Gaspar Alberto Motta Ramírez, MD
1. Background, snapshot of recent epidemics, reasons for
emergence and spread in a variety of infectious liver
diseases.
2...
4. Discuss the importance of clinical and biochemical
information in characterizing these diseases and
describe the correl...
Situated at the confluence of the
portal and systemic circulations,
the liver represents the most
common site of visceral ...
The liver plays an important role in host
defense against invasive microorganisms.
The liver: Basic facts
Infectious disea...
Infectious liver diseases
Clin Liver Dis 2011;15:111–130
Infectious liver diseases
Assessing the silent
progress of liver
disease:
RISK FACTORS:
•substance use (includes sharing, ...
Infectious liver diseases
Clin Liver Dis 2011;15:111–130
 Asymptomatic/symptomatic
 Age, gender
 Risk factors for chronic liver disease
 History of primary malignancy
 Travel...
Liver lesions in adults
Exact knowledge of the number, size, and regional
distribution of liver lesions is essential.
Feat...
A, B, C, E
They all look similar, ranging from a few extra
portal triad lymphocytes, to “FULMINANT”
hepatitis with total c...
BHepatitis B is endemic in China, South East
Asia, the Amazon, eastern and central Europe,
Sub-saharan Africa, the Middle ...
C
LESS common than B (one fourth)
LESS dangerous than B in the acute phase
MORE likely to go chronic than B
MORE closely l...
VIRAL HEPATITIS
So acute hepatitis may be similar to fatty liver in CT
Note the heterogeneous contrast enhancement in the ...
1. Infection due to HCV accounts for (worldwide):
 20% of cases of acute hepatitis
 70% of cases of chronic hepatitis
 ...
HCV infection –
DIFFUSE LIVER DISEASE
Two distinct sonographic patterns in diffuse liver disease have been
described in th...
HCV infection –
DIFFUSE LIVER DISEASE
The second pattern is the centrilobular or starry sky liver,
characterized by clearl...
Male, 35yoCase # 1
Acute hepatitis
Periportal edema -periportal tracking decreased attenuation, which highlights the porta...
• Most cases detected on US or single phase CT
• Practically triple phase CT can characterize any
liver lesion/mass(es)
• ...
Male, 65yoCase # 2
Focal decreased attenuation
Male, 37yoCase # 3
Heterogeneous lesion with hypoechoic areas &
internal septa
Liver windows have a window level equal to the
attenuation level of hepatic parenchyma (50 HU
without contrast material; 1...
Female, 60yoCase # 4
Well demarcated hypoenhancing lesion
Rim of increased enhancement relative to central region, hyperem...
Segmental hepatic enhancement on
dynamic CT is frequently associated
with hepatic abscesses and may be caused
by decreased...
Male, 40yoCase # 5
Double-target sign
When an hepatic abscesses are suspected clinically, it is
necessary to perform dynamic contrast-enhanced CT.
Segmental or ...
Male, 34yoCase # 6
Cluster sign
Multilocular
Case # 7 Male, 36yo
Double-target sign
High-density material within abscess is due to hemorrhage.
AJR 1988;150:1297-1301
HEPATIC ABSCESS and PYELONEPHRITIS
World J Gastroenterol 2013; 19(43): 7603-7619
Hepatic abscess
Organisms may reach the
liver either from the biliary
tree (ie, secondary to
ascending cholangitis),
hemat...
ABSCESSES
can be classified as PYOGENIC, AMEBIC or
FUNGAL.
1. Pyogenic abscess, which is most often
polymicrobial (80%,USA...
Case Rep Gastroenterol 2013;7:482–486
Fusobacterium should be considered in the differential diagnosis of a culture-negati...
ABSCESSES
can be classified as PYOGENIC, AMEBIC or
FUNGAL.
In acute settings, abscess frequently manifiest as a
cluster of...
Case # 8 Male, 74yo
Cluster sign
Multilocular, with peripheral and septal enhancement
ABSCESSES
can be classified as PYOGENIC, AMEBIC or
FUNGAL.
A thin-walled abscess, internal necrotic debris, the
presence o...
