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91

Case . .

Peliosis

Hepatis

. ,

.

Infection

D. Randall

Radin1 and Gary C. KaneI2

:‘

Report

diarrhea

with

pulmonary

homosexual

20-kg

was

had

loss.

oral

Physical

Iamb/ia

man

weight

tuberculosis,

HIV antibodies. Giardia

Medical

candidiasis,

examination

present

a several-month

in the

history and

showed stool.

history

included

positive

of

syphilis,

serology

for

hepatosplenomegaly.

Laboratory

evaluation

was

remarkable for anemia, hypoalbuminemia, and moderate to marked elevation of serum levels of alkaline phosphatase, ranging from 350 to 1 045 U/I (normal, 35-1 1 0 U/I) during 3 weeks. Abdominal tation

of

splenic and

CT the

bilateral

showed

portal

lesions,

vein,

portal

pleural

enlargement

of the

splenomegaly,

and retroperitoneal effusions

(Fig.

1). Most

left

diffuse

hepatic small

lobe, hepatic

lymphadenopathy, of the

liver

dila-

up to 1 .5 cm

in diameter.

Small,

central

lesions,

Received May 15, 1990; accepted June 12, 1990. 1 Department of Radiology, University of Southem 1 084. Address 2 Department AJR 156:91-92,

reprint requests to D. A. Radin. of Pathology, University of Southern January

1991 0361 -803X/91/1561-0091

enhancing

‘L

within

and

lmmunodeficiency

some of the splenic

homogeneous,

lesions.

The enlarged

lymph nodes and showed

up to 2 cm in diameter,

measured

significant

contrast enhancement. aspirations of hepatic and spienic lesions and paraaortic adenopathy were performed with CT guidance. Cytologic evaluation showed only blood. Smears and cultures for fungi, mycobacteria, and parasites were negative. Smears and cultures of blood, sputum,

Fine-needle

and

urine

yielded

specimens

also

serosanguinous

were

fluid

plasm. The ascites decreased Core

biopsy

negative.

with

no

with

of the liver revealed

Abdominal

evidence

paracentesis

of infection

diuretic

therapy.

an intact

basic

or

architecture.

neoPortal

tracts were normal in size, with minimal fibrosis and a mild mononuclear inflammatory infiltrate. Bile ducts were unremarkable. The cordsinusoid pattern of the parenchyma was intact. Numerous cystlike spaces were present within the lobules. The cysts were filled with and

granular

representing organizing

proteinaceous

plasma. thrombi,

Rarely, were

eosinophilic

present

within

was

No tumor

peliosis

hepatotoxic

hepatis.

agents,

to be associated The

cells

patient

presentation,

were

The

with peliosis was

alive

but refused

and

of the

likely

with early

cysts.

in some

whereas in others, a occasionally merged

present.

patient

including

most

consistent

some

areas the cysts had an endothelial lining, was absent. In addition, dilated sinusoids

the cysts.

material,

small new vessels,

The

denied

pathologic

use

of

or

lining into

diagnosis exposure

alcohol, or drugs or chemicals

to

known

hepatis. well

follow-up

when

last

seen,

9 months

after

examination.

ascites, which

were seen as hypodense nodules smaller than 1 cm in diameter on unenhanced CT, became isodense with IV contrast enhancement. Most of the splenic lesions were seen as nonenhancing hypodense nodules

present were

RBCs

A 34-year-old

‘

:

;:,.

with Human

The AIDS epidemic in the United States was first recognized 1 0 years ago when Pneumocystis carinii pneumonia and Kaposi sarcoma were seen with alarming frequency in young homosexual men. Since then, more and more unusual diseases have become familiar to physicians caring for patients infected by the human immunodeficiency virus (HIV). Several reports indicate that peliosis hepatis (multiple blood-filled cayities in the liver) is another condition for which HIV-infected patients are at increased risk [1 -3]. We wish to report the CT findings in an HIV-seropositive man with biopsy-proved peliosis of the liver and possible involvement of the spleen and abdominal lymph nodes.

Case

.

,

. ‘:%

..-

.....

in a Patient

Virus

.

Report

foci

were

Discussion Peliosis hepatis is an uncommon condition characterized by multiple blood-filled cavities in the hepatic parenchyma [4]. These cavities range in size from less than 1 mm to

California

School

of Medicine, L.A. County-USC

California

School

of Medicine,

C American

Roentgen

Aancho

Los Amigos

Ray Society

Medical Center, 1200 N. State St., Los Angeles, CA 90033Medical

Center,

Downey,

CA 90242.

Fig. 1.-A, Unenhanced CT scan shows hypodense nodules in liver and spleen and enlarged retroperitoneal lymph nodes. B, Enhanced CT scan shows small, central enhancing foci (arrowheads)

within

some hypodense

splenic nod-

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ules. Most hepatic nodules are isodense. Retroperftoneai nodes are similar in density to aorta and vena cava.

(.

