Infección por Mycobacterium tuberculosis en una niña sometida a trasplante de progenitores hematopoyéticos / Mycobacterium tuberculosis infection in a pediatric patient who underwent a hematopoietic stem cell transplant

We report the case of a 10 year old girl with a relapsed acute lymphoblastic leukemia, who underwent a haploidentical hematopoietic stem cell transplant (HSCT), with grade II skin and digestive graft versus host disease, treated with corticosteroids and cyclosporine. On day + 54, she presented fever, with no other remarkable clinical findings. Imaging study showed the presence of lung and liver nodules, liver biopsy was performed. The study included histology, staining and culture for bacteria and fungi, and the preservation of a piece of tissue at -20°C for future prospective studies. Ziehl Nielsen stain was positive, and study for Mycobacterium infection was performed. Microbiological smears of tracheal and gastric aspirate, and bronchial fluid obtained by bronchoalveolar lavage (BAL) were positive. The final report confirmed Mycobacterium tuberculosis in gastric content, sputum, BAL and liver tissue, susceptible to rifampin, isoniazid, streptomycin and ethambutol, with determination of mutations for genes rpoβ and kat G (-). Tuberculosis (TB) diagnosis was confirmed. The girl received daily therapy for two months and then she continued on three times per week therapy for 9 months. Controlled by the transplant, infectious diseases and respiratory teams, the patient remained in good general condition, with radiologic resolution of pulmonary and liver involvement and negative smears. We conclude that Mycobacterium tuberculosis infection should be part of differential diagnosis of febrile illness in patients undergoing HSCT, and biopsy should be a standard practice of early diagnosis in these patients.

Se presenta el caso clínico de una niña de 10 años, con una leucemia linfoblástica aguda en recaída, sometida a un trasplante de progenitores hematopoyéticos (TPH) haploidéntico, con enfermedad injerto contra hospedero cutánea y digestiva grado II, en tratamiento con corti-costeroides y ciclosporina, que presentó el día +54 posttrasplante fiebre y compromiso de estado general. Dentro del estudio de su cuadro febril se practicaron imágenes que mostraron presencia de nódulos pulmonares y hepáticos. Se realizó una biopsia hepática cuyo estudio incluyó histología, tinciones y cultivo para bacterias y hongos. La tinción de Ziehl Nielsen de tejido hepático, así como las baciloscopias de contenido gástrico, aspirado traqueal y de fluido bronquial obtenido por lavado broncoalveolar (LBA) fueron positivas. El informe definitivo de cultivo confirmó Mycobacterium tuberculosis en contenido gástrico, esputo, LBA y tejido hepático, sensible a rifampicina, isoniazida, estreptomicina y etambutol, con determinación de mutaciones de genes rpoβ y kat G (-). Se confirmó el diagnóstico de tuberculosis, por lo que recibió tratamiento diario con cuatro fármacos por dos meses y luego terapia trisemanal con rifampicina, isoniazida y etambutol por nueve meses. Controlada por los equipos de trasplante, infectología y broncopulmonar, la paciente se mantiene actualmente en buenas condiciones generales, con imágenes con resolución del compromiso hepático y pulmonar y baciloscopias negativas. La infección por M. tuberculosis debe formar parte del diagnóstico diferencial de los cuadros febriles en los pacientes sometidos a TPH, y la toma de biopsia debe ser una práctica habitual y precoz en el enfrentamiento diagnóstico de estos pacientes.

Pigmented Liver Cell Adenoma with Nodule-in-Nodule Appearance: Case Report

Pigmented liver cell adenoma is very rare benign hepatic tumor and only four cases have been reported in the literature until now. We experienced one case of pigmented liver cell adenoma with nodule-in-nodule appearance, and we report on the ultrasonographic, CT and pathologic findings.

Focal Nodular Hyperplasia of the Liver: Triphasic Helical CT Findings

PURPOSE: To analyze the morphologic and enhancement patterns of focal nodular hyperplasia (FNH) of the liver observed at triphasic helical CT. MATERIALS AND METHODS: The triphasic helical CT findings of 15 pathologically-proven FNHs in 15 patients (male: female = 7:8; mean age, 40 years) were retrospectively analyzed. Triphasic helical CT images were obtained at 30 secs (arterial phase), 70 secs (portal phase), and 3 mins (equilibrium phase) after the initiation of contrast injection of a total of 120 mL nonionic contrast material at a rate of 3 mL/sec. Image analysis focused on the morphologic and enhancement patterns of the FNHs. Morphologically, their size and margin conspicuity were determined, as well as the presence or absence of a capsule, central scar, malformed arterial vessel, calcification, and mosaic pattern. As for the enhancement pattern, the degree of tumor enhancement (hyper-, iso-, or hypoattenuation) was compared with the surrounding hepatic parenchyma at each phase. All hyperattenuating FNHs were further analyzed after dividing them into two groups, strongly and weakly enhanced. RESULTS: Ten of the 15 tumors were less than 3 cm in diameter. With regard to the other morphologic parameters, a central scar, malformed arterial vessel, and capsule were found in four, four, and five FNHs, respectively. Eleven FNHs showed hyperattenuation, with strong enhancement at the arterial phase. During the portal and equilibrium phases, the enhancement pattern changed to iso- or hypoattenuation in nine and 13 FNHs, respectively. Of six hyperattenuating FNHs at the portal phase, five were weakly enhanced. CONCLUSION: Though our sample was small, we found that FNHs were hyperattenuating lesions, strongly enhanced at the arterial phase but iso- or hypoattenuating during the portal and equilibrium phases. A central scar, malformed arterial vessel, and capsule were observed fairly frequently. Thus, for the differentiation of FNH from other hypervascular hepatic tumors, precise recognition of their CT findings is important.