Hospital: Hospital Universitario Puerta de Hierro.
Nº: C2019-272
Aut@r o Autores: P. García Benedito, M. Alfageme Zubillaga, G.T. Vázquez-Benítez.
Presentación
A 55 year-old-man with an haploidentic hematopoietic stem cell transplantation (HSCT) performed five months before to treat a acute myeloid leukemia (AML) was hospitalised with a CMV infection, with more than 4 million copies. Gastrointestinal infection with adenovirus was also diagnosed. Due to worsening dyspnoea and hepatic enzime alteration an urgent toracoabdominal CT was requested. On CT ground glass opacities and interstitial reticulation was noted but was more surprising was the presence of multiple small hipoenhancing lesions situated on the periphery of the liver parenquima (circles on images A and B). Those lesions were not seem on a recent CT performed just one month before (image C). Althogh the diagnosis of virical liver abscesses was proposed a liver core biopsy was performed to rule out AML relapse with hepatic involvement. On the biopsy a submasive necrosis with peripheric microabscesses was described, with nuclear and cytoplasmic inclusions, with a definitive diagnosis of adenovirus expresion on inmunihistochemistry techniques. Small hemoperitoneum was seen on a latter scan (not shown). Both adenovirus and CMV were intensively treated and antibiotic prophilaxis was also established but the patient rapidly deteriorated, requiring ICU mecanical ventilation and died soon after. On autopsy the core biopsy findings were sustained (image D) and adenovirus related necrosis was also found in other tissues.
Discusión
Viral involvement of the liver is not uncommon, but normally findings are inespecific and CT is used to rule out other pathologies. Normal liver, hepatomegaly, periportal edema or uneven enhancement may be seen in viral hepatitis. Low attenuation regions may appear. Severe gallbladder edema with a non distended gallbladder is seen in up to 70% of viral hepatitis, as in our case (image B), and can be an ancilary extrahepatic finding that may support the diagnosis of viral hepatitis. Adenoviral disease can be diagnosed by histology but liver biopsy is difficult to perform due to the high risk of bleeding. To our knowledge only a few cases of adenoviral hepatitis have been described and only in some cases the mass like necrosis has been found, all of them in inmunocompromised patients with solid organ or HSCT
Conclusión
Adenoviral hepatitis should be considered as a possible cause of liver injury in HSCT recipients with multiple low-density lesions of the liver although such findings are not specific to adenovirus infection.
Bibliografía
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