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The Infected Liver: Radiologic-Pathologic Correlation¹

¹ From the Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham & Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115. Received July 31, 2003; revision requested October 3 and received January 2, 2004; accepted January 5. All authors have no financial relationships to disclose. Address correspondence to K.J.M. (e-mail: kmortele@partners.org).

View larger version (100K): [in a new window]   Figure 1a.  (a) Pyogenic abscess. Photograph of a gross liver specimen shows a large, necrotic cavity with a perceptible fibrous wall in the right lobe (arrow). Note the yellowish pus content and inflammation of the adjacent liver parenchyma (arrowheads). (b) Pyogenic microabscesses. Photograph of a gross liver specimen obtained in a different patient shows multiple white nodules representing pyogenic microabscesses scattered throughout the parenchyma.

View larger version (83K): [in a new window]   Figure 1b.  (a) Pyogenic abscess. Photograph of a gross liver specimen shows a large, necrotic cavity with a perceptible fibrous wall in the right lobe (arrow). Note the yellowish pus content and inflammation of the adjacent liver parenchyma (arrowheads). (b) Pyogenic microabscesses. Photograph of a gross liver specimen obtained in a different patient shows multiple white nodules representing pyogenic microabscesses scattered throughout the parenchyma.

View larger version (145K): [in a new window]   Figure 2a.  Pyogenic abscess. (a) Low-power photomicrograph (hematoxylin-eosin [H-E] stain) shows an area of liquefaction necrosis. (b) Photograph of a gross liver specimen obtained in a different patient shows a zone of fibrosis (arrow) that has replaced the abscess cavity.

View larger version (136K): [in a new window]   Figure 2b.  Pyogenic abscess. (a) Low-power photomicrograph (hematoxylin-eosin [H-E] stain) shows an area of liquefaction necrosis. (b) Photograph of a gross liver specimen obtained in a different patient shows a zone of fibrosis (arrow) that has replaced the abscess cavity.

View larger version (195K): [in a new window]   Figure 3.  Pyogenic microabscesses. Arterial phase contrast-enhanced CT scan shows multiple small hypoattenuating nodules representing pyogenic microabscesses scattered throughout the liver. Note the faint peripheral enhancement (arrow) and perilesional edema (arrowhead).

View larger version (90K): [in a new window]   Figure 4a.  Pyogenic abscess. (a) Longitudinal US image demonstrates a pyogenic abscess with a typical hypoechoic appearance due to exudation and liquefaction necrosis (arrows). (b) Longitudinal US image obtained in a different patient shows a pyogenic abscess with the typical echogenic appearance caused by fibrotic changes (arrow).

View larger version (191K): [in a new window]   Figure 4b.  Pyogenic abscess. (a) Longitudinal US image demonstrates a pyogenic abscess with a typical hypoechoic appearance due to exudation and liquefaction necrosis (arrows). (b) Longitudinal US image obtained in a different patient shows a pyogenic abscess with the typical echogenic appearance caused by fibrotic changes (arrow).

View larger version (131K): [in a new window]   Figure 5.  Pyogenic abscess. Delayed-phase contrast-enhanced CT scan shows a large, hypoattenuating lesion in the right hepatic lobe with thin peripheral enhancement and surrounded by other smaller hypoattenuating areas (arrows). These smaller abscesses cluster or aggregate in a pattern that suggests coalescence into a single large cavity.

View larger version (119K): [in a new window]   Figure 6.  Amebic abscess. Photograph of a gross liver specimen shows an amebic abscess filled with a chocolate-colored, pasty material (anchovy paste).

View larger version (142K): [in a new window]   Figure 7a.  Amebic abscess. (a) Contrast-enhanced CT scan demonstrates a large, lobulated, well-defined cystic mass in the right hepatic lobe. Note the enhanced, thickened wall of the lesion (arrows). (b) Contrast-enhanced CT scan obtained in a different patient shows a rounded, well-defined low-attenuation lesion in the right hepatic lobe with a small focus of air and mild hyperemia of the adjacent liver parenchyma.

View larger version (131K): [in a new window]   Figure 7b.  Amebic abscess. (a) Contrast-enhanced CT scan demonstrates a large, lobulated, well-defined cystic mass in the right hepatic lobe. Note the enhanced, thickened wall of the lesion (arrows). (b) Contrast-enhanced CT scan obtained in a different patient shows a rounded, well-defined low-attenuation lesion in the right hepatic lobe with a small focus of air and mild hyperemia of the adjacent liver parenchyma.

