Hola amigos, las imágenes de hoy son las de un varón de 48 años con dolor en hipocondrio derecho, anorexia y pérdida de peso desde hace un mes. Presenta leucocitosis con desviación izquierda. Fosfatasa alcalina y proteína C reactiva elevadas.
1. Colangiocarcinoma
2. Actinomicosis hepática
3. Absceso amebiano
4. Nada de lo expuesto
Podéis dar vuestra opinión hasta el viernes, día en el que se publicará la solución.
Hallazgos: CT abdominal muestra una masa hepática periférica y heterogénea, que capta contraste discretamente (A, flecha). Hay retracción capsular e infiltración de la grasa perihepática (A, flecha roja). El PET-TAC revela actividad hipermetabólica (B, flecha) con una captación de 5,7 SUV:
La RM revela una masa sólida heterogénea, de contornos lobulados e indefinidos, hiperintensa en la secuencia T2 con saturación grasa (C, flecha). En el estudio dinámico con contraste (T1 con saturación grasa) muestra captación progresiva con un halo grueso hipercaptante en fase tardía, delimitándose pequeños focos hipointensos (D, flecha):
En la biopsia percutánea se encontró fibrosis e inflamación, sin evidencia de células malignas. El paciente desarrolló signos de sepsis, por lo que se realizó un nuevo estudio de RM. T2 Axial TSE (A) y T2 Axial con saturación grasa (B) muestran progresión de la afectación perihepática con aparición de colecciones (A-B, flechas) y líquido libre. Se observa una segunda lesión intrahepática yuxtahiliar (A-B, flechas rojas):
El paciente fue intervenido con el diagnóstico final de actinomicosis hepática.
Discusión
La actinomicosis hepática es una causa infrecuente de infección abdominal. Representa el 5% de todos los casos de actinomicosis. Es una enfermedad granulomatosa supurativa crónica secundaria a infección por Actinomyces israelii.
La patogénesis de la infección hepática es hematógena secundaria a un foco abdominal y propagada a través de la vena porta. Se considera primaria cuando no se encuentra un foco abdominal.
Se consideran factores de riesgo una infección abdominal previa, historia de manipulación del tracto gastrointestinal, perforación intestinal o trauma abdominal, dispositivos intrauterinos o inmunosupresión. En nuestro caso, el paciente tenía el antecedente de colecistectomía dos años antes.
Los síntomas son inespecíficos: fiebre y dolor en hipocondrio derecho por lo que el diagnóstico clínico es difícil. Se suele observar leucocitosis con elevación de los enzimas hepáticos y colostasis. El CA 19.9 y la alfa fetoproteina pueden estar elevados.
El TAC abdominal muestra una lesión hepática única en el 68% de los casos, que puede ser sólida o multiloculada con septos fibrosos. Hay una discreta captación en fases tempranas tras la inyección de contraste. En la RM la lesión es hiperintensa en T2 e hipointensa en T1 con un halo hiperintenso en T2. La lesión generalmente muestra pequeños focos quísticos que corresponden a zonas abcesificadas.
Al progresar suele invadir estructuras adyacentes y fistulizar.
El diagnóstico diferencial incluye otras enfermedades inflamatorias, sin permitir descartar enfermedades neoplásicas.
El diagnóstico definitivo se basa en la demostración macroscópica de “gránulos de azufre” en biopsia o aspiración del pus o cultivo de tejidos. Más del 80% de los casos requieren cirugía para llegar al diagnóstico definitivo, como ocurrió en nuestro caso.
El tratamiento de elección es drenaje del absceso y antibioterapia, con penicilina parenteral las primeras semanas, seguida de terapia oral durante 6-12 meses. Se recomienza control por métodos de imagen para controlar la respuesta al tratamiento.
El consejo de Dr. Pepe:
En conclusión, la actinomicosis hepática puede simular una neoplasia y debe incluirse en el diagnóstico diferencial de las lesiones solitarias hepáticas, especialmente, cuando la biopsia es negativa para células malignas.
Debe sospecharse si hay historia previa de cirugía abdominal o trauma. También cuando la lesión progresa rápidamente. La cirugía es esencial para el diagnóstico definitivo.
Caso preparado por la Dra. Nadine Romera.
Hola Pepe! para nosotros puede ser una actinomicosis hepática, porque es un cuadro subagudo, con síntomas clínicos y de laboratorio sugerentes de un proceso infeccioso y una imagen ocupante de espacio,redondeada, con realce periférico en la tac y heterogéneo en la RMI.
El absceso amebiano presenta características mas quisticas y clínica mas aguda y para colangio carcinoma faltaría dilatación de la via biliar e ictericia.
Semiología y diagnóstico correctos. Enhorabuena!
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