INTERESTING IMAGE
Diffuse Hepatic Amebiasis Detected by FDG PET/CT Weiyan Zhou, MD, Jinhua Zhao, MD, Yan Xing, MD, Xiang Chen, MD, and Jianhua Song, MD Abstract: A 39-year-old man presented with sudden decreased visual acuity in his left eye. Orbital CT and MRI revealed a soft tissue lesion in his left orbital apex. FDG PET/CT showed increased FDG uptake by the left orbital lesion, abnormal focal FDG uptake in the soft tissues of the external ears, and abnormal heterogeneous FDG activity throughout the liver. Percutaneous liver biopsy, external auditory canal discharge, and stool specimens revealed amebiasis. The patient responded to antiamebic therapy, and his lesions improved. The case demonstrates that during its early stage, hepatic amebiasis may be associated with a relatively heterogeneous pattern of FDG uptake. Key Words: hepatic amebiasis, diffuse, FDG, PET/CT (Clin Nucl Med 2015;40: e167–e170)
Received for publication October 4, 2010; revision accepted November 7, 2010. From the Department of Nuclear Medicine, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, People's Republic of China. Conflicts of interest and sources of funding: none declared. Reprints: Jinhua Zhao, MD, Department of Nuclear Medicine, Shanghai First People's Hospital, Shanghai Jiaotong University, No. 85, Wujin Rd, Shanghai 200080, People's Republic of China. E-mail: [email protected]. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4002–e167
REFERENCES 1. Kaneko K, Nishie A, Arima F, et al. A case of diffuse-type primary hepatic lymphoma mimicking diffuse hepatocellular carcinoma. Ann Nucl Med. 2011;25: 303–307. 2. Kanematsu M, Semelka RC, Leonardou P, et al. Hepatocellular carcinoma of diffuse type: MR imaging findings and clinical manifestations. J Magn Reson Imaging. 2003;18:189–195. 3. Wong SM, Yuen HY, Ahuja HY. Hepatic tuberculosis: a rare cause of fluorodeoxyglucose hepatic superscan with background suppression on positron emission tomography. Singapore Med J. 2014;55:e101–e103. 4. Cheng W, Li F, Zhuang H, et al. Hepatic paragonimiasis revealed by FDG PET/ CT. Clin Nucl Med. 2010;35:726–728. 5. Kao PF, Tsao TC, Kuo KT, et al. Lung parasite ova granuloma mimicking lung malignancy on FDG PET-CT. Clin Nucl Med. 2009;34:243–244. 6. Bresson-Hadni S, Delabrousse E, Blagosklonov O, et al. Imaging aspects and non-surgical interventional treatment in human alveolar echinococcosis. Parasitol Int. 2006;55(suppl):S267–272. 7. Kim WH, Kim SH, Kim YH, et al. Fluorine-18-FDG PET findings of focal eosinophilic liver disease: correlation with CT and/or MRI, laboratory, and pathologic findings. Abdom Imaging. 2010;35:437–446. 8. Haque R, Huston CD, Hughes M, et al. Amebiasis. N Engl J Med. 2003;348: 1565–1573. 9. Wuerz T, Kane JB, Boggild AK, et al. A review of amoebic liver abscess for clinicians in a nonendemic setting. Can J Gastroenterol. 2012;26:729–733. 10. Cavailloles FA, Mure A, Nasser H, et al. Multiple liver amoebic abscesses detected on FDG PET/CT. Clin Nucl Med. 2014;39: 79–80. 11. Metser U, Even-Sapir E. Increased (18)F-fluorodeoxyglucose uptake in benign, nonphysiologic lesions found on whole-body positron emission tomography/ computed tomography (PET/CT): accumulated data from four years of experience with PET/CT. Semin Nucl Med. 2007;37:206–222. 12. Yapar AF, Reyhan M, Canpolat ET. Interesting image. Ameboma mimicking lung cancer on FDG PET/CT. Clin Nucl Med. 2010;35:55–56. 13. Tsutsumi V, Martinez-Palomo A. Inflammatory reaction in experimental hepatic amebiasis. An ultrastructural study. Am J Pathol. 1988;130: 112–119. 14. Doxiades T, Candreviotis N, Tiliakos M, et al. Chronic diffuse non-suppurative amoebic hepatitis. Br Med J. 1961;1:460–462.
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Zhou et al
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015
FIGURE 1. A 39-year-old male was referred to our hospital for sudden painless decreased visual acuity in his left eye. Orbital CT and MRI revealed a soft tissue lesion of uncertain etiology in the left optic apex. An 18F-FDG PET/CT scan was requested for further evaluation. MIP view showed abnormal focal activity in bilateral temporal regions (arrows, A) and abnormal heterogeneous FDG activity throughout the liver. The focal activity in bilateral temporal regions localized to soft tissues of external ears on CT. The liver uptake demonstrated a relatively patchy distribution and a SUVmax of 4.8, with a predominant localization in the right hepatic lobe and inferior segment of the left lateral lobe (B, axial PET image; C, fused PET/CT image). No distinct liver abnormalities were noted on noncontrast CT (D), despite the presence of suspicious portal and retroperitoneal lymph nodes. The left orbital lesion was better visualized on axial view (E, PET image; F, fused PET/CT image; G, CT image) and was also FDG avid. Given that a variety of hepatic conditions can demonstrate a relatively diffuse of patchy distribution,1–3 an abdomen MRI was performed to evaluate the findings.
