Radiological imaging plays a crucial role in the diagnosis of hepatocellular carcinoma (HCC) as the noninvasive diagnosis of HCC in high-risk patients by typical imaging findings alone is widely adopted in major practice guidelines for HCC. While imaging techniques have markedly improved in detecting small liver lesions, they often detect incidental benign liver lesions and non-hepatocellular malignancy that can be misdiagnosed as HCC. The most common mimicker of HCC in cirrhotic liver is nontumorous arterioportal shunts that are seen as focal hypervascular liver lesions on dynamic contrast-enhanced cross-sectional imaging. Rapidly enhancing hemangiomas can be easily misdiagnosed as HCC especially on MR imaging with liver-specific contrast agent. Focal inflammatory liver lesions mimic HCC by demonstrating arterial-phase hypervascularity and subsequent washout on dynamic contrast-enhanced imaging. It is important to recognize the suggestive imaging findings for intrahepatic cholangiocarcinoma (CC) as the management of CC is largely different from that of HCC. There are other benign mimickers of HCC such as angiomyolipomas and focal nodular hyperplasia-like nodules. Recognition of their typical imaging findings can reduce false-positive HCC diagnosis.
Carcinoma, Hepatocellular/*diagnosis/radiography ; Diagnosis, Differential ; Hemangioma/complications/radiography/ultrasonography ; Hepatitis B/complications ; Humans ; Inflammation/radiography/ultrasonography ; Liver/radiography/ultrasonography ; Liver Cirrhosis/complications/radiography ; Liver Neoplasms/*diagnosis/radiography ; Magnetic Resonance Imaging ; Non-alcoholic Fatty Liver Disease/radiography/ultrasonography

Hepatitis A virus (HAV) infection is common in developing countries, including Korea. It can be accompanied by extrahepatic complications such as renal failure, arthritis, and vasculitis. Pleural effusion is a very rare complication of HAV infection, which has been reported usually in children, and has benign clinical courses. Here we report a case of pleural effusion with ascites which occurred in an adult hepatitis A patient. A 26-year-old-woman presented generalized myalgia and fever and was diagnosed as acute hepatitis A. Despite of the improvement of laboratory findings, fever and cough persisted. Pleural effusion newly appeared on the serial chest radiologic images. After the fever settled down, the pleural effusion resolved spontaneously at 13th day of admission.
Acute Disease ; Adult ; Female ; Hepatitis A/complications/*diagnosis ; Humans ; Pleural Effusion/complications/*diagnosis/radiography ; Tomography, X-Ray Computed

Hepatic myelopathy is a rare complication of chronic liver disease that is associated with extensive portosystemic shunts. The main clinical feature of hepatic myelopathy is progressive spastic paraparesis in the absence of sensory or sphincter impairment. Early and accurate diagnosis of hepatic myelopathy is important because patients with early stages of the disease can fully recover following liver transplantation. Motor-evoked potential studies may be suitable for the early diagnosis of hepatic myelopathy, even in patients with preclinical stages of the disease. Here we describe two patients who presented with spastic paraparesis associated with a spontaneous splenorenal shunt and without any previous episode of hepatic encephalopathy. One patient experienced improved neurologic symptoms after liver transplantation, whereas the other patient only received medical treatment, which did not prevent the progression of spastic paraparesis.
Adult ; Disease Progression ; Evoked Potentials, Motor/physiology ; Hepatitis B, Chronic/complications/diagnosis ; Hepatitis C, Chronic/complications/diagnosis ; Humans ; Liver Cirrhosis/*complications/diagnosis ; Liver Transplantation ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Paraparesis, Spastic/etiology/pathology ; Renal Veins/*radiography ; Spinal Cord Diseases/*diagnosis/etiology/radiography ; Splenic Vein/*radiography ; Tomography, X-Ray Computed ; Vascular Fistula/*radiography

Reversible focal lesions on the splenium of the corpus callosum (SCC) have been reported in patients with mild encephalitis/encephalopathy caused by various infectious agents, such as influenza, mumps, adenovirus, Varicella zoster, Escherichia coli, Legionella pneumophila, and Staphylococcus aureus. We report a case of a reversible SCC lesion causing reversible encephalopathy in nonfulminant hepatitis A. A 30-year-old healthy male with dysarthria and fever was admitted to our hospital. After admission his mental status became confused, and so we performed electroencephalography (EEG) and magnetic resonance imaging (MRI) of the brain, which revealed an intensified signal on diffusion-weighted imaging (DWI) at the SCC. His mental status improved 5 days after admission, and the SCC lesion had completely disappeared 15 days after admission.
Adult ; Alanine Transaminase/blood ; Corpus Callosum/*radiography ; Creatinine/blood ; Electroencephalography ; Encephalitis/complications/*diagnosis ; Hepatitis A/complications/*diagnosis ; Humans ; Magnetic Resonance Imaging ; Male ; Renal Dialysis

