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JAMA Surgery Clinical Challenge

An Unusual Inflammatory Hepatic Lesion

Image of Figure 1
Image of Figure 2

Figure 1.
Computed tomographic scan showing a large, hypodense, multiloculated lesion in liver segment 6.

Figure 2.
Magnetic resonance imaging scan showing an heterogeneous, capsulated lesion, with numerous septa delimiting large areas of necrosis.

Damiano Patrono, MD; Caterina Porru, MD; Gianluca Paraluppi, MD; Paolo Strignano, MD; Renato Romagnoli, MD; Mauro Salizzoni, MD

A 26-year-old man was admitted to our institution for a fever (temperature, 39°C) and abdominal pain on the right side of his hypochondrium. He complained of nausea, vomiting, and asthenia as well. His medical history was significant for pharyngitis associated with scarlet fever that he had a month before; the pharyngitis was treated by his general practitioner with clarithromycin (500 mg twice daily for a week). No throat culture or rapid antigen test for group A streptococci was performed at that time. On physical examination, he presented with mild right upper abdominal quadrant tenderness. He met all the criteria for systemic inflammatory response syndrome, and his blood tests showed a marked increase in inflammatory markers. Blood and urine cultures were obtained, and the results were negative. Empirical antibiotic therapy with ampicillin sodium/sulbactam sodium was started. His chest radiograph was normal. An abdominal ultrasonographic examination revealed a 6-cm, solid, inhomogeneous mass in liver segment 6. A contrast-enhanced computed tomographic scan of the abdomen (Figure 1) showed that the lesion was hypodense with numerous septa without contrast enhancement. Magnetic resonance imaging (Figure 2) evidenced a mixed solid-liquid lesion, with some septa delimiting large areas of necrosis. The results of a serological detection test for echinococcosis were negative. His carcinoembryonic antigen, carbohydrate antigen 19-9, and α1-fetoprotein blood levels were normal. Serological markers for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative. A study of leukocyte populations and immunoglobulin electrophoresis did not reveal any disorder of the immune system.

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