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Fungal Liver Infection in Immunocompromised Patients: Depiction with Multiphasic Contrast-enhanced Helical CT¹

¹ From the Department of Medical Imaging, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada. Received August 1, 2003; revision requested October 14; final revision received April 24, 2004; accepted June 16. Address correspondence to U.M., Department of Nuclear Medicine, Tel-Aviv Sourasky Medical Center, 6 Weizman St, Tel-Aviv, Israel 64239 (e-mail: umetser@tasmc.health.gov.il).

View larger version (146K): [in a new window]   Figure 1a. Transverse CT scans obtained in 44-year-old woman with acute lymphocytic leukemia and candidemia. (a) Arterial phase scan shows multiple type 2 (with rim enhancement) lesions (arrows). (b) Portal venous phase scan obtained at same level as a shows no focal lesions. (c) On nonenhanced scan, two of the lesions (arrows) seen in a can be appreciated.

View larger version (128K): [in a new window]   Figure 1b. Transverse CT scans obtained in 44-year-old woman with acute lymphocytic leukemia and candidemia. (a) Arterial phase scan shows multiple type 2 (with rim enhancement) lesions (arrows). (b) Portal venous phase scan obtained at same level as a shows no focal lesions. (c) On nonenhanced scan, two of the lesions (arrows) seen in a can be appreciated.

View larger version (113K): [in a new window]   Figure 1c. Transverse CT scans obtained in 44-year-old woman with acute lymphocytic leukemia and candidemia. (a) Arterial phase scan shows multiple type 2 (with rim enhancement) lesions (arrows). (b) Portal venous phase scan obtained at same level as a shows no focal lesions. (c) On nonenhanced scan, two of the lesions (arrows) seen in a can be appreciated.

View larger version (199K): [in a new window]   Figure 2a. Transverse CT scans obtained in 67-year-old man with acute myeloid leukemia and candidemia. (a) Initially obtained arterial phase scan shows a type 4 (hyperattenuating) lesion (arrows) in liver segment V. (b) On portal venous phase scan, no lesion can be appreciated. (c) Follow-up arterial phase scan obtained several weeks later shows the same lesion as in a but with type 2b morphologic features—specifically, a hypoattenuating center with a thick hyperattenuating rim (arrows). Scan also shows an additional lesion (arrowhead) in liver segment III.

View larger version (163K): [in a new window]   Figure 2b. Transverse CT scans obtained in 67-year-old man with acute myeloid leukemia and candidemia. (a) Initially obtained arterial phase scan shows a type 4 (hyperattenuating) lesion (arrows) in liver segment V. (b) On portal venous phase scan, no lesion can be appreciated. (c) Follow-up arterial phase scan obtained several weeks later shows the same lesion as in a but with type 2b morphologic features—specifically, a hypoattenuating center with a thick hyperattenuating rim (arrows). Scan also shows an additional lesion (arrowhead) in liver segment III.

View larger version (177K): [in a new window]   Figure 2c. Transverse CT scans obtained in 67-year-old man with acute myeloid leukemia and candidemia. (a) Initially obtained arterial phase scan shows a type 4 (hyperattenuating) lesion (arrows) in liver segment V. (b) On portal venous phase scan, no lesion can be appreciated. (c) Follow-up arterial phase scan obtained several weeks later shows the same lesion as in a but with type 2b morphologic features—specifically, a hypoattenuating center with a thick hyperattenuating rim (arrows). Scan also shows an additional lesion (arrowhead) in liver segment III.

View larger version (25K): [in a new window]   Figure 3. Graph illustrates distribution of different lesion types on both kinds of contrast-enhanced-phase CT scans; proportions are based on a total of 536 lesions. Type 1 lesions were hypoattenuating and either subcentimeter in diameter (type 1a) or at least 1 cm in diameter (type 1b). Type 2 lesions had hypoattenuating centers with a hyperattenuating rim, the thickness of which was either equal to or less than the radius of the hypoattenuating center (type 2a) or greater than the radius of the hypoattenuating center (type 2b). Type 3 lesions were any lesions with associated transient hepatic enhancement, defined as an adjacent wedge-shaped region of increased enhancement. Type 4 lesions were hyperattenuating—that is, brighter than the surrounding liver parenchyma on scans. AP = arterial phase, ND = not detected, PVP = portal venous phase.