BACKGROUND/AIMS: Fitz-Hugh-Curtis syndrome is defined as perihepatitis associated with pelvic inflammatory disease (PID). We retrospectively analyzed clinical and laboratory manifestations as well as the therapeutic response in patients with clinically diagnosed Fitz-Hugh-Curtis syndrome. METHODS: A cohort of 25 patients with PID and perihepatitis (as diagnosed by dynamic abdominal computed tomography (CT)) was enrolled. The prognosis, clinical manifestations, and physical examination, laboratory, and CT findings were analyzed. RESULTS: The mean (+/-SD) age of the patients was 32(+/-8) years, and all of them were sexually active, premenopausal women, and presented with abdominal pain. Of these, 52% complained of vaginal discharge. On physical examination, right upper-quadrant tenderness was the most common finding (84%), with lower-abdominal tenderness being present in 20% of patients. On laboratory examination, erythrocyte sedimentation rate and C-reactive protein were increased in 76% and 92% of the patients, respectively. The white blood cell count was increased in 60% of them. Most patients had a normal liver function test. Using a specimen of the cervical discharge, the polymerase chain reaction to test for Chlamydia trachomatis were positive in 87% (13/15) of the patients, and Chlamydia antigen was found in 75% (9/12) of them. Dynamic abdominal CT revealed subcapsular enhancement of the liver in the arterial phase. All of the patients improved with antibiotic therapy. CONCLUSIONS: Symptoms and physical findings suggestive of PID are not present in many patients with Fitz-Hugh-Curtis syndrome. When a premenopausal woman complains of upper abdominal pain and shows CT findings compatible with perihepatitis, examination of cervical discharge would be recommended to assess the possibility of Fitz-Hugh-Curtis syndrome.
Adult ; Anti-Bacterial Agents/therapeutic use ; Chlamydia Infections/diagnosis/microbiology ; Chlamydia trachomatis/isolation & purification ; Cohort Studies ; Diagnosis, Differential ; Drug Therapy, Combination ; Female ; Gonorrhea/complications/*diagnosis/radiography ; Hepatitis/complications/*diagnosis/radiography ; Humans ; Pelvic Inflammatory Disease/complications/*diagnosis/radiography ; Retrospective Studies ; Syndrome ; Tomography, X-Ray Computed

A 63-year-old man with a history of hepatitis-B-related hepatocellular carcinoma (HCC) in the left lateral portion of the liver received repeated transcatheter arterial chemoembolization (TACE) and salvage radiotherapy. Two months after completing radiotherapy, he presented with dysphagia, epigastric pain, and a protruding abdominal mass. Computed tomography showed that the bulging mass was directly invading the adjacent stomach. Endoscopy revealed a fistula from the HCC invading the stomach. Although the size of the mass had decreased with the drainage through the fistula, and his symptoms had gradually improved, he died of cancer-related bleeding and hepatic failure. This represents a case in which an HCC invaded the stomach and caused a hepatogastric fistula after repeated TACE and salvage radiotherapy.
Carcinoma, Hepatocellular/complications/radiography/*therapy ; *Chemoembolization, Therapeutic ; Drainage ; Gastric Fistula/*etiology ; Gastroscopy ; Hepatitis B/diagnosis ; Humans ; Liver Diseases/*etiology ; Liver Neoplasms/complications/radiography/*therapy ; Male ; Middle Aged ; Neoplasm Invasiveness ; Stomach/pathology ; Tomography, X-Ray Computed

Cryptococcus neoformans, an encapsulated fungus, is an important opportunistic pathogen that can cause meningitis in immunocompromised patients. Since patients with cryptococcemia have high mortality, it is essential to make an early diagnosis and promptly initiate antifungal therapy. However, it is often very difficult to differentiate between cryptococcal meningitis and hepatic encephalopathy in patients with liver cirrhosis, and there is delay in making the diagnosis. Therefore, these patients have a particularly grave prognosis and consequently many patients die before culture results become available. In one study, starting antifungal therapy within 48 hours of the blood culture was associated with improved survival, but patients with liver cirrhosis were significantly less likely to receive antifungal therapy within 48 hours compared to those without liver cirrhosis. Recently, the authors experience a case of a 68-year-old woman with liver cirrhosis who presented with fever and a drowsy mental status. She had a previous history of having been admitted for infection-associated hepatic encephlopathy. Cryptococcal meningitis and cryptococcemia were diagnosed by spinal puncture and culture of cerebrospinal fluid. In spite of adequate treatment, the patient developed multi-system organ failure and eventually expired. Herein, we report a case of cryptococcal meningitis mimicking hepatic encephalopathy in a patient with liver cirrhosis.
Aged, 80 and over ; Brain/radiography ; Cryptococcus/isolation & purification ; Female ; Hepatic Encephalopathy/complications/*diagnosis ; Hepatitis C, Chronic/complications/pathology ; Humans ; Liver Cirrhosis/etiology/pathology ; Meningitis, Cryptococcal/complications/*diagnosis/microbiology ; Tomography, X-Ray Computed