ABSCESSES
can be classified as PYOGENIC, AMEBIC or
FUNGAL.
The identification of a rim-enhancing fluid
collection within t...
Gas within a cystic lesion is characteristic for an
abscess.
Gas can be seen in as many as 20% of lesions (esp.
Klebsiella...
One outstanding aspects, are a biliary predominant
origin of the abscesses; Gram negatives(-)
organisms, mainly E. coli, n...
Case # 9 Male, 67yo
The rim sign
Hepatic abscesses that mimicked metastases in patients having undergone Whipple surgery.
...
Case # 10 Male, 60yo
PILEPHLEBITIS
Features Amebic abscess Pyogenic abscess
Organisms Entamoeba histolytica Polymicrobial: Escherichia coli, Clostridium
spec...
Infectious liver diseases
• Distinguishing amebic from pyogenic liver
abscess should not depend on image or
clinical crite...
Case # 11 Female, 48yo
Double-target sign
Perilesional edema can be used to differentiate a hepatic
abscess from a benign ...
Consequences of HIV, Aging
and the Liver
Clinical manifestations of aging HIV
and the liver
• Chronic elevations of liver ...
Adult hepatic toxocariasisPolymicrobial cholangitis and liver abscess
62-year-old man with hepatic tubercular abscess.
Jou...
Case # 12 Male, 30yo,HIV+
Amebic Liver Abscess (ALA) should be considered in HIV-
infected patients with space-occupying l...
Routine HIV testing is recommended in patients
with ALA, even without HIV symptoms.
Case # 13 Male, 34yo,HIV+
Hydatid cyst, I,CE1
Case # 14 Male, 43yo
Gharbi classification of
cystic hydatid disease
World J Gastroenterol 2013 ; 19(43): 7603-7619
World Health
Organization-I...
Echinoccoccus
shows large cystic mass in right
lobe of liver with serpiginous
floating internal membrane (water
lily sign)...
 Not restricted to Asians, but
association with parasitic infection
by Clonorchis sinensis and/or
Ascaris lumbricoides ha...
Case # 15 Female, 60yo
Tuberculosis, histoplasmosis, coccidioidomycosis,
brucellosis, echinococcal cyst , schistosomiasis,
cysticercosis, filaria...
Case # 16 Male, 25yo
Starry sky liver
Diagnostic imaging changes include track-like lesions that
are a characteristic feature of acute fascioliasis on CT of
the...
Geographical distribution, clinical syndromes,
diagnosis and treatment of fascioliasis,
opisthorchiasis and clonorchiasis
...
Mem Inst Oswaldo Cruz, Rio de Janeiro, 2010;105(4): 467-470
SCHISTOSOMIASIS
Radiology 2005; 235:97–105
Technical tip,
Fungal Liver Infection in
Immunocompromised Patients
The significant increase in...
Male, 53yoCase # 17
CANDIDIASIS
Multiple hypoattenuating microabscesses less than 1 cm in diameter, throughout both parenc...
Male, 41yo, HIV +Case # 18
7 days
Necrosis and liquefaction predominates
9 days
HEPATIC TUBERCULOSIS
Male, 50yoCase # 19
Multiple low attenuating areas of varying size in the liver
HEPATIC TUBERCULOSIS
Non-specific hepatosplenomegaly
Hepatic involvement is very frequent in miliary
Tb
On US, a bright...
Most imaging findings in liver infectious are
nonspecific.
However, if analyzed together with the clinical
features and ep...
My advice & approach:
Thank you !
1. A lot of images
2. Scrolling image review
3. BE SYSTEMATIC
4. Correlate findings on a...
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EUROPEAN SCHOOL OF RADIOLOGY INFECTIOUS LIVER DISEASE

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E s o r april 4th, 2014

  1. 1. Gaspar Alberto Motta Ramírez, MD
  2. 2. 1. Background, snapshot of recent epidemics, reasons for emergence and spread in a variety of infectious liver diseases. 2. Identify the most common imaging features and illustrate the radiologic findings in a variety of infectious liver diseases. 3. We will discuss the relevance of each imaging method concerning detection and characterization of liver infections and highlight most typical findings. Learning objectives Infectious diseases of the liver.