View larger version (124K): [in a new window]   Figure 8.  Hydatid disease. Photograph of a resected hydatid cyst shows the composition of the cyst wall: an outer pericyst (arrowheads), which corresponds to compressed liver tissue, and an endocyst (arrow), or inner germinal layer. The ectocyst, a thin, translucent interleaved membrane, is not seen.

View larger version (135K): [in a new window]   Figure 9a.  Hydatid disease. (a) Photograph of a resected hydatid cyst reveals numerous daughter cysts. (b) Low-power photomicrograph (H-E stain) of a hepatic hydatid cyst in a different patient shows multiple daughter cysts and the matrix.

View larger version (167K): [in a new window]   Figure 9b.  Hydatid disease. (a) Photograph of a resected hydatid cyst reveals numerous daughter cysts. (b) Low-power photomicrograph (H-E stain) of a hepatic hydatid cyst in a different patient shows multiple daughter cysts and the matrix.

View larger version (142K): [in a new window]   Figure 10a.  Hydatid disease. (a) Longitudinal US image of the liver shows a rounded, well-defined, multilocular hypoechoic lesion with echogenic internal septa (arrows). (b) US image of the right hepatic lobe obtained in a different patient demonstrates a rounded hydatid lesion (cursors) with a global echogenic appearance. (c) US image of the liver obtained in a third patient shows a hydatid cyst in the right lobe with wavy bands of delaminated endocyst ("water lily sign") (arrows).

View larger version (149K): [in a new window]   Figure 10b.  Hydatid disease. (a) Longitudinal US image of the liver shows a rounded, well-defined, multilocular hypoechoic lesion with echogenic internal septa (arrows). (b) US image of the right hepatic lobe obtained in a different patient demonstrates a rounded hydatid lesion (cursors) with a global echogenic appearance. (c) US image of the liver obtained in a third patient shows a hydatid cyst in the right lobe with wavy bands of delaminated endocyst ("water lily sign") (arrows).

View larger version (105K): [in a new window]   Figure 10c.  Hydatid disease. (a) Longitudinal US image of the liver shows a rounded, well-defined, multilocular hypoechoic lesion with echogenic internal septa (arrows). (b) US image of the right hepatic lobe obtained in a different patient demonstrates a rounded hydatid lesion (cursors) with a global echogenic appearance. (c) US image of the liver obtained in a third patient shows a hydatid cyst in the right lobe with wavy bands of delaminated endocyst ("water lily sign") (arrows).

View larger version (159K): [in a new window]   Figure 11a.  Hydatid disease. (a) Unenhanced CT scan of the liver shows a large, cystic mass with multiple septa. Note the presence of peripheral calcifications (arrows). (b) Unenhanced CT scan obtained in a different patient shows a large, multilocular hydatid cyst in the right hepatic lobe with multiple daughter cysts at the periphery. Note the hyperattenuating appearance of the matrix.

View larger version (133K): [in a new window]   Figure 11b.  Hydatid disease. (a) Unenhanced CT scan of the liver shows a large, cystic mass with multiple septa. Note the presence of peripheral calcifications (arrows). (b) Unenhanced CT scan obtained in a different patient shows a large, multilocular hydatid cyst in the right hepatic lobe with multiple daughter cysts at the periphery. Note the hyperattenuating appearance of the matrix.

View larger version (177K): [in a new window]   Figure 12a.  Hydatid disease. (a) Axial gradient-echo T1-weighted MR image shows a hydatid cyst with a hypointense fibrous pericyst (arrow). The hydatid matrix has intermediate signal intensity, and peripheral daughter cysts that are hypointense relative to the matrix are seen. (b) On an axial T2-weighted MR image, the matrix is hyperintense and the daughter cysts again relatively hypointense.

View larger version (104K): [in a new window]   Figure 12b.  Hydatid disease. (a) Axial gradient-echo T1-weighted MR image shows a hydatid cyst with a hypointense fibrous pericyst (arrow). The hydatid matrix has intermediate signal intensity, and peripheral daughter cysts that are hypointense relative to the matrix are seen. (b) On an axial T2-weighted MR image, the matrix is hyperintense and the daughter cysts again relatively hypointense.

View larger version (142K): [in a new window]   Figure 13.  E multilocularis cysts. Transverse US images obtained at different levels of the liver show E multilocularis infection with the typical hailstorm pattern, characterized by multiple echogenic nodules with irregular and indistinct margins.

