Multiple liver masses mimicking metastatic liver disease in an elderly patