An Enigmatic Patient: Puzzles On The Liver
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| liver |
Leipzig doctors discover liver cancer in a 44-year-old man, they are worried about cancer. But on CT scans the tumor suddenly disappears. Only tissue removal brings the doctors on the right track.
The Leipzig University Hospital is home to a 44-year-old man who is constantly feeling tired. He tells his doctors about fever and nocturnal sweats, it's been like that for ten days. In addition, in the past week, the knee joints have hurt after sports.
When the internist Thomas Karlas and his colleagues question the man, he can recall similar complaints in the past. In the past year and in the previous year, he had already done so once, reports the patient. At that time, however, the symptoms went by themselves, the doctors describe the case in the journal "Gastroenterology".
Otherwise, the patient's history is unremarkable: Until ten years ago, the man had smoked, he does not suffer from chronic diseases, there is no evidence of infectious diseases, which he might have brought from travel.
Swollen knees, elevated liver values
While examining the doctors notice that both knees are slightly swollen. Otherwise, they will not notice anything that would explain the man's complaints. The blood analysis shows clear evidence of inflammation, also a part of the liver values is increased. Of the red blood pigment, the hemoglobin important for the transport of oxygen, the patient has too low a concentration in the blood. In addition, the concentration of platelets, the platelets needed for coagulation, is slightly elevated. There are different causes for both findings. The man is X-rayed, his urine analyzed - without noticeable results.
At the ultrasound examination, the doctors will finally find something. In the liver, they encounter a structure about two by two centimeters in size (pictured: A), which could be a malignant tumor. Using a contrast agent, the doctors see how the structure is supplied by a blood vessel (in the picture: B and C). This is the case for most tumors above a certain size, but not for many benign changes. They feel confirmed in their assumption that the patient is suffering from cancer.
But their hypothesis shakes when they examine the man also computer tomographically. On the CT images (in the picture: D) the tumor almost disappears. Only a magnetic resonance tomography (MRI, in the picture: E) makes the structure visible again. In a positron emission tomography (PET, in the picture: F), the physicians recognize that the cells at the suspect site consume large amounts of blood sugar, which in turn would fit into a malignant tumor. Because the different images seem contradictory, the doctors decide to biopsy the liver, removing a small piece of tissue.
A completely different tumor
The pathologists find no evidence of a malignant tumor when analyzing the tissue. However, they notice a variety of tightly packed defense cells. A closer examination of the cells in the laboratory gives the diagnosis: The patient suffers from an inflammatory pseudotumor (inflammatory pseudotumor) in the liver.
Inflammatory pseudotumors are very rare, the defense system is directed against the body itself. So it is an autoimmune disease that can affect various organs such as the pancreas, lungs or just the liver. The correct diagnosis only results if the doctors think in time to perform the biopsy. For a long time, the pseudotumors were recognized only after the operation of the supposedly malignant tumor.
Now the patient gets prednisolone, a relative of the body's hormone cortisol. The drug suppresses inflammatory reactions. The symptoms of the mango back quickly, his inflammatory levels in the blood normalize.
When the doctors try to treat him with a smaller amount of cortisone-related medication, the patient relapses. With the help of a combination of various immune system suppressing agents, it finally succeeds in permanently suppressing its symptoms. In the ultrasound studies, the doctors can still see the pseudotumor, but the inflammation seems to have lost activity.
In some patients, the tumors shrink even without treatment, but the majority of those affected need treatment with steroids, the relatives of cortisol. Only if that does not help, the pseudotumor must be removed in one operation.