Multinodular fatty change in the liver in patients with chronic hepatic porphyria

Case 304: Porphyria Cutanea Tarda

HISTORY

In 2017, a 72-year-old woman was seen in the gastroenterology department with a 2-month history of mild and intermittent abdominal pain without other accompanying symptoms. Her medical history was unremarkable, except for a previous visit due to facial photodermatitis 3 years earlier. Diazepam for a sleeping disorder was the only chronic medication recorded. Results of physical examination, blood count, and basic metabolic panels including assessment of renal and liver function were normal; only the ferritin level was slightly elevated (265 ng/mL [595 pmol/L]; normal range, 10-120 ng/mL [22-269 pmol/L]). Abdominal US was performed, followed by multiphasic contrast-enhanced CT and liver MRI due to the findings of the first study. A diagnosis was not established in that moment, and acetaminophen was prescribed for pain relief. As the symptoms continued, laboratory tests and imaging studies were repeated 2 years later, with similar findings and no notable changes.

Multinodular fatty change in the liver in three patients with chronic hepatic porphyria: Contribution of sonography to the diagnosis

We present three cases of chronic hepatic porphyria (CHP) in alcoholic patients, in which grayscale ultrasound (US) revealed multiple echogenic masses in the liver, mimicking multinodular hepatocellular carcinoma on alcoholic liver injury. In all cases, contrast-enhanced US (CEUS) showed iso-enhancement of the mass lesions throughout all vascular phases. Additionally, two-dimensional shear wave elastography (2DSWE) (performed in two cases) revealed the mass to have almost the same SWE value as the surrounding parenchyma. When encountering alcoholic patients with multiple echogenic masses in the liver, CHP must be included in the differential diagnosis. CEUS and 2DSWE allow us to increase our diagnostic confidence of CHP.

Multiple liver pseudotumors due to hepatic steatosis and fatty sparing: A non-invasive imaging approach

Hepatic steatosis is a frequent benign liver condition that can be idiopathic or secondary. The degree of fatty liver infiltration can be focal, diffuse or patchy. In this study, we present two patients with hepatic steatosis and multiple nodular liver lesions, due to fatty infiltration and fatty sparing respectively, mimicking a primary tumor or metastases (“pseudotumors”).

Since the differential diagnosis of this kind of lesions can be difficult based on imaging alone, the knowledge of Contrast-Enhanced Ultrasound (CEUS) and Magnetic Resonance Imaging (MRI) findings may help radiologists to avoid an incorrect diagnosis of liver tumor, and unnecessary biopsies.

Analysis of refractive artifacts by reconstructed three-dimensional ultrasound imaging

PURPOSE

Refractive artifacts are frequently encountered in clinical settings, and they have been analyzed on the basis of conventional two-dimensional (2-D) ultrasound (US) images, but this method is restricted to monoplane data and is limited by its inability to assess the three-dimensional (3-D) structure of refractive artifacts. The aim of this study was to evaluate the role of reconstructed 3-D US images in the analysis of refractive artifacts.

METHODS

The following representative refractive artifacts were analyzed on the basis of reconstructed 3-D US images: (a) a distorted image of a fine tube behind a cyst (balloon); (b) a deformed image of the bottom of a balloon; and (c) a duplication artifact due to the acoustic lens effect.

RESULTS

(a) A tube was imaged as a fine echogenic line with two points of sudden interruption, unlike a curved needle, which was imaged without interruption. (b) 3-D US allowed us to visualize the mode of deformity in the image of the bottom of a fluid-filled balloon in a water bath. When the acoustic velocity in the fluid was greater than that in the surrounding water, the bottom of the balloon appeared to be shrunken. When the acoustic velocity in the fluid was less than that in the surrounding water, the bottom of the balloon appeared to be swollen. (c) When we placed two pieces of white chicken meat in front of a fine needle, the needle was duplicated in the resulting image. In this case, the needle appeared to be vague and fuzzy. In this case, 3-D US did not add further information to the 2-D images.

CONCLUSIONS

Our study suggests that reconstructed 3-D US images provide a better understanding of the mode of refractive artifacts than do 2-D US images.

Multifocal Nodular Fatty Infiltration of the Liver: A Case Report of a Challenging Diagnostic Problem

Patient: Female, 59

Final Diagnosis: Multifocal nodular fatty infiltration of the liver

Symptoms: None

Medication: —

Clinical Procedure: Laparoscopy

Specialty: Surgery

Computed tomography findings of congenital generalized lipodystrophy: multiple nodular fatty liver and diffuse sclerosis of bones

Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive disease that is also referred to as Berardinelli-Seip syndrome. It is characterized by a lack of adipose tissue throughout the body from birth, muscular hypertrophy, advanced bone age, fatty liver, and insulin resistance. We describe computed tomography (CT) and magnetic resonance findings for a 35-year-old woman with CGL. Multiple nodular, well-defined regions of fatty infiltration of the liver are rare and have never been previously reported in a patient with lipodystrophy. To our knowledge, this is the first report describing CT findings of bone sclerotic changes associated with CGL.

Gyriform Liver Foci in Chronic Hepatic Porphyria

A patient with suspected liver metastases detected by routine sonography of the abdomen was admitted to our clinic for further testing. Liver sonography disclosed multiple irregular gyriform foci of a hyperechoic structure with a maximum diameter of 3.5 cm. In magnetic resonance imaging, these foci appeared as hyperintense in T1-weighted images and isointense in T2-weighted images. A biopsy showed a discrete portal and periportal fibrosis. UV light fluorescence of the specimen was negative. Analysis of urine revealed an almost fourfold el-evation of total porphyrin of 591 µg/24 h, proving the diagnosis of chronic hepatic porphyria. Characteristic liver foci in hepatic porphyria are detected by sonography in some affected patients. Usually, they can also be depicted by magnetic resonance imaging and computed tomography. These foci often appear before any other symptoms of the disease and are reversible when triggering factors, such as certain drugs or alcohol, are discontinued.