  3. 3. 4. Discuss the importance of clinical and biochemical information in characterizing these diseases and describe the correlation between imaging findings and histopathologic findings in infectious liver diseases. Learning objectives
  4. 4. Situated at the confluence of the portal and systemic circulations, the liver represents the most common site of visceral abscess, accounting for up to 48% of such infections in one case series. The liver: Basic facts Infectious diseases of the liver.
  5. 5. The liver plays an important role in host defense against invasive microorganisms. The liver: Basic facts Infectious diseases of the liver. The effect of microbial pathogens on the liver can vary greatly, presenting with a wide variety of manifestations from asymptomatic, increases in aminotransaminases, acute liver failure, hepatic fibrosis, and cirrhosis.
  6. 6. Infectious liver diseases Clin Liver Dis 2011;15:111–130
  7. 7. Infectious liver diseases Assessing the silent progress of liver disease: RISK FACTORS: •substance use (includes sharing, drug snorting, smoking or injection equipment); • high-risk sexual activity or sexual partner with viral hepatitis; • household contact with an infected person especially if personal items (e.g., razors, toothbrushes, nail clippers) are shared; • receiving of unscreened blood products; • needle-stick injury or other occupational exposure (e.g., healthcare workers); • children born to mothers with chronic hepatitis B or C infection; • tattoos and body piercing; • history of incarceration; • HIV or other sexually transmitted infection; and • haemodialysis.
  8. 8. Infectious liver diseases Clin Liver Dis 2011;15:111–130
  9. 9.  Asymptomatic/symptomatic  Age, gender  Risk factors for chronic liver disease  History of primary malignancy  Travel history  Lab tests, including tumor markers  Imaging studies  Majority of lesions characterized without biopsy, 98% correct pre-op diagnosis. Infectious liver diseases, CLINICAL FEATURES
  10. 10. Liver lesions in adults Exact knowledge of the number, size, and regional distribution of liver lesions is essential. Features to assess include the presence and thickness of a wall or any internal septations or mural nodules, the presence of either internal or mural calcification, and the pattern of enhancement following IV contrast. Infectious liver diseases
  11. 11. A, B, C, E They all look similar, ranging from a few extra portal triad lymphocytes, to “FULMINANT” hepatitis with total collapse of lobules Associated with full recovery (usual), chronic progression over years leading to cirrhosis (not rare), risk of hepatoma (uncommon), or death (uncommon) VIRAL HEPATITIS Normal US don’t rule out hepatitis
  12. 12. BHepatitis B is endemic in China, South East Asia, the Amazon, eastern and central Europe, Sub-saharan Africa, the Middle East and the Indian subcontinent.
  13. 13. C LESS common than B (one fourth) LESS dangerous than B in the acute phase MORE likely to go chronic than B MORE closely linked with hepatoma than B Hepatitis C is endemic in Egypt, Pakistan , and China.
