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Presentation of an unusual case of hepatic alveolar echinococcosis : multidetector CT and US findings

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A 40 year old male farmer admitted to internal medicine clinic with post prandial dyspnea and excessive sweating lasting for the last two months. In his physical examination, hepatosplenomegaly and right upper quadrant tenderness were detected. He had no jaundice or pruritus. His liver function tests were elevated with normal bilirubin levels. He was referred to our department for Ultrasound (US) examination which revealed multiple well defined, nodular, homogeneous lesions isoechoic with the liver parenchyma and with surrounding hypoechoic rims (Fig. 1a). Further evaluation with abdominal Computed Tomography (CT) demonstrated a total of six masses in both lobes of the liver. The largest of them located at segment 7 was 10 cm to 7.5 cm. All lesions were solid, with well defined, lobular borders and all had a central calcification. Densities of the lesions were ranging from forty to forty- five Hounsfield Units. Lesions had no contrast enhancement in arterial, portal venous or late phases. Although they were compressing the vascular structures, there was no sign of invasion. Compression to biliary system produced intrahepatic bile duct dilatation which was more evident in the left lobe while common bile duct was within normal limits (Fig. 1b). Lymphadenopathy at distal paraesophageal and portal hilus regions were present, largest of them measuring 3 cm in length. CT examination was otherwise unremarkable. A primary diagnosis of metastasis was made though hepatocellular carcinoma could not be excluded. Cranial and thoracic CT scans were also obtained to find out a primary neoplasm but they were unremarkable. Histological diagnosis was recommended because it would affect the choice of treatment. However, the biopsy specimen obtained revealed alveolar echinococcal lesion, a diagnosis that was not considered. The serologic test applied afterwards was positive for Echinococcus multilocularis and diagnosis was made to be alveolar hydatid disease of the liver. The patient was accepted as inoperable and liver transplantation following albendazole treatment was decided. By the time of this writing, he had had a successful transplantation from a living donor and no complications occurred for two months until now.Alveolar hydatid disease is a rare parasitic disease with a mortality rate of 90% within 10 years in untreated cases (1,2). It has the characteristics of a slow growing cancer infiltrating the liver and surrounding structures, especially the vascular and biliary system. Central [Product Details...]