Now You See Me, Now You Donʼt: A Case of the Recurring Liver Lesions in Crohnʼs Disease

Abstract

A 41 year old woman with history of stable colonic Crohn's disease on mesalamine, psoriasis, and celiac disease, presented with subacute substernal pleuritic chest pain. MRI abdomen showed greater than 20 left liver lobe lesions with ill-defined borders. Liver biopsies demonstrated focal fibrosis and cholangiolar proliferation suggestive of focal nodular hyperplasia. Three months later, she presented for a Crohn's flare confirmed with colonoscopy and initiated on prednisone with a slow taper with relief of her symptoms. Surveillance MRI 6 months after presentation revealed complete resolution of previously seen liver lesions. She remained asymptomatic for another 6 months, until she returned with subacute symptoms of fever/chills, abdominal pain, bloody diarrhea and associated leukocytosis with elevated ESR. She was initiated on prednisone taper given concern for Crohn's flare however her symptoms did not improve, prompting CT enterography which revealed abnormal liver lesions without obvious small bowel changes. Imaging showed at least 10 hypodense lesions (largest 6 x 4 cm) throughout the liver resulting in multiple CT guided drainages along with liver biopsies. Pathology demonstrated multiple areas of necrotic tissue with fibrotic walls with reactive spindled cells and occasional multi-nucleated giant cells suggestive of pyogenic liver abscesses. Microbial cultures on these specimens including bacterial, fungal, and acid-fast were all repeatedly negative. She was discharged with an antibiotic course and maintained on prednisone indefinitely (patient refused escalation of maintenance therapy) in addition to mesalamine. Surveillance MRI 6 months after discharge shows complete resolution of previously seen liver lesions. This case exemplifies a rare extraintestinal complication of inflammatory bowel disease presenting as recurrent liver lesions in Crohn's disease. Although prevalence of this entity is unknown, about 60 cases have been reported, the majority of which were found in active Crohn's disease. Abscess cultures are positive in most cases, however for our patient her infectious workup proved negative. It was only after aggressive management of her Crohn's disease with the addition of steroid therapy did her lesions dramatically resolve.