  14. 14. VIRAL HEPATITIS So acute hepatitis may be similar to fatty liver in CT Note the heterogeneous contrast enhancement in the enlarged, edematous liver. Secondary causes of fatty liver = Hepatitis C
  15. 15. 1. Infection due to HCV accounts for (worldwide):  20% of cases of acute hepatitis  70% of cases of chronic hepatitis  40% of cases of end-stage cirrhosis  60% of cases of HCC  30% of liver transplants. 2. Hepatitis C is a leading cause of end-stage liver disease and HCC. 3. Despite a declining incidence of new infections, the burden of disease, both in terms of mortality and in terms of cost, is expected to increase over the next decade. 4. Important personal, social, economic implications and costs NIH Consensus Development Conference. Management of Hepatitis C -2002 June 10-12. Hepatology 2003 HCV infection – epidemiology
  16. 16. HCV infection – DIFFUSE LIVER DISEASE Two distinct sonographic patterns in diffuse liver disease have been described in the literature. The most common pattern is the bright liver, which has increased parenchymal echogenicity and sound attenuation. The bright liver pattern has been seen with fatty infiltration, chronic hepatitis, acute alcoholic hepatitis, chronic passive congestion, and cirrhosis Nl liver Bright liver AJR 2002;178:78
  17. 17. HCV infection – DIFFUSE LIVER DISEASE The second pattern is the centrilobular or starry sky liver, characterized by clearly identified portal venules and diminished parenchymal echogenicity that accentuates the portal venule walls. This pattern has been identified in patients with acute hepatitis, leukemia, toxic shock syndrome, Burkitt’s lymphoma and fasting liver. Female, 45yo
  18. 18. Male, 35yoCase # 1 Acute hepatitis Periportal edema -periportal tracking decreased attenuation, which highlights the portal vein-, free fluid, gallbladder wall thickening, hepato-splenomegaly World J Gastroenterol 2013; 19(16): 2543-2549
  19. 19. • Most cases detected on US or single phase CT • Practically triple phase CT can characterize any liver lesion/mass(es) • Where to work up a liver lesion depends on local expertise and resources and likelihood of referring to a tertiary centre for treatment/management. Technical tip, Infectious liver diseases Imaging work up of a liver lesion
  20. 20. Male, 65yoCase # 2 Focal decreased attenuation
  21. 21. Male, 37yoCase # 3 Heterogeneous lesion with hypoechoic areas & internal septa
  22. 22. Liver windows have a window level equal to the attenuation level of hepatic parenchyma (50 HU without contrast material; 100 HU after the intravenous administration of contrast material) and a narrower window width (150 HU) than conventional soft-tissue windows. Specific hepatic window Radiology 1999; 210:601–604 The Radiographer 2006; 53 (1): 12–19 Iran J Radiol 2008;5(2):65-70 Technical tip
  23. 23. Female, 60yoCase # 4 Well demarcated hypoenhancing lesion Rim of increased enhancement relative to central region, hyperemia =
  24. 24. Segmental hepatic enhancement on dynamic CT is frequently associated with hepatic abscesses and may be caused by decreased portal flow resulting from inflammation of the portal tracts. Dynamic CT of Hepatic Abscesses: Significance of Transient Segmental Enhancement AJR 2001;176:675–679 Technical tip Anales Rad Mex 2012;1: 46-58
  25. 25. Male, 40yoCase # 5 Double-target sign
  26. 26. When an hepatic abscesses are suspected clinically, it is necessary to perform dynamic contrast-enhanced CT. Segmental or wedge-shaped hepatic enhancement and the rim sign ("rim" or blush of increased vascularity around the perimeter of the abscess, depending on the intensity of the inflammatory reaction) or double-target sign are useful to diagnose hepatic abscess. Dynamic CT of Hepatic Abscesses: Significance of Transient Segmental Enhancement AJR 2001;176:675–679 Curr Probl Diagn Radiol 2004; 33:239-53.
  27. 27. Male, 34yoCase # 6 Cluster sign Multilocular
  28. 28. Case # 7 Male, 36yo Double-target sign High-density material within abscess is due to hemorrhage. AJR 1988;150:1297-1301
  29. 29. HEPATIC ABSCESS and PYELONEPHRITIS
  30. 30. World J Gastroenterol 2013; 19(43): 7603-7619
  31. 31. Hepatic abscess Organisms may reach the liver either from the biliary tree (ie, secondary to ascending cholangitis), hematogenously, or because of superinfection of necrotic tissue. Infective cystic liver lesions in adults
  32. 32. ABSCESSES can be classified as PYOGENIC, AMEBIC or FUNGAL. 1. Pyogenic abscess, which is most often polymicrobial (80%,USA) 2. Amebic abscess due to Entamoeba histolytica (10%) 3.Fungal abscess, most often due to Candida species (less than 10%) Infectious liver diseases
  33. 33. Case Rep Gastroenterol 2013;7:482–486 Fusobacterium should be considered in the differential diagnosis of a culture-negative liver abscess, particularly in the setting of thrombosis. Infectious liver diseases
  34. 34. ABSCESSES can be classified as PYOGENIC, AMEBIC or FUNGAL. In acute settings, abscess frequently manifiest as a cluster of small-low attenuation lesions. This coalescent, grouped appearance is specially suggestive of PYOGENIC ABSCESS. Infectious liver diseases
  35. 35. Case # 8 Male, 74yo Cluster sign Multilocular, with peripheral and septal enhancement
  36. 36. ABSCESSES can be classified as PYOGENIC, AMEBIC or FUNGAL. A thin-walled abscess, internal necrotic debris, the presence of metastatic infection and the absence of underlying biliary disease may be useful CT findings in the early diagnosis of K. pneumoniae liver abscesses. Infectious liver diseases
  37. 37. ABSCESSES can be classified as PYOGENIC, AMEBIC or FUNGAL. The identification of a rim-enhancing fluid collection within the liver often raises the differential diagnosis of tumor versus infection. Perilesional edema is seen on imaging in 50% of abscess although it may be also seen in 20-30% of pts. with primary or secondary hepatic malignancies. Infectious liver diseases Radiographics 2001; 21: 895-910
  38. 38. Gas within a cystic lesion is characteristic for an abscess. Gas can be seen in as many as 20% of lesions (esp. Klebsiella) Infectious liver diseases ABSCESSES can be classified as PYOGENIC, AMEBIC or FUNGAL.
