Postgrad Med J (1990) 66, 290 - 291 A The Fellowship of Postgraduate Medicine, 1990 Postgrad Med J: first published as 10.1136/pgmj.66.774.290 on 1 April 1990. Downloaded from

Missed Diagnosis Focal fatty infiltration ofthe mimicking metastatic disease Y. Bashir Cardiac Department, John Radcliffe Hospital, Headington, Oxford OX3 9BU, UK.

Summary: We report the mistaken diagnosis of metastatic by ultrasonography in a patient with congestive heart failure and focal fatty infiltration of the liver. Multiple echogenic space-occupying lesions in the liver can be caused by benign conditions as well as tumour deposits and in a debilitated patient the possibility of focal fatty infiltration should always be considered.

Introduction Ultrasound scanning has an established role in the X-ray showed cardiomegaly with bilateral pleural detection of hepatic metastases in patients with effusions and pulmonary venous congestion but no known primary tumours."2 With the widespread other lesion. Her were use of abdominal ultrasonography for the investi- 43 gamol/l, aspartate transaminase 71 lU/I (normal gations of upper gastrointestinal symptoms, abdo- 10-35) and 655 IU/I (normal minal pain, and , it is not 100-300) and a repeat abdominal ultrasound scan uncommon to identify cases of metastatic liver confirmed that there were multiple round echo- copyright. disease before the primary tumour is known and genic lesions in the liver (Figure 1). She was sometimes the ultrasound scan provides the only commenced on bumetanide 1 mg daily for her definite indication that the patient is suffering from cardiac failure and investigations were performed widespread malignancy. Unfortunately, the sono- to establish the primary tumour, including abdo- graphic appearances of liver metastases can be minal/pelvic ultrasonography, barium studies, mimicked by benign lesions3-` and failure to recog- mammography and urinary 5-hydroxyindoleacetic nize this possibility may result in a mistaken acid, all of which were negative. She continued to diagnosis of carcinomatosis. deteriorate and 10 days after admission she was http://pmj.bmj.com/ transferred to a medical firm for 'terminal care'. Case report The impressive cardiovascular clinical findings were noted again and it was felt that her condition A previously fit 72 year old woman was admitted could be entirely explained by heart failure with under a general surgical team with a three month hepatic congestion and cardiac cachexia. Since the history of breathlessness, nausea, vomiting and only evidence of malignancy came from the ultra- sound scan, this was repeated again but the findings weight loss of approximately 2 stones. Her general on September 23, 2021 by guest. Protected practitioner had organized an abdominal ultra- were unchanged from the previous two scans. The sound scan which had been reported as showing 'an patient's therapy was intensified with the intro- enlarged liver containing several echogenic meta- duction of captopril and intravenous diuretic but stases' and so a presumptive diagnosis of dis- she died the next day. A post-mortem examination seminated malignancy had been made. There was confirmed severe congestive cardiac failure with no history of cardiovascular disease or hyperten- extensive atherosclerosis of all the coronary sion. arteries but no myocardial infarction. The liver was On examination she appeared cachectic and enlarged and congested with several areas of focal mildly jaundiced with signs of gross congestive fatty infiltration and a single haemangioma 1.5 cm cardiac failure including smooth hepatomegaly but in diameter but there was no evidence of tumour. no specific evidence of malignant disease. A chest Correspondence: Y. Bashir, B.A., M.R.C.P., Department Discussion of Cardiological Sciences, St. George's Hospital Medical School, Cranmer Terrace, London SW17 ORE, UK. The use of ultrasonography for the diagnosis of Accepted: 16 June 1989 malignant liver lesions has been extensively studied FATTY LIVER INFILTRATION 291 Postgrad Med J: first published as 10.1136/pgmj.66.774.290 on 1 April 1990. Downloaded from

ANT consists of one or more echogenic space-occupying lesions within the liver parenchyma.4 9 This appear- ance may be simulated by benign lesions such as haemangioma, focal nodular hyperplasia, ade- noma, abscess and also focal fatty infiltration.3-5 Focal fatty infiltration of the liver has not been widely recognized as a distinct entity until recently.'0 It is seen with conditions traditionally associated with diffuse fatty liver such as congestive heart failure, obesity, malnutrition, alcoholism, parenteral feeding and corticosteroid therapy, all of which occur quite commonly in hospitalized patients.'0"' Such patients may be in poor health and have hepatomegaly and abnormal liver func- tion tests, and in this context, the finding of multiple echogenic lesions in the liver would not be entirely surprising and would naturally lead to a presumptive diagnosis ofmetastatic disease. There have been previous reports of focal fatty infil- tration of the liver mimicking the appearance of solitary'2 and multiple'3 tumour deposits. In the present case, the multiple echogenic Figure 1 Ultrasound scan of the liver demonstrating a lesions were indeed due to areas of focal fatty 2 cm echogenic lesion (SQL). Several similar lesions were change (and a haemangioma) rather than meta- noted in other parts of the liver. (GB =gall bladder, stases. Unfortunately the presumptive diagnosis of HV = hepatic vein). carcinomatosis was not challenged until too late and the patient received only minimal treatment for her cardiac failure in the belief that her demise was copyright. inevitable. This case illustrates the need for caution and in most series the predictive accuracy of a in making a diagnosis of metastatic liver disease positive scan was in the range of 85-95%.1,2,5-i solely on the basis of ultrasonography, even if the Thus, even in experienced hands the technique appearances are typical and the patient is debili- yields a small number of false positive reports of tated and 'looks like someone with cancer'. Where malignancy. Metastases can cause several sono- necessary, a guided should be performed to graphic abnormalities but the commonest pattern confirm the malignant nature of the lesions. http://pmj.bmj.com/

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