Spontaneous regression of hepatocellular carcinoma (HCC) is extremely rare. We report a case of 67-year-old man having HBV-associated HCC with multiple lung metastases which regressed spontaneously. The patient had single liver mass and received surgical resection. The mass was confirmed as HCC histopathologically. Nine years after surgical resection, a 3.3 cm sized recurred HCC was detected on the resection margin in CT scan. Transarterial chemoembolization (TACE) was performed 3 times, and lung metastases developed thereafter. The patient received 2 more sessions of TACE, however, metastatic lung nodules were in progress very rapidly. We decided to stop TACE and followed the patient regularly without any anti-cancer treatment. Nine months after development of lung metastasis, the size and number of metastatic lung nodules decreased and were not detected anymore after 14 months. Serum alpha-fetoprotein levels also decreased to normal range and no viable tumor was noted in the liver. The patient is still alive 12 years after the first diagnosis of HCC and 16 months after lung metastasis developed.
Aged ; Carcinoma, Hepatocellular/*pathology/secondary/therapy ; Chemoembolization, Therapeutic ; Hepatitis B, Chronic/complications/diagnosis ; Humans ; Liver Neoplasms/complications/*pathology/therapy ; Lung Neoplasms/*diagnosis/radiography/secondary ; Male ; Neoplasm Regression, Spontaneous ; Neoplasm Staging ; Tomography, X-Ray Computed ; alpha-Fetoproteins/analysis

We report on a case of a 57-year-old male who underwent a curative resection for hepatocellular carcinoma (HCC) with histological confirmation of a spontaneously necrotized tumor. Initial serum AFP level was 4,778 ng/mL. A 3.7 cm hyperechoic mass in segment 6 of the liver was observed on ultrasonography and dynamic contrast-enhanced liver MRI showed a 3.7x3.1 cm sized HCC. He was scheduled to undergo curative surgical resection under the clinical diagnosis of an early stage HCC (Barcelona Clinic Liver Cancer stage A). Without treatment, the serum AFP level declined rapidly to 50 ng/mL over five weeks. He underwent curative wedge resection of segment 6 of the liver. Histology revealed complete necrosis of the mass rimmed by inflamed fibrous capsule on a background of HBV-related cirrhosis with infiltration of lymphoplasma cells. Exact pathophysiology underlying this event is unknown. Among the proposed mechanisms of spontaneous neoplastic remission of HCC, circulatory disturbance and activation of host immune response offer the most scientific explanation for the complete histologic necrosis of HCC in the resected mass seen in our patient.
Carcinoma, Hepatocellular/*diagnosis/diagnostic imaging/pathology ; Hepatitis B/complications/diagnosis ; Humans ; Liver/diagnostic imaging/pathology ; Liver Cirrhosis/etiology ; Liver Neoplasms/*diagnosis/diagnostic imaging/pathology ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Necrosis ; Radiography ; Remission, Spontaneous ; Ultrasonography ; alpha-Fetoproteins/analysis

Variceal bleeding and hepatorenal syndrome (HRS) are serious and life-threatening complications of advanced liver disease. Terlipressin is widely used to manage both acute variceal bleeding and HRS due to its potency and long duration of action. The most severe (though rare) adverse event is ischemia. The present report describes the case of a patient with gangrene and osteomyelitis secondary to terlipressin therapy. A 71-year-old male with alcoholic liver cirrhosis (Child-Pugh B) and chronic hepatitis C was admitted due to a drowsy mental status. The patient had several experiences of orthopedic surgery. His creatinine level had gradually elevated to 4.02 mg/dL, and his urine output decreased to 500 mL/24 hr. The patient was diagnosed as having grade III hepatic encephalopathy (HE) and type II HRS. Terlipressin and albumin were administered intravenously to treat the HRS over 11 days. Although he recovered from the HE and HRS, the patient developed peripheral gangrene and osteomyelitis in both feet. His right toes were cured with the aid of rescue therapy, but his left three toes had to be amputated. Peripheral gangrene and osteomyelitis secondary to terlipressin therapy occur only rarely, and there is no specific rescue therapy for these conditions. Thus, attention should be paid to the possibility of ischemia of the skin and bone during or after terlipressin therapy.
Aged ; Creatinine/blood ; Foot/pathology ; Gangrene/*etiology ; Hepatitis C, Chronic/complications ; Humans ; Liver Cirrhosis/complications/diagnosis ; Liver Diseases/*diagnosis/drug therapy ; Lypressin/adverse effects/*analogs & derivatives/therapeutic use ; Male ; Osteomyelitis/*etiology ; Severity of Illness Index ; Toe Phalanges/radiography ; Vasoconstrictor Agents/*adverse effects/therapeutic use