View larger version (186K): [in a new window]   Figure 4a. Transverse CT scans obtained in 29-year-old woman with acute myeloid leukemia, fever after a neutropenic episode, and candidemia. (a) Arterial phase scan shows a type 2b (hypoattenuating center with thick hyperattenuating rim) lesion (arrow). (b) Portal venous phase scan shows the same lesion (arrow) in a as a type 1a (subcentimeter and hypoattenuating) lesion.

View larger version (189K): [in a new window]   Figure 4b. Transverse CT scans obtained in 29-year-old woman with acute myeloid leukemia, fever after a neutropenic episode, and candidemia. (a) Arterial phase scan shows a type 2b (hypoattenuating center with thick hyperattenuating rim) lesion (arrow). (b) Portal venous phase scan shows the same lesion (arrow) in a as a type 1a (subcentimeter and hypoattenuating) lesion.

View larger version (114K): [in a new window]   Figure 5a. Transverse CT scans obtained in 62-year-old woman with acute myeloid leukemia, prolonged fever after a neutropenic episode, and altered liver enzymes. Initially obtained portal venous phase CT scan (not shown) showed no focal liver lesions. (a) Arterial phase scan obtained 3 weeks later shows two lesions in the liver dome: a type 2a (hypoattenuating center with thin hyperattenuating rim) lesion (arrowhead) anteriorly and a type 4 (hyperattenuating) lesion (arrow) posteriorly. (b) Neither lesion seen in a can be appreciated on the portal venous phase scan. (c) Follow-up arterial phase scan obtained several weeks later shows that the type 2a lesion seen in a resolved; however, the posterior lesion (arrow) seen in a is still depicted. (d) Follow-up portal venous phase scan obtained several weeks later also does not show any focal lesions.

View larger version (125K): [in a new window]   Figure 5b. Transverse CT scans obtained in 62-year-old woman with acute myeloid leukemia, prolonged fever after a neutropenic episode, and altered liver enzymes. Initially obtained portal venous phase CT scan (not shown) showed no focal liver lesions. (a) Arterial phase scan obtained 3 weeks later shows two lesions in the liver dome: a type 2a (hypoattenuating center with thin hyperattenuating rim) lesion (arrowhead) anteriorly and a type 4 (hyperattenuating) lesion (arrow) posteriorly. (b) Neither lesion seen in a can be appreciated on the portal venous phase scan. (c) Follow-up arterial phase scan obtained several weeks later shows that the type 2a lesion seen in a resolved; however, the posterior lesion (arrow) seen in a is still depicted. (d) Follow-up portal venous phase scan obtained several weeks later also does not show any focal lesions.

View larger version (110K): [in a new window]   Figure 5c. Transverse CT scans obtained in 62-year-old woman with acute myeloid leukemia, prolonged fever after a neutropenic episode, and altered liver enzymes. Initially obtained portal venous phase CT scan (not shown) showed no focal liver lesions. (a) Arterial phase scan obtained 3 weeks later shows two lesions in the liver dome: a type 2a (hypoattenuating center with thin hyperattenuating rim) lesion (arrowhead) anteriorly and a type 4 (hyperattenuating) lesion (arrow) posteriorly. (b) Neither lesion seen in a can be appreciated on the portal venous phase scan. (c) Follow-up arterial phase scan obtained several weeks later shows that the type 2a lesion seen in a resolved; however, the posterior lesion (arrow) seen in a is still depicted. (d) Follow-up portal venous phase scan obtained several weeks later also does not show any focal lesions.

View larger version (151K): [in a new window]   Figure 5d. Transverse CT scans obtained in 62-year-old woman with acute myeloid leukemia, prolonged fever after a neutropenic episode, and altered liver enzymes. Initially obtained portal venous phase CT scan (not shown) showed no focal liver lesions. (a) Arterial phase scan obtained 3 weeks later shows two lesions in the liver dome: a type 2a (hypoattenuating center with thin hyperattenuating rim) lesion (arrowhead) anteriorly and a type 4 (hyperattenuating) lesion (arrow) posteriorly. (b) Neither lesion seen in a can be appreciated on the portal venous phase scan. (c) Follow-up arterial phase scan obtained several weeks later shows that the type 2a lesion seen in a resolved; however, the posterior lesion (arrow) seen in a is still depicted. (d) Follow-up portal venous phase scan obtained several weeks later also does not show any focal lesions.

View larger version (25K): [in a new window]   Figure 6. Graph illustrates comparison of lesion conspicuity scores for the three CT phases. AP = arterial phase, NC = nonenhanced phase, PVP = portal venous phase.