Radiological Category Ultrasound Principal Modality 1 Ultrasound Principal

Radiological Category: Ultrasound Principal Modality (1): Ultrasound Principal Modality (2): CT Case Report #0087 Submitted by: Judy Himmerich , M. D. Faculty reviewer: Chitra Chandrasekhar, M. D Date accepted: 12 February 2004

Case History 44 y. o. Latin American female, G 1 P 1, who presented to the emergency room with fever and pelvic mass. The patient also had an elevated white count of 23, 000.

Radiological Presentations Pelvic ultrasound of both adnexae with color flow.

Radiological Presentations Ultrasound of the liver with color flow.

Radiological Presentations CT images of the pelvis and right upper quadrant with IV, oral, and rectal contrast.

Test Your Diagnosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. • Ovarian CA with liver metastases. • Bilateral tubo-ovarian abscesses with liver micro-abscesses. • Bilateral tubo-ovarian abscesses and unrelated liver metastases from breast CA. • Multiple liver abscesses from pyogenic infection and unrelated ovarian CA.

Findings and Differentials Findings: The pelvic ultrasound demonstrates complex, thick walled, multi-cystic masses in the adnexae, bilaterally. The cysts contain internal debris. The ultrasound of the right upper quadrant demonstrates diffuse hypoechoic, sub-centimeter masses in all lobes of the liver. The CT confirms the findings on US. No adenopathy is present in the CT images. Differentials: • Ovarian CA with liver metastases. • Bilateral tubo-ovarian abscesses with liver micro-abscesses. • Bilateral tubo-ovarian abscesses and unrelated liver metastases from breast CA. • Multiple liver abscesses from pyogenic infection and unrelated ovarian CA.

Discussion Complex, multi-loculated adnexal masses in the setting of the patient’s clinical presentation of fever and leukocytos, are highly suspicious for tubo-ovarian abscesses. They are most commonly bilateral and are the sequelae of PID. Multiple, hypo-echoic masses in the liver of this size would be consistent with micro-abscesses secondary to the TOA’s. The size and multiplicity of the nodules make them less likely to be metastatic disease, although breast and lung CA, melanoma, and primary non-Hodgkin’s lymphoma of the liver in AIDS patients can have this appearance.

Diagnosis Bilateral tubo-ovarian abscesses with multiple hepatic abscesses. The patient also had an unrelated finding of Hepatitis C on the liver biopsy Reference 1. Rumack C M, Wilson S R, Charboneau J W. Diagnostic Ultrasound. St. Louis, MO: Mosby, 1998: 87 -154, 519 -576