1. Fever of unknown origin with liver lesions
HingKiu Chan, MS4

2. HPI
21 y.o man with history of Crohn’s disease on immunosuppressive medications transferred from OSH presents with 3 weeks of fever and new lesions found on MRI. Associated symptoms include headache, nausea, non-bilious vomit, back pain, decrease appetite, RLQ pain that radiates to RUQ. Labs show transaminase. Blood and urine culture NGTD. No previous hx of PSC.

3. T1 - 0 mins
New liver lesions, the largest of which is in segment 4B. In addition there is new splenomegaly with few tiny nonenhancing lesions associated with retroperitoneal and periportal lymphadenopathy.
There is a lesion in segment 4B near the porta hepatis which demonstrates mild increased T2 signal and peripheral enhancement on arterial phase imaging with progressive filling in of contrast material on later phases.

4. T1 - 0 min

5. T1 - 0 min

6. T1 - 0 min
Lesion near the portal vein

7. T1 - 5 min
The central portion of the lesion does not enhance on the 5-minute postcontrast sequence (image 19-22).
Cholangiocarcinoma because of the hyperenchaning rim enhancement but very unlikely given age, multiple lesions, and no hx of PSC

8. T2 mildly enhance

11. DDX Fungal infection Lymphoma Cholangiocarcinoma PSC
Metastatic disease
New liver lesions, the largest of which is in segment 4B. In addition there is new splenomegaly with few tiny nonenhancing lesions associated with retroperitoneal and periportal lymphadenopathy. Findings are concerning for infection in this immunosuppressed patient, specifically fungal. Lymphoma is also in the differential diagnosis. Mass forming cholangiocarcinoma of the largest hepatic lesion should be considered given the pattern of enhancement, however is considered less likely given the absence of background of primary sclerosing cholangitis. Metastatic disease is also considered unlikely.

12. Lesion was not very well defined on US -> patient was clinically improving -> talked with primary team and ID and we proceed with FNAx2 and core biopsyx2

13. favored granulomatous inflammation at preliminary assessment because there was only 1 good granuloma.

14. H&E stain 10x, necrotizing granulomatous inflammation
Epithelioid Histiocytes surrounding the central necrotic region
Epithelioid histiocytes (Epithelioid cells) are activated macrophages resembling epithelial cells: elongated, with finely granular, pale eosinophilic (pink) cytoplasm and central, ovoid nucleus (oval or elongate), which is less dense than that of a lymphocyte.

15. Silver stain 10x
Because most Yeast can’t be seen in H&E, so silver stain

16. GMS (silver stain) 40x

17. Diagnosis Disseminated Histoplasmosis Urine antigen was positive
Patient’s condition is mild/moderate and required 12 months of Itraconazole treatment and may need prophylaxis in the future
Patient was discharged the next day