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© 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015
Diffuse Hepatic Amebiasis on FDG PET/CT
FIGURE 2. Precontrast MR images revealed multiple tiny lesions with fuzzy boundaries and a heterogeneous distribution throughout the liver. Most of these lesions displayed increased signal intensity on fat-suppressed T2-weighted (A) and diffusion-weighted (B) images. Postcontrast images (C) demonstrated multiple areas of patchy enhancement throughout the liver and a tendency of the lesions to coalesce. The patient underwent percutaneous liver biopsy, which revealed amebiasis. External auditory canal discharge and stool specimens confirmed the diagnosis of multifocal amebiasis.
© 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
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Zhou et al
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015
FIGURE 3. The patient was administered with antiamebic therapy, and his condition improved. A posttherapy CT scan of the abdomen with contrast enhancement demonstrated regression of the hepatic lesions (A and B, pretherapy images; C and D, posttherapy images). Although the left orbital lesion was not amenable to biopsy, the patient's visual acuity fully recovered after antiamebic therapy. His external auditory canal lesions also improved, and he was discharged. FDG uptake is not tumor specific and can be noted in a variety of infectious or inflammatory diseases, including parasitic infestations.4–7 Intestinal amebiasis is relatively common in many countries. The liver represents the most frequent extraintestinal site of disease; however, an insidious onset and atypical presentations may pose significant diagnostic challenges.8,9 Although increased FDG uptake in amebic lesions has been reported,10–12 the typical findings in patients with liver disease are related to the development of large hepatic lesions. Our case shows that heterogeneous or patchy hepatic FDG uptake can be also noted in such patients. We believe this can be at least partly attributed to the inflammatory reaction during the early stages of hepatic infestation, before the amebic microabscesses coalesce into larger lesions.13 Various conditions and underlying hepatic pathology may also affect the course of the disease.14
e170
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© 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Diffuse Hepatic Amebiasis Detected by FDG PET/CT Weiyan Zhou, MD, Jinhua Zhao, MD, Yan Xing, MD, Xiang Chen, MD, and Jianhua Song, MD Abstract: A 39-year-old man presented with sudden decreased visual acuity in his left eye. Orbital CT and MRI revealed a soft tissue lesion in his left orbital apex. FDG PET/CT showed increased FDG uptake by the left orbital lesion, abnormal focal FDG uptake in the soft tissues of the external ears, and abnormal heterogeneous FDG activity throughout the liver. Percutaneous liver biopsy, external auditory canal discharge, and stool specimens revealed amebiasis. The patient responded to antiamebic therapy, and his lesions improved. The case demonstrates that during its early stage, hepatic amebiasis may be associated with a relatively heterogeneous pattern of FDG uptake. Key Words: hepatic amebiasis, diffuse, FDG, PET/CT (Clin Nucl Med 2015;40: e167–e170)
Received for publication October 4, 2010; revision accepted November 7, 2010. From the Department of Nuclear Medicine, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, People's Republic of China. Conflicts of interest and sources of funding: none declared. Reprints: Jinhua Zhao, MD, Department of Nuclear Medicine, Shanghai First People's Hospital, Shanghai Jiaotong University, No. 85, Wujin Rd, Shanghai 200080, People's Republic of China. E-mail: [email protected]. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4002–e167
REFERENCES 1. Kaneko K, Nishie A, Arima F, et al. A case of diffuse-type primary hepatic lymphoma mimicking diffuse hepatocellular carcinoma. Ann Nucl Med. 2011;25: 303–307. 2. Kanematsu M, Semelka RC, Leonardou P, et al. Hepatocellular carcinoma of diffuse type: MR imaging findings and clinical manifestations. J Magn Reson Imaging. 2003;18:189–195. 3. Wong SM, Yuen HY, Ahuja HY. Hepatic tuberculosis: a rare cause of fluorodeoxyglucose hepatic superscan with background suppression on positron emission tomography. Singapore Med J. 2014;55:e101–e103. 4. Cheng W, Li F, Zhuang H, et al. Hepatic paragonimiasis revealed by FDG PET/ CT. Clin Nucl Med. 2010;35:726–728. 5. Kao PF, Tsao TC, Kuo KT, et al. Lung parasite ova granuloma mimicking lung malignancy on FDG PET-CT. Clin Nucl Med. 2009;34:243–244. 6. Bresson-Hadni S, Delabrousse E, Blagosklonov O, et al. Imaging aspects and non-surgical interventional treatment in human alveolar echinococcosis. Parasitol Int. 2006;55(suppl):S267–272. 