Case Report # 1

Submitted By: Samuel Oats, MSIV

Radiological Category: BodyPrincipal Modality (1):

Principal Modality (2): PET/CT

CT

Faculty Reviewer: Sandra Oldham, MD

Date accepted: August 28, 2014

Case History

• 75 year old female with intermittent fever, headache, arthralgia, night sweats, and weight loss since March 2014

Radiological Presentations

Radiological Presentations

• Histoplasmosis

• Lymphoma

• Metastases

•Tuberculosis

•Splenic Infarction

•Hydatid Cyst

•Sarcoidosis

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On CT, there are multiple splenic hypodensities, the largest of which measures 1.6 by 1.5 cm. There is bilateral adrenal enlargement and an enlarged left iliac lymph node measuring 19 mm (normal <15 mm in the pelvis). On PET-CT, there is increased FDG uptake in the aforementioned splenic lesions, bilateral diffuse uptake in the adrenal glands, and scattered FDG uptake throughout the abdomen, pelvis, and bone marrow.

• Histoplasmosis

• Lymphoma

•Metastases

•Tuberculosis

•Splenic Infarction

•Hydatid cyst

•Sarcoidosis

Findings:

Differentials:

Findings and Differentials

Splenic Infarction

-May occur due to atherosclerotic emboli,

Sickle cell disease, endocarditis, ateritis,

hypercoagulable states, etc..•Wedge-shaped defects extending to the

intact splenic capsule •Often occur in the setting of

splenomegaly

Multiple infarcts may fuse, resulting in loss

of the wedge shape

Discussion

Hydatid Cyst

-Echinococcus granulosis aka dog tapeworm

-Splenic lesions found in only 2% of patients

with hydatid disease

-In spleen involved, cysts are also usually

present in the liver or lung

-Calcified rim in chronic lesion

Discussion

Splenic Granulomas•May be seen with histoplasmosis, TB, or sarcoidosis •May be calcified but not necessarily so

Discussion

Metastases•Rare: only 7% of autopsied cancer patients have splenic involvement•Most commonly seen with melanoma, lung, ovarian, gastric, and prostate cancer •Usually splenic metastases are microscopic and not detectable on imaging

Discussion

Non-Hodgkin’s lymphoma is the most common hematological neoplasm, with 85% of B-cell origin. The median time of diagnosis is during the sixth decade. Symptoms may include painless peripheral adenopathy, fever, fatigue, etc.

The most common malignant tumor of the spleen is lymphoma. CT is 65% sensitive for splenic involvement, and patterns seen can include splenomegaly, miliary nodules, or a single large mass. Importantly, when the spleen is involved in lymphoma, adenopathy is often seen elsewhere in the abdomen.

In this case, a right iliac wing biopsy was obtained, and the pathology work-up revealed diffuse large B-cell lymphoma.

Discussion

Non-Hodgkin Lymphoma (Diffuse Large B Cell)

Diagnosis

1. Brant, W.F. Helms, C. A. Fundamentals of Diagnostic Radiology. Fourth Edition. Lipincott Williams and Williams. 2012.

2. Abdominal lymphadenopathy: Spectrum of CT findings. Radiographics. 1991 May; 11(3):457-72

3. Isolated splenic tuberculosis: A case report. World J Gastrointest Pathophysiol. 2010 Aug 15;1(3):109-11. doi: 10.4291/wjgp.v1.i3.109.

4. Non-Hodgkin Lymphoma. http://emedicine.medscape.com/article/203399-overview July 21, 2013.

5. Whole body FDG PET and Staging of Non-Small-Cell Lung Cancer. http://www.med.harvard.edu/JPNM/TF99_00/Jan18/WriteUp.html . January 18th, 2000.

6. Splenic lesions and anomalies. http://radiopaedia.org/articles/splenic-lesions-and-anomalies August 26th 2014

References