gastric aspiration. Ultrasonography showed enlarged lymph nodes in the pancreatic and peripancreatic areas and also in the mesenteric, perivascular and hepatic pedicle areas. CT showed hypertrophied lymph nodes with low tissue density ranging from 20 to 35 Hounsfield units. Although non pathognomonic, these aspects were suggestive of tuberculosis. Intravenous contrast medium administration failed to increase the density in the center of lymph nodes but disclosed the existence of a thick hyperdense rim surrounding the hypodense center of the caseous lymph nodes. Repeated ultrasound and CT examination allowed to control the efficacy of antituberculous chemotherapy.     

Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.     

Single photon emission computed tomography procedure improves accuracy of somatostatin receptor scintigraphy in gastro-entero pancreatic tumours

In patients with gastro-enteropancreatic neuroendocrine tumours the localization of all the neoplastic lesions and an accurate staging of the diseases have important therapeutic implications. Somatostatin receptor scintigraphy with In-111 pentatreotide has proved to be useful in detecting gastro-enteropancreatic tumours; however, the role of abdominal single photon emission computed tomography has not yet been definitively established. In a series of 52 patients with gastro-enteropancreatic tumours (9 non-functioning islet cell carcinomas, 4 insulinomas, 3 somatostatinomas, 2 VIPomas, 1 glucagonoma and 33 carcinoids) we compared somatostatin receptor scintigraphy with the results of computed tomography and magnetic resonance imaging performed within one month. Four and 24-hour total body planar images and 4-hour abdominal single photon emission computed tomography were acquired after the i.v. injection of approximately 250 MBq of In-111 pentatreotide. Only abdominal localizations were considered: planar scans detected 16 extrahepatic lesions in 13 patients and 54 liver sites in 21 patients; single photon emission computed tomography visualized 31 extrahepatic lesions and 89 liver metastases in 27 and 28 patients, respectively; computed tomography and magnetic resonance imaging detected 11 extrahepatic lesions in 10 patients and 73 liver sites in 21 patients. In-111 pentatreotide single photon emission computed tomography was the only imaging method able to localize tumoural lesions in 13 patients; all these localizations were then histologically verified. The scintigraphic positivity did not depend on the site or on the presence of hormonal hypersecretions. In conclusion, our results indicate that single photon emission computed tomography is more sensitive than planar images and computed tomography/magnetic resonance imaging in detecting abdominal gastro-enteropancreatic tumours and their metastases; it is able to increase both the number of visualized lesions and that of patients with positive findings. Single photon emission computed tomography is particularly useful in patients in whom tumoural lesions have not been already localized; it should be the first imaging modality in patients with gastro-enteropancreatic tumours: its initial use will result in more information and proper management.     

Relapsing pancreatitis associated with duodenal wall cysts. Diagnostic approach and treatment

A case of enterogenous cysts of the duodenum in a 44-yr-old man complicated by duodenal obstruction and relapsing pancreatitis is presented. The cystic duodenal lesions were visualized by endoscopic retrograde cholangiopancreatography and for the first time by computed tomography and abdominal sonography. Thus, the diagnosis was made preoperatively. The cysts were excised successfully during a Whipple procedure. Awareness of this rare condition combined with modern x-ray, sonographic, and endoscopic techniques permit accurate preoperative diagnosis.     

Brain lesions in patients with acquired immunodeficiency syndrome

Infections involving the brain have become a major complication in patients with acquired immunodeficiency syndrome. We have reviewed 48 cases of central nervous system lesions in patients with acquired immunodeficiency syndrome. and its related complex. All patients had computed tomographic scans with contrast performed; 31 of 48 were intravenous drug abusers. Computed tomographic abnormalities found included 21 patients with multiple ring-enhancing lesions, 13 with single ring-enhancing lesions, 11 with single hypodense lesions, and three with multiple hypodense lesions. Twenty-five patients had a positive serologic reaction for Toxoplasma. Sixteen patients had brain tissues examined. Of the 16 patients, six had cerebral Toxoplasma (one with concomitant Mycobacterium tuberculosis), and ten had diagnoses other than toxoplasmosis (three of whom had a positive serologic reaction for Toxoplasma). Two patients had M tuberculosis; one patient had Nocardia asteroides with Salmonella enteritidis. Of the remaining seven patients, three had encephalitis of unknown cause, two had inconclusive tissue diagnoses, one had progressive multifocal leukoencephalopathy, and one had vasculitis. In the population of intravenous drug users, brain lesions from diseases other than toxoplasmosis may be just as prevalent. Attempts to obtain a diagnosis from brain tissue is highly recommended to permit the design of effective and specific therapy for those diseases amenable to therapy.     

Tuberculous liver abscess in an immigrant patient with pulmonary tuberculosis

Liver abscess due to Mycobacterium tuberculosis associated with pulmonary tuberculosis is a rare diagnosis, particularly in patients without AIDS. We report the case of a male immigrant with no HIV infection who developed a tuberculous liver abscess and pulmonary tuberculosis simultaneously. Ziehl-Neelsen stain, PCR and L?wenstein-Jensen culture of material sampled from the abscess established the microbiological diagnosis. The patient's course was good, with disappearance of symptoms and the abscess after tuberculostatic treatment and drainage of the abscess with monitoring by computed tomography.     

