Multiple Liver Lesions in an Immunosuppressed Patient: Is Infection Always the Answer?
A 17-year-old female with long-standing fibrostenotic CD necessitating ileocecostomy presented with a 3-week history of worsening abdominal pain and increased stool frequency. Additionally, she reported increased fatigue and recent initiation of 17.5 mg of methotrexate weekly for enteropathic arthritis. Physical examination was remarkable for mild abdominal tenderness to palpation. Medications at the time included 9 mg of budesonide per day and adalimumab 40 mg weekly in addition to methotrexate. Computed tomography (CT) enterography revealed active inflammation of the ileum as well as multiple small branching low-density areas in the inferior aspect of the right lobe of the liver and near the porta hepatis, suggestive of small fluid collections versus thrombosed peripheral veins (fig. ). Due to concern for hepatic abscesses and CD exacerbation, she was subsequently admitted to the hospital for broad-spectrum intravenous antibiotic therapy. Laboratory workup revealed: hemoglobin 10.8 g/dl, leukocyte count 6.3 × 109/l, platelets 459 × 109/l, aspartate aminotransferase 18 U/l (normal 8–43), alanine aminotransferase 8 U/l (normal 7–45), alkaline phosphatase 102 U/l (normal 52–144), and total bilirubin 0.2 mg/dl (normal 0.1–1.0). C-reactive protein was elevated up to 13.7 mg/l and sedimentation rate was 24 mm/h. A coagulation panel was notable for an elevated D-dimer of 820 mg/ml and elevated fibrinogen of 472 mg/dl. Further history and physical examination revealed no recent fever, right upper quadrant pain, tenderness or hepatomegaly. Review of the CT scan revealed patent portal, mesenteric and splenic veins.\nTo confirm our working diagnosis, a liver ultrasound with Doppler was performed and demonstrated several small, ill-defined, echogenic areas near the porta hepatis and in the inferior aspect of the right lobe of the liver, corresponding to the low attenuation area on the CT enterography, with sonographic appearance most consistent with focal fatty infiltration (fig. ), and a patent portal vein. Magnetic resonance imaging of the abdomen with fat saturation confirmed that the hepatic lesions represented focal areas of fatty deposition. The patient's blood cultures did not grow any organisms, intravenous antibiotics were discontinued, methotrexate was optimized at 25 mg per week, and the patient was discharged home on a taper of budesonide.