Teaching Case

A 38-year-old man with fever during 4 weeks and right-sided abdominal pain.

A 38-year-old man was admitted for fever during 4 weeks and right-sided abdominal pain. The history yielded a consumption of she-camel milk. Ultrasonography showed in addition to hepatic steatosis in the right liver multiple hyperechoic nodular lesions with an isoechoic center. Computed tomography demonstrated a hypervascular aspect of these lesions with early arterial blush and portal wash-out suggesting hypervascular metastases of an endocrine tumor, hepatic hemangioma with rapid flow, or a multifocal hepatocellular carcinoma. The diagnosis of brucellosis was made by Wright’s method and the finding of brucellous granuloma at hepatic biopsy.

A liver brucelloma, or pseudo-tumoral necrotizing granuloma, is a rare type of hepatic manifestation by Brucella. It rarely represents the first clinical manifestation, but is most often latent, becoming then an integral part of the stage of chronic brucellosis. A review of the cases reported indicates that the diagnosis is almost never made histologically or by bacterial examination.
The infrequent and unspecific clinical findings are fever, pain in the right upper abdominal quadrant, and asthenia and loss of weight.
The biological tests show in most cases a specific inflammatory syndrome and the liver function tests are usually within normal limits. The Wright’s and rose Bengal tests are often positive.
US, CT and magnetic resonance imaging (MRI) yield important diagnostic information.
The images obtained by US and CT are characteristic. They show a usually solitary and heterogeneous pseudo-tumoral lesion, hypoechogenic on US and hypodense on CT. The center of the lesion may exhibit one or more calcium deposits.
Our case with an hypervacular aspect on CT, i.e. early arterial blush and portal wash-out has not been described so far.
MRI findings described are a heterogenic area with necrotic fluid, a high signal intensity on T2-weighted images and a peripheral enhancement following the intravenous injection of gadolinium.

The differential diagnoses include fibrolamellar carcinoma, metastasis of a mucin-secreting carcinoma of the stomach or colon, cystoadenocarcinoma and benign masses, such as cavernous hemangioma.