Imaging findings of biliary hamartomas

AIM: To evaluate the imaging findings of biliary hamartomas (von Meyenburg complexes, VMCs) and discuss the differential diagnosis with other related diseases.METHODS: Imaging findings of biliary hamartomas on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), MR cholangiopancreatography (MRCP)and hepatobiliary scintigraphy were retrospectively analyzed in six patients.RESULTS: On ultrasound images, five of the six cases showed multiple small hyper- and hypo-echoic lesions with comet-tail echoes, especially when magnified by US with the usage of zoom function. In all the six cases,multiple tiny hypodense lesions less than 10 mm in diameter were revealed as scattered throughout the liver with no enhancement on CT. These tiny lesions were demonstrated to be hyper- and hypo-intensity on T2- and TI-weighed images, respectively, in three patients who underwent MRI examinations. MRCP was performed in two patients, and clearly showed multiple tiny irregular- and round-shaped hyper-intensity lesions.MRCP and hepatobiliary scintigraphy showed normal appearances of intra- and extra-hepatic bile ducts in two and one patients, respectively.CONCLUSION: Imaging modalities are useful in the diagnosis and differential diagnosis of VMCs. A correct diagnosis might be obtained when typical imaging findings are present even without a histological confirmation.     

Splenic abscess: diagnosis and management

BACKGROUND/AIMS: To evaluate the usefulness of a combination of computed tomography and sonography for splenic abscess diagnosis and management determination. METHODOLOGY: From January 1986 to June 1999, 30 patients of pyogenic splenic abscess were collected in our hospital. Computed tomograms of the spleen were performed on all of the patients, and abdominal sonographies were performed on 26 of them. The imaging findings of all the patients were reviewed with respect to the clinical presentations, predisposing factors, infective organisms, method of treatment and clinical outcome. RESULTS: The clinical triad of splenic abscess was the main presentation of the 30 patients; it included fever (92%), left upper abdominal pain (77%) and leukocytosis (66%). Infective bacteria were identified in 19 patients, and the most offending bacteria were aerobes (82.6%). The radiological findings included single abscess were found in 16 patients and multiple abscesses were noted in 14 patients. The computed tomography and sonography findings included abnormal gas content (6 cases), progressive enlargement of lesion (6 cases), subcapsular extension of lesion (6 cases), extracapsular fluid collection (8 cases) and cystic lesion (7 cases). 59% of the cases had at least one of the above imaging findings. With the combination of the clinical triad and the imaging findings, the diagnostic rate rose up to 86.7%. CONCLUSIONS: Although splenic abscess is rare, it has a high mortality rate if there is delay in diagnosis and treatment. With the combination of computed tomography, sonography and clinical features, early diagnosis and treatment can be made. Percutaneous drainage for single abscess and splenectomy for multiple abscesses are the safe and effective treatment choice. The computed tomography and sonography appearance of splenic abscess is a valuable predictor of outcome of splenic abscess drainage. Medical treatment alone was definitely insufficient.     

Cerebral aspergillosis due to Aspergillus fumigatus in AIDS patient: first culture-proven case reported in Brazil

Cerebral aspergillosis is a rare cause of brain expansive lesion in AIDS patients. We report the first culture-proven case of brain abscess due to Aspergillus fumigatus in a Brazilian AIDS patient. The patient, a 26 year-old male with human immunodeficiency virus (HIV) infection and history of pulmonary tuberculosis and cerebral toxoplasmosis, had fever, cough, dyspnea, and two episodes of seizures. The brain computerized tomography (CT) showed a bi-parietal and parasagittal hypodense lesion with peripheral enhancement, and significant mass effect. There was started anti-Toxoplasma treatment. Three weeks later, the patient presented mental confusion, and a new brain CT evidenced increase in the lesion. He underwent brain biopsy, draining 10 mL of purulent material. The direct mycological examination revealed septated and hyaline hyphae. There was started amphotericin B deoxycholate. The culture of the material demonstrated presence of the Aspergillus fumigatus. The following two months, the patient was submitted to three surgeries, with insertion of drainage catheter and administration of amphotericin B intralesional. Three months after hospital admission, his neurological condition suffered discrete changes. However, he died due to intrahospital pneumonia. Brain abscess caused by Aspergillus fumigatus must be considered in the differential diagnosis of the brain expansive lesions in AIDS patients in Brazil.     

Imaging findings of biliary hamartomas

AIM: To evaluate the imaging findings of biliary hamartomas (von Meyenburg complexes, VMCs) and discuss the differential diagnosis with other related diseases. METHODS: Imaging findings of biliary hamartomas on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), MR cholangiopancreatography (MRCP)and hepatobiliary scintigraphy were retrospectively analyzed in six patients. RESULTS: On ultrasound images, five of the six cases showed multiple small hyper- and hypo-echoic lesions with comet-tail echoes, especially when magnified by US with the usage of zoom function. In all the six cases, multiple tiny hypodense lesions less than 10 mm in diameter were revealed as scattered throughout the liver with no enhancement on CT. These tiny lesions were demonstrated to be hyper- and hypo-intensity on T2- and T1-weighed images, respectively, in three patients who underwent MRI examinations. MRCP was performed in two patients, and clearly showed multiple tiny irregular- and round-shaped hyper-intensity lesions. MRCP and hepatobiliary scintigraphy showed normal appearances of intra- and extra-hepatic bile ducts in two and one patients, respectively. CONCLUSION: Imaging modalities are useful in the diagnosis and differential diagnosis of VMCs. A correct diagnosis might be obtained when typical imaging findings are present even without a histological confirmation.     

