Liver scalloping – An unusual presentation of a benign disease

Armando Carvalho,Sara Neves Sintra

doi:10.5348/101001z01ss2019cr

Abstract

Introduction: Abdominal tuberculosis frequently mimics other conditions such as inflammatory bowel disease, sarcoidosis, advanced ovarian tumour, lymphoma, mesothelioma or carcinomatosis. Case Report: The authors report the case of a 19-year-old woman with fever, abdominal pain and history of right pleural empyema. Laboratory findings showed anaemia, lymphopenia and positive interferon-gamma release assay. Computed tomography findings included apical lung nodules, pleural thickening, right pleural effusion and ascites. Treatment for suspected tuberculosis was started. Two months later, computed tomography showed peritoneal thickening causing liver scalloping. Fluid collection from a peritoneal fluid-filled nodule confirmed the diagnosis. Conclusion: Visceral scalloping is a common finding of carcinomatosis and pseudomyxoma peritonei; only seven cases are reported in peritoneal tuberculosis. We emphasize the need for a high suspicion level and early sample collection.

Highlights

Abdominal tuberculosis frequently mimics other conditions such as inflammatory bowel disease, sarcoidosis, advanced ovarian tumour, lymphoma, mesothelioma or carcinomatosis
Two months later the patient complained of abdominal pain and underwent a second computed tomography (CT) which showed nodules with lobulated contours and heterogeneous enhancement in each lung apex, measuring 16 mm at the left and 4 mm at the right apex; focal nodular pleural thickening; absence of pleural effusion; a small pericardial effusion; Sintra et al 2 focal nodular contrast-enhanced and hypodense peritoneal thickening, the largest measuring 51 mm with a large central fluid component causing scalloping of the liver margins; absence of mediastinal, hilar, abdominal or pelvic lymph node enlargement; and a small amount of ascites (Figure 1)
Three patterns of peritoneal TB have been described: i) wet type, the most frequent one (90%), which is characterized by abundant ascites, ii) dry type (3%) characterized by loculated ascites with predominant adhesions, fibrosis, peritoneal thickening and caseating nodules iii) fibrotic type (7%) which is associated with low-volume ascites and intestinal adhesions to the mesentery with omental mass [4,5]

Summary

INTRODUCTION

Peritoneal and pleural effusions due to tuberculosis (TB) occur most commonly following reactivation of latent tubercular foci due to haematogenous spread from previous pulmonary TB [1]. Two months later the patient complained of abdominal pain and underwent a second CT which showed nodules with lobulated contours and heterogeneous enhancement in each lung apex, measuring 16 mm at the left and 4 mm at the right apex; focal nodular pleural thickening; absence of pleural effusion; a small pericardial effusion; Sintra et al 2 focal nodular contrast-enhanced and hypodense peritoneal thickening, the largest measuring 51 mm with a large central fluid component causing scalloping of the liver margins; absence of mediastinal, hilar, abdominal or pelvic lymph node enlargement; and a small amount of ascites (Figure 1). The diagnosis of TB was initially suspected due to the presence of pleural and peritoneal effusion and relevant epidemiologic risk factors for TB, namely past residence in and recent travel to an epidemic area, and confirmed after ultrasound-guided fluid collection from a caseating nodule. Radiological investigations play a pivotal role in the diagnosis of abdominal TB in conjunction with clinical presentation and cytological and immunological investigations [8]

DISCUSSION

Findings

CONCLUSION