Hyperechogenic hepatic lesions in an AIDS patient with bacillary angiomatosis
The diagnosis of opportunistic infections due to uncommon pathogens is still a challenge in AIDS patients, in spite of introduction of HAART. Bacillary Angiomatosis (BA) is a rare, perhaps under-diagnosed, and potentially treatable opportunistic infection in immunocompromised patients. We describe a case of BA with hepatic peliosis as the first manifestation of AIDS in a patient who was contemporarily diagnosed to be HIV-positive, with severe immune- depression, diffuse cutaneous nodules on the trunk, back and arms highly suggestive for BA at histology, and cerebral lesions on MRI. Antibodies against Bartonella were positive on ELISA. An abdominal US scan revealed some hyperecogenic lesions, two of them suggestive of hemangiomas. CEUS, CT scan and MRI showed different patterns of vascularity. Because it was difficult to establish a definitive diagnosis from imaging findings alone, we performed an echo-guided fine-needle biopsy (USG-FNB), resulting in a non-specific histology: However, the fragment resulted positive for Bartonella Henselae at Polimerase Chain Reaction. Electronic microscopy on the liver tissue revealed the presence of intracellular bacilli. The patient was treated for twelve weeks of antibiotic therapy with eryithromycin, combined with antiretroviral treatment. During treatment, cutaneous and encephalic lesions improved. US follow-up resulted in reduction of echogenicity of hepatic lesions, suggesting that they were related to Bartonella.
The imaging pattern of hepatic peliosis are generally referred as non-specific. However, peliotic cavities can be life-threatening due to risk of rupture in the abdomen. US follow-up allowed simple serial examinations, therefore achieving diagnostic conclusions.