7. Kim WH, Kim SH, Kim YH, et al. Fluorine-18-FDG PET findings of focal eosinophilic liver disease: correlation with CT and/or MRI, laboratory, and pathologic findings. Abdom Imaging. 2010;35:437–446. 8. Haque R, Huston CD, Hughes M, et al. Amebiasis. N Engl J Med. 2003;348: 1565–1573. 9. Wuerz T, Kane JB, Boggild AK, et al. A review of amoebic liver abscess for clinicians in a nonendemic setting. Can J Gastroenterol. 2012;26:729–733. 10. Cavailloles FA, Mure A, Nasser H, et al. Multiple liver amoebic abscesses detected on FDG PET/CT. Clin Nucl Med. 2014;39: 79–80. 11. Metser U, Even-Sapir E. Increased (18)F-fluorodeoxyglucose uptake in benign, nonphysiologic lesions found on whole-body positron emission tomography/ computed tomography (PET/CT): accumulated data from four years of experience with PET/CT. Semin Nucl Med. 2007;37:206–222. 12. Yapar AF, Reyhan M, Canpolat ET. Interesting image. Ameboma mimicking lung cancer on FDG PET/CT. Clin Nucl Med. 2010;35:55–56. 13. Tsutsumi V, Martinez-Palomo A. Inflammatory reaction in experimental hepatic amebiasis. An ultrastructural study. Am J Pathol. 1988;130: 112–119. 14. Doxiades T, Candreviotis N, Tiliakos M, et al. Chronic diffuse non-suppurative amoebic hepatitis. Br Med J. 1961;1:460–462.
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
e167
Zhou et al
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015
FIGURE 1. A 39-year-old male was referred to our hospital for sudden painless decreased visual acuity in his left eye. Orbital CT and MRI revealed a soft tissue lesion of uncertain etiology in the left optic apex. An 18F-FDG PET/CT scan was requested for further evaluation. MIP view showed abnormal focal activity in bilateral temporal regions (arrows, A) and abnormal heterogeneous FDG activity throughout the liver. The focal activity in bilateral temporal regions localized to soft tissues of external ears on CT. The liver uptake demonstrated a relatively patchy distribution and a SUVmax of 4.8, with a predominant localization in the right hepatic lobe and inferior segment of the left lateral lobe (B, axial PET image; C, fused PET/CT image). No distinct liver abnormalities were noted on noncontrast CT (D), despite the presence of suspicious portal and retroperitoneal lymph nodes. The left orbital lesion was better visualized on axial view (E, PET image; F, fused PET/CT image; G, CT image) and was also FDG avid. Given that a variety of hepatic conditions can demonstrate a relatively diffuse of patchy distribution,1–3 an abdomen MRI was performed to evaluate the findings.
e168
www.nuclearmed.com
© 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015
Diffuse Hepatic Amebiasis on FDG PET/CT
FIGURE 2. Precontrast MR images revealed multiple tiny lesions with fuzzy boundaries and a heterogeneous distribution throughout the liver. Most of these lesions displayed increased signal intensity on fat-suppressed T2-weighted (A) and diffusion-weighted (B) images. Postcontrast images (C) demonstrated multiple areas of patchy enhancement throughout the liver and a tendency of the lesions to coalesce. The patient underwent percutaneous liver biopsy, which revealed amebiasis. External auditory canal discharge and stool specimens confirmed the diagnosis of multifocal amebiasis.
© 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.nuclearmed.com
e169
Zhou et al
Clinical Nuclear Medicine • Volume 40, Number 2, February 2015
FIGURE 3. The patient was administered with antiamebic therapy, and his condition improved. A posttherapy CT scan of the abdomen with contrast enhancement demonstrated regression of the hepatic lesions (A and B, pretherapy images; C and D, posttherapy images). Although the left orbital lesion was not amenable to biopsy, the patient's visual acuity fully recovered after antiamebic therapy. His external auditory canal lesions also improved, and he was discharged. FDG uptake is not tumor specific and can be noted in a variety of infectious or inflammatory diseases, including parasitic infestations.4–7 Intestinal amebiasis is relatively common in many countries. The liver represents the most frequent extraintestinal site of disease; however, an insidious onset and atypical presentations may pose significant diagnostic challenges.8,9 Although increased FDG uptake in amebic lesions has been reported,10–12 the typical findings in patients with liver disease are related to the development of large hepatic lesions. Our case shows that heterogeneous or patchy hepatic FDG uptake can be also noted in such patients. We believe this can be at least partly attributed to the inflammatory reaction during the early stages of hepatic infestation, before the amebic microabscesses coalesce into larger lesions.13 Various conditions and underlying hepatic pathology may also affect the course of the disease.14
e170
www.nuclearmed.com
© 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
