This document discusses infectious diseases of the liver. It begins by providing background on recent epidemics and reasons for emergence of various infectious liver diseases. It then identifies the most common imaging features of different infectious liver diseases and illustrates radiologic findings. The document discusses various imaging methods for detecting and characterizing liver infections and highlights typical findings. It emphasizes the importance of clinical and biochemical information in characterizing these diseases and describing correlations between imaging findings and histopathology. The document provides details on viral hepatitis, hepatic abscesses, and pyogenic, amebic and fungal abscesses. It includes several case studies and images showing characteristic radiologic findings of different infectious liver conditions.

1. Gaspar Alberto Motta Ramírez, MD

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. 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. 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. 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. Infectious liver diseases
Clin Liver Dis 2011;15:111–130

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. Infectious liver diseases
Clin Liver Dis 2011;15:111–130

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. • 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. Male, 65yoCase # 2
Focal decreased attenuation

21. Male, 37yoCase # 3
Heterogeneous lesion with hypoechoic areas &
internal septa

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. Female, 60yoCase # 4
Well demarcated hypoenhancing lesion
Rim of increased enhancement relative to central region, hyperemia =

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. Male, 40yoCase # 5
Double-target sign

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. Male, 34yoCase # 6
Cluster sign
Multilocular

28. Case # 7 Male, 36yo
Double-target sign
High-density material within abscess is due to hemorrhage.
AJR 1988;150:1297-1301

29. HEPATIC ABSCESS and PYELONEPHRITIS

30. World J Gastroenterol 2013; 19(43): 7603-7619

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. 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. 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. 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. Case # 8 Male, 74yo
Cluster sign
Multilocular, with peripheral and septal enhancement

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. 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. 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. 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. 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. Case # 10 Male, 60yo

42. PILEPHLEBITIS

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. 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. 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. 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. 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. Case # 12 Male, 30yo,HIV+
Amebic Liver Abscess (ALA) should be considered in HIV-
infected patients with space-occupying lesions in the liver

49. Routine HIV testing is recommended in patients
with ALA, even without HIV symptoms.
Case # 13 Male, 34yo,HIV+

50. Hydatid cyst, I,CE1
Case # 14 Male, 43yo

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. 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.  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. Case # 15 Female, 60yo

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. Case # 16 Male, 25yo
Starry sky liver

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. Geographical distribution, clinical syndromes,
diagnosis and treatment of fascioliasis,
opisthorchiasis and clonorchiasis
Current Opinion in Infectious Diseases 2008, 21:523–530

59. Mem Inst Oswaldo Cruz, Rio de Janeiro, 2010;105(4): 467-470
SCHISTOSOMIASIS

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. Male, 53yoCase # 17
CANDIDIASIS
Multiple hypoattenuating microabscesses less than 1 cm in diameter, throughout both parenchymas

62. Male, 41yo, HIV +Case # 18
7 days
Necrosis and liquefaction predominates

63. 9 days

64. HEPATIC TUBERCULOSIS
Male, 50yoCase # 19
Multiple low attenuating areas of varying size in the liver

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. 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. 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.