View larger version (123K): [in a new window]   Figure 14a.  E multilocularis. Unenhanced (a) and contrast-enhanced (b) CT scans of the liver reveal a large, irregularly shaped, hypoattenuating lesion with diffuse punctate calcifications, which are more clearly seen on the unenhanced image. Note the poor enhancement of the lesion after bolus administration of contrast material.

View larger version (139K): [in a new window]   Figure 14b.  E multilocularis. Unenhanced (a) and contrast-enhanced (b) CT scans of the liver reveal a large, irregularly shaped, hypoattenuating lesion with diffuse punctate calcifications, which are more clearly seen on the unenhanced image. Note the poor enhancement of the lesion after bolus administration of contrast material.

View larger version (154K): [in a new window]   Figure 15.  Schistosomiasis. Low-power photomicrograph of a liver specimen reveals calcified eggs (arrows) and fibrosis in the subcapsular region.

View larger version (133K): [in a new window]   Figure 16.  Schistosomiasis. Longitudinal US image through the liver shows the characteristic US network pattern, with echogenic septa (arrows) outlining polygonal areas of relatively normal liver parenchyma.

View larger version (139K): [in a new window]   Figure 17.  Schistosomiasis. CT scan of the liver reveals characteristic pericapsular and periportal calcifications, which give the liver a tortoise shell appearance. The calcifications form as a result of embolization of the schistosome eggs to these areas in the liver, with ensuing inflammatory reaction and fibrosis.

View larger version (158K): [in a new window]   Figure 18a.  Candidiasis. (a) Photograph of a gross specimen of the spleen shows multiple small, white nodules representing involvement by candidiasis throughout the parenchyma. (b) Low-power photomicrograph shows multiple candidiasis microabscesses with a peripheral zone of fibrosis and a central area of necrosis (arrows).

View larger version (144K): [in a new window]   Figure 18b.  Candidiasis. (a) Photograph of a gross specimen of the spleen shows multiple small, white nodules representing involvement by candidiasis throughout the parenchyma. (b) Low-power photomicrograph shows multiple candidiasis microabscesses with a peripheral zone of fibrosis and a central area of necrosis (arrows).

View larger version (154K): [in a new window]   Figure 19.  Candidiasis. Contrast-enhanced CT scan of the liver shows multiple hypoattenuating microabscesses less than 1 cm in diameter disseminated throughout the hepatic parenchyma.

View larger version (158K): [in a new window]   Figure 20.  Candidiasis. Axial T1-weighted MR image reveals relatively hyperintense lesions less than 1 cm in diameter in the liver (arrows).

View larger version (109K): [in a new window]   Figure 21.  Tuberculosis. Contrast-enhanced CT scan demonstrates multiple low-attenuation areas of varying size in the liver and spleen. The imaging findings in hepatic tuberculosis are nonspecific; therefore, biopsy is mandatory in almost all cases in which this disease is suspected.

View larger version (144K): [in a new window]   Figure 22.  Acute viral hepatitis. Axial T2-weighted MR image shows hepatomegaly with the presence of periportal edema.

View larger version (158K): [in a new window]   Figure 23.  Bacillary angiomatosis. Contrast-enhanced CT scan reveals multiple punctate hypervascular nodules scattered throughout the hepatic parenchyma.

View larger version (136K): [in a new window]   Figure 24.  AIDS-related cholangiopathy. Single endoscopic retrograde cholangiopancreatogram shows dilatation of the gallbladder and bile ducts with multiple strictures involving the intrahepatic bile ducts and papillae.

View larger version (173K): [in a new window]   Figure 25.  Cat-scratch disease. Delayed phase contrast-enhanced CT scan of the liver and spleen shows multiple small, low-attenuation lesions disseminated throughout the hepatic parenchyma.

View larger version (87K): [in a new window]   Figure 26a.  Cat-scratch disease. (a) Axial contrast-enhanced T1-weighted MR images obtained at different levels show multiple nodular lesions with peripheral enhancement (arrows). (b) On a T2-weighted MR image, the lesions (arrowheads) demonstrate homogeneous high signal intensity.

View larger version (152K): [in a new window]   Figure 26b.  Cat-scratch disease. (a) Axial contrast-enhanced T1-weighted MR images obtained at different levels show multiple nodular lesions with peripheral enhancement (arrows). (b) On a T2-weighted MR image, the lesions (arrowheads) demonstrate homogeneous high signal intensity.