::

A

B

several centimeters, may or may not have an endothelial lining, and may communicate with dilated sinusoids. Originally described as an incidental autopsy finding in patients with chronic wasting due to tuberculosis or cancer, peliosis hepatis has been reported in patients treated with a variety of drugs, including anabolic steroids, azathioprine, and corticosteroids,

and may present

with

hepatomegaly,

cirrhosis

with

portal

hypertension, hepatic failure, or shock due to hepatic rupture [4, 5]. Pathogenetic theories include toxic effect of a substance on the sinusoidal wall, hepatic venous outflow obstruction, and hepatocellular necrosis [4]. Peliosis also has been reported in the rest of the reticuloendothelial system and elsewhere. Although peliosis hepatis is also present in most of these cases, symptoms from extrahepatic involvement may predominate. In 24 patients with peliosis of the spleen, splenic rupture occurred in 25% of cases [2, 6, 7]. Peliosis of the liver, spleen, retroperitoneal lymph nodes, bone marrow, lungs, pleura, kidneys, adrenal glands, stomach, and ileum was found during autopsy in a man who presented with bilateral spontaneous pneumothorax followed by pulmonary hemorrhage and disseminated intravascular coagulation [8]. Peliosis hepatis has been reported in eight patients with AIDS or AIDS-related complex [1 -3]. In one case, involvement of the spleen, porta hepatis lymph nodes, and bone marrow in addition to the liver was seen during autopsy [2]. In a patient with biopsy-proved peliosis hepatis, CT showed “hepatosplenomegaly with multiple zones of diminished density involving both lobes of the liver and the spleen” [2]. Because peliosis was diagnosed by liver biopsy in the other six patients, it is unknown whether or not extrahepatic sites were involved [1 , 3]. Possible mechanisms for the development of peliosis in patients with HIV infection include direct or indirect cytopathic effect of the virus on sinusoidal endothelial cells. Inappropriate secretion of immunoregulatory factors acting on vascular endothelium has been suggested as the cause of both peliosis and Kaposi sarcoma [1 , 3].

The CT appearance of peliosis hepatis by the pathologic findings. If the peliotic smaller than 1 cm in diameter, Larger cavities that communicate same attenuation characteristics

bosed cavities our

patient,

CT findings may be normal. with sinusoids will have the as blood vessels. Throm-

will appear as nonenhancing the

CT

demonstration

can be suggested cavities are much

nodules.

of multiple,

Thus, in

hypodense

hepatic nodules that became isodense with IV contrast enhancement is consistent with (but not specific for) peliosis.

The additional

findings

of enlargement

of the left hepatic

lobe,

dilatation of the portal vein, splenomegaly, and ascites mdicate the presence of portal hypertension, a complication of peliosis hepatis. Although not proved, it seems likely that the spleen and retroperitoneal lymph nodes in our patient also were involved by peliosis. No other evidence of infection or neoplasm was found, and multiple fine-needle aspirations yielded only blood. The enlarged

lymph

nodes

were

similar

in density

to the aorta

and vena cava both before and after IV contrast enhancement. However, most of the splenic lesions did not enhance. This finding could be explained by thrombosis of the peliotic cavities,

although

the reason

that

thrombosis

might

involve

predominantly the splenic lesions with relative sparing of the hepatic and nodal lesions is not known. The small, central, enhancing foci seen within some of the splenic nodules in our patient may represent recanalization of organized thrombi [7] We expect that additional cases of peliosis will be encountered as the AIDS epidemic continues. Awareness of this entity by radiologists is important for three reasons. The CT findings in peliosis may be mistaken for a neoplastic or infectious process for which AIDS patients are at increased risk. Peliosis may have life-threatening complications, including hepatic failure, portal hypertension, and hemorrhage from hepatic or splenic rupture. And, finally, nonoperative diagnosis may require core biopsy rather than fine-needle aspiration.

REFERENCES

1 . Scoazec

JY, Marche C, Girard PM, et al. Peliosis hepatis and sinusoidal dilatation during infection by the human immunodeficiency virus (HIV): an ultrastructural study. Am J Pathol 1988;131 :38-47 2. Czapar CA, Weldon-Linne CM, Moore DM, Rhone DP. Peliosis hepatis in the acquired immunodeficiency syndrome. Arch Pathol Lab Med 1986;1 10:611-613 3. Devars du Mayne JF. Hepatic vascular lesions in AIDS. JAMA 1985;254:53-54 4. Simon DM, Krause A, Galambos JT. Peliosis hepatis in a patient with marasmus. Gastroenterology 1988:95:805-809

5. van Erpecum KJ, Janssens AR, Kreuning J, Ruiter DJ, Kroon HMJA, Grond AJK. Generalized peliosis hepatis and cirrhosis after long-term use of oral contraceptives. Am J Gastroenterol 1988;83:572-575 6. DiebOld J, Audouin J. Peliosis of the spleen. Am J Surg Pathol 1983;7: 197204

7. Kubosawa

H, Konno A, Komatsu T, Ishige H, Kondo V. Peliosis hepatis:

an unusual case involving the spleen and lymph nodes. Acta Pathol Jpn 1989;39:212-215 8. Ichijima K, Kobashi Y, Yamabe H, Fujii Y, lnoue Y. Peliosis hepatis: an unusual case involving multiple organs. Acta PatholJpn 1980;30: 109-120