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.