2. Case Report
The patient was a 66-year-old woman living in Chenran, Razavi Khorasan
Province, Iran. In 2013, she was admitted to the hospital due to
abdominal pain. An ultrasound examination of the abdomen showed that
liver is enlarged with coarse and heterogeneous echotexture. Suspicious
hyperechoic and heterogeneous ill-defined mass like lesion was noted. In
the next examination, Computed tomography (CT) scan of the abdomen and
pelvis showed an enlarged liver with abnormal ill-defined hypo-hetro
density in both liver lobes. Right lobe was more affected. Caudate lobe
was intact. A Core needle biopsy was taken from liver lesions in July
2013. The H&E stained section showed necrotic material containing
multiple micro cysts covered by hyaline layered membranes with
inflammation. Parasite abscess compatible with Echinococcus
multilocularis were identified. At that time, the patient was not
diagnosed as a candidate for surgery and received treatment with
Albendazole.
In 2019, the patient was admitted again at the Imam Reza Tertiary
Teaching Hospital, Mashhad University of Medical Sciences, Mashhad,
Iran, with a chief complaint of abdominal pain. She suffered from new
onset sever pain in the right upper quadrant (RUQ) and periumbilical
with extension to right flank from the day before hospitalization. On
physical examination, vital signs were stable with low-grade fever and
icterus. On abdominal examination, epigastric and RUQ tenderness were
observed. She had hepatomegaly and splenomegaly without ascites.
Laboratory tests revealed anemia without thrombocytopenia, elevated
liver enzymes with hepatocellular pattern with hyperbilirubinemia (AST
(IU/l):149), ALT (IU/l):118 Alkaline phosphatases (U/l):284, Total
bilirubin:3.3, Direct bilirubin:2.1, INR:1.21). ESR = 98, and CRP = 18.9
mg/dl.
Other etiologies of liver failure such as viral hepatitis B, C and
autoimmune hepatitis, Wilson and hemochromatosis were negative.
Ultrasound showed enlarged liver with heterogeneous parenchymal echo,
containing echogenic masses (the largest 101×73 in 5 segment of liver),
intrahepatic bile duct dilatation, common bile duct = 7; normal
gallbladder; echogenic foci suggesting thrombosis in porta hepatic and
slow flow in inferior vena cava (IVC), especially intrahepatic; large
spleen (140×140); collateral vessels in the umbilicus, liver, and
spleen;
Doppler ultrasound showed the hepatic arteries of the left branch of the
vein of the port were narrow with the partial venous flow; involvement
of the left port vein wall by parenchymal lesions of the IVC fluvial
liver was highly slow and reciprocating in suprahepatic and subhepatic:
IVC thrombosis and susceptibility to thrombosis; narrowing of the right
hepatic vein caused by thrombosis as well as the compressive effect of
the involved liver parenchyma; and collateral vessels around the spleen
hill and evidence of splenorenal shunt.
The findings obtained from contrast and Triphasic CT of the abdomen
showed huge hepatomegaly (Its span in midclavicular 200 mm);
disseminated internal calcified areas of the liver with pressure effect
on the peripheral organs and its branches and their displacement to the
opposite; hypertrophy caudate lobe of liver; IVC, intrahepatic and
hepatic veins were invisible ; portal vein and its right and left
branches in quite narrow status; dilated intrahepatic bile ducts; free
fluid in the abdominal and pelvic cavities (figure 1)
Due to acute hepatic and portal vein thrombosis, and hydatid cyst
treatment with heparin and Albendazol initiated, the liver enzyme and
bilirubin decreased and clinical condition improved. The patient’s
laboratory tests are shown in Table (1).
Due to thrombosis and extensive liver involvement inEchinococcus , the patient received treatment with ceftriaxone and
albendazole 4oo mg twice a day, heparin infusion, and then warfarin. The
patient was discharged in good condition and is currently waiting for
liver transplantation.