  39. 39. One outstanding aspects, are a biliary predominant origin of the abscesses; Gram negatives(-) organisms, mainly E. coli, nevertheless a progressive identification of Gram(+), such as Streptococcus milleri is found. Cir Esp 2001; 70: 164-172 PYOGENIC ABSCESS Infectious liver diseases
  40. 40. Case # 9 Male, 67yo The rim sign Hepatic abscesses that mimicked metastases in patients having undergone Whipple surgery. Case Reports in Hepatology Volume 2012, Article ID 817314, 5 pages doi:10.1155/2012/817314
  41. 41. Case # 10 Male, 60yo
  42. 42. PILEPHLEBITIS
  43. 43. Features Amebic abscess Pyogenic abscess Organisms Entamoeba histolytica Polymicrobial: Escherichia coli, Clostridium species History Travel - Diarrhea Ascending cholangitis, portal phlebitis, septicemia & trauma Presentation Acute Subacute Patients 30–40y/o, much more common in males Elderly, 50-60y/o, underlying GI or biliary tract disease Leukocytosis Moderate Elevate Hemocultive (-) (+) Serology (+) Amebic serology (Amebic immunofluorescent antibody test) sensitivity of about 95%, highly specific for E. histolytica infection (-) Aspiration Reddish-brown pasty aspirate (“anchovy paste” or “chocolate sauce”) is typical Thick, purulent Smell No Yes Culture/Stools examination (-) (+) Imaging No perceptible wall, lesion with low attenuation & enhancing wall; perilesional edema Cluster sign, w/wo perilesional edema or rim enhancement Number Solitary abscess, right lobe Single or multiple Diagnosis US or CT & serology US or CT, +/- aspiration Infectious liver diseases
  44. 44. Infectious liver diseases • Distinguishing amebic from pyogenic liver abscess should not depend on image or clinical criteria • In areas of low endemicity, suspected amebic liver abscess should be aspirated to exclude pyogenic liver abscess
  45. 45. Case # 11 Female, 48yo Double-target sign Perilesional edema can be used to differentiate a hepatic abscess from a benign cystic hepatic lesion Radiographics 2001;21:895-910
  46. 46. Consequences of HIV, Aging and the Liver Clinical manifestations of aging HIV and the liver • Chronic elevations of liver enzymes • Steatosis/steatohepatitis • Increased drug-related toxicity • More severe liver disease in aging patients with hepatitis B and C; liver disease has emerged as a major cause of morbidity and mortality in individuals infected with HIV, including those infected with HBV and HCV • Later stage and less treatable HCC
  47. 47. Adult hepatic toxocariasisPolymicrobial cholangitis and liver abscess 62-year-old man with hepatic tubercular abscess. Journal of Clinical Imaging Science 2013;3(2):1-7 Non-Hodgkin’s lymphoma presenting as a single liver mass. Radiol Bras 2009;42(1):15–19.