Progressive multifocal leukoencephalopathy associated with human immunodeficiency virus infection. A review of the literature with a report of sixteen cases

Progressive multifocal leukoencephalopathy, a common complication of infections with human immunodeficiency virus (HIV), occurs in as many as 3.8% of patients with the acquired immunodeficiency syndrome (AIDS). We report 16 cases and review 12 previously reported cases of progressive multifocal leukoencephalopathy associated with HIV infection. This illness was the presenting manifestation of HIV infection in 8 cases. Limb weakness, gait abnormalities, visual loss, aand altered mental status were the commonest initial complaints. Computed tomography of the brain frequently showed hypodense, nonenhancing white matter lesions. Magnetic resonance imaging was more sensitive than computed tomography in detecting lesions. Cerebrospinal fluid analysis and electroencephalography were nondiagnostic. Impaired cell-mediated immunity was typically noted, even in the absence of other immunodeficiency-associated illnesses. Death occurred within 10 days to 18 months of the onset of symptoms in 22 patients. However, 4 patients remain alive at 3 to 23 months; of these 4, 2 have had significant improvement without treatment. Various therapies were unsuccessful.     

25例肝结核临床分析

目的探讨肝结核的诊断和治疗措施。方法报道1999年1月~2005年1月收治确诊的肝结核病人25例,对其临床资料进行回顾分析。结果25例病人临床表现主要为发热、腹痛、腹胀和肝肿大,反复肝功能异常。病理类型粟粒型8例,结节型17例。5例手术切除治疗。所有病人都经过9~18月的抗结核治疗,经随访预后良好。结论肝结核临床表现和影像学表现多样,且无特异性,误诊误治率高。肝结核诊断需综合临床表现、实验室检查、影像学检查和病理检查,确诊手段主要是肝组织活检,系统性的抗结核治疗及选择性手术治疗是肝结核的主要有效治疗手段。     

Retention mucocele of distal viable remnant tip of appendix： An unusually rare late surgical complication following incomplete appendectomy

A 67-year old man was presented with a 6-mo historyof recurrent right lower quadrant abdominal pain.Onphysical examination,a vague mass was palpable inthe right lumbar region.His routine laboratory testswere normal.Ultrasonography showed a hypoechoiclesion in the right lumbar region anterior to the rightkidney with internal echoes and fluid components.Abdominal contrast-enhanced computed tomography(CECT)showed a well-defined hypodense cystic masslesion lateral to the ascending colon/caecum,notcommunicating with the lumen of colon/caecum.Aftercomplete open excision of the cystic mass lesion,grosspathologic examination revealed a turgid cystic dilatationof appendiceal remnant filled with the mucinousmaterial.On histopathological examination,mucinouscyst adenoma of appendix was confirmed.We report thisrare unusual late complication of mucocele formation inthe distal viable appendiceal remnant,which was leftoverfollowing incomplete retrograde appendectomy.Thisunusual complication is not described in the literatureand we report it in order to highlight the fact that a highindex of clinical and radiological suspicion is essentialfor the diagnosis of mucocele arising from a distal viableappendiceal remnant in a patient who has alreadyundergone appendectomy presenting with recurrentabdominal pain.     

Splenosis--important differential diagnosis in splenectomized patients presenting with abdominal masses of unknown origin

A 40-year-old female patient was admitted for work-up of multiple abdominal masses. The lymphoma-mimicking tumors were detected accidentally during an ultrasound course. The past medical history was unremarkable besides a status post-traumatic splenic rupture and splenectomy. The patient was asymptomatic, especially there were no complaints of fever, night sweats or weight loss. Laboratory tests did not show pathological results. Ultrasound of the abdomen revealed multiple hypoechoic mesenterial and peritoneal enlarged tumors as well as a subhepatic mass (30 x 20 mm). Transmission computed tomography (CT) showed a normal chest, excluded abnormal thoracal masses and confirmed the multiple abdominal nodules. Microparticles were trapped only by tissue with phagocytosis function as cells of the reticulohistiocytary system in liver and spleen. Uptake of (99 m)Tc-labeled microparticles is specific for splenic tissue. All abdominal masses were detectable by single photon emission computed tomography (SPECT) after intravenous administration of this radiotracer. Ultrasound-guided biopsy proved the presence of spleen tissue with follicular hyperplasia. In conclusion, we report a case of post-traumatic splenosis. In 16 - 67 % of patients who experienced traumatic splenic rupture autotransplanted spleen tissue can be detected. Splenosis therefore is an important differential diagnosis of abdominal masses in splenectomized patients.