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Surprising change in diagnosis and treatment of focal liver lesion

Abstract number: P1374

van Dommelen L., Stoot J.H., Cappendijk V.C., Abdul Hamid M.A., Stelma F.F., Kortbeek L.M., Oude Lashof A.M.

Case report: A 55-year-old female, with a history of multiple myxoid liposarcomas, presented at our hospital with cervical pain. Metastases in the cervical spinal column were suspected. MRI showed no abnormalities of the spinal column and FDG-PET-scan was negative. However, the diagnostic abdominal CT-scan showed seven hypodens lesions in the liver, suspect for metastases, not present 6 months earlier. Her liver enzymes were normal. After two chemotherapy cycles, partial hepatectomy was performed, leaving four lesions in situ.

Pathologic examination of the liver revealed three circumscribed nodules with central necrosis, a peripheral wall of histiocytes and containing foreign material, resembling Echinococcus structures. Echinococcus granulosis serology was borderline positive and therefore isolated DNA from unpreserved resected liver material was used for a nucleic acid amplification test and found positive for E. multilocularis (Em) using two targets (CO1 and NADH) and sequencing. Genotyping is in progress. After this diagnosis, our patient started with albendazole 400 mg twice daily.

Patient's travel history was only significant for three short holidays to Switzerland, Italy and Austria in 2006 and 2007. She was not extensively exposed to forest environment, did not consume forest fruits, had no contact with animals, did not work in the garden and bought her fruits and vegetables in regular supermarkets.

Discussion: This case displays two remarkable findings. Firstly, the PET-scan-negative, multiple, circumscript, hypodens lesions in the liver seen at regular CT in our patient are not classical for Em and represents a highly unlikely diagnosis in our region. Taking in account our patient's history, it is therefore reasonable to suspect metastases.

Secondly, our patient's history did not reveal behaviour associated with acquiring Em (like hunting and gardening) and only undertook short holidays to known endemic areas. Em however, is also prevalent in Dutch foxes and surveillance data have shown that Em is increasing its range by 2.7 kilometres per year in Northern direction. Considering duration of exposition, domestically acquired Em therefore seems most likely.

Conclusions: This patient probably represents the first case of Echinococcus multilocularis acquired in The Netherlands. Future research has to reveal whether Em is an emerging pathogen in Western Europe or whether we are facing isolated cases.

Session Details

Date: 10/04/2010
Time: 00:00-00:00
Session name: Abstracts 20th European Congress of Clinical Microbiology and Infectious Diseases
Subject:
Location: Vienna, Austria, 10 - 13 April 2010
Presentation type:
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