  48. 48. Case # 12 Male, 30yo,HIV+ Amebic Liver Abscess (ALA) should be considered in HIV- infected patients with space-occupying lesions in the liver
  49. 49. Routine HIV testing is recommended in patients with ALA, even without HIV symptoms. Case # 13 Male, 34yo,HIV+
  50. 50. Hydatid cyst, I,CE1 Case # 14 Male, 43yo
  51. 51. Gharbi classification of cystic hydatid disease World J Gastroenterol 2013 ; 19(43): 7603-7619 World Health Organization-Informal Working Group on Echinococcosis Cystic hydatid disease, Echinococcosis
  52. 52. Echinoccoccus shows large cystic mass in right lobe of liver with serpiginous floating internal membrane (water lily sign). Hydatid cyst, III,CE3 Cystic hydatid disease, Echinococcosis Water lily sign
  53. 53.  Not restricted to Asians, but association with parasitic infection by Clonorchis sinensis and/or Ascaris lumbricoides has been associated  Caused by obstructing pigment stones in intra and extrahepatic bile ducts  Often include gram negative bacterial infection  Exacerbations and remissions of cholangitis resulting in biliary duct injury, cholestasis and eventual biliary cirrhosis A/k/a Oriental Cholangitis or Oriental Cholangiohepatitis Recurrent pyogenic cholangitis
  54. 54. Case # 15 Female, 60yo
  55. 55. Tuberculosis, histoplasmosis, coccidioidomycosis, brucellosis, echinococcal cyst , schistosomiasis, cysticercosis, filariasis, paragonimiasis, guinea worm, cytomegalovirus, toxoplasma, Pneumocystis carinii, chronic amebic and pyogenic abscess, ascariasis, and chlonorchis. Hepatic calcification Infectious liver diseases Radiologic Clinics of North America 1998;36(2):391-398
  56. 56. Case # 16 Male, 25yo Starry sky liver
  57. 57. Diagnostic imaging changes include track-like lesions that are a characteristic feature of acute fascioliasis on CT of the liver. The most common imaging findings of fascioliasis are multiple small nodular and branching linear lesions—frequently in the subcapsular areas of the liver parenchyma—. FASCIOLIASIS Diagn Interv Radiol 2009; 15:247–251
  58. 58. Geographical distribution, clinical syndromes, diagnosis and treatment of fascioliasis, opisthorchiasis and clonorchiasis Current Opinion in Infectious Diseases 2008, 21:523–530
  59. 59. Mem Inst Oswaldo Cruz, Rio de Janeiro, 2010;105(4): 467-470 SCHISTOSOMIASIS
  60. 60. Radiology 2005; 235:97–105 Technical tip, Fungal Liver Infection in Immunocompromised Patients The significant increase in sensitivity and lesion conspicuity at arterial phase CT indicates that a multiphasic technique is needed for the assessment of focal liver lesions in immunocompromised patients suspected of having hepatosplenic fungal infection.
  61. 61. Male, 53yoCase # 17 CANDIDIASIS Multiple hypoattenuating microabscesses less than 1 cm in diameter, throughout both parenchymas
  62. 62. Male, 41yo, HIV +Case # 18 7 days Necrosis and liquefaction predominates
  63. 63. 9 days
  64. 64. HEPATIC TUBERCULOSIS Male, 50yoCase # 19 Multiple low attenuating areas of varying size in the liver
  65. 65. HEPATIC TUBERCULOSIS Non-specific hepatosplenomegaly Hepatic involvement is very frequent in miliary Tb On US, a bright liver can be observed Contrast-enhanced CT is similar to that of an abscess whereas more advanced lesions usually calcify Infectious liver diseases EJR 2005; 55:173-180
  66. 66. Most imaging findings in liver infectious are nonspecific. However, if analyzed together with the clinical features and epidemiologic context, they may point at a specific diagnosis. The importance of the clinical history in these patients cannot be overstated. Infectious liver diseases World J Gastroenterol 2013;19(21): 3173-3188
  67. 67. My advice & approach: Thank you ! 1. A lot of images 2. Scrolling image review 3. BE SYSTEMATIC 4. Correlate findings on all phases and sequences 5. High index of suspicion We need to do more to fight liver disease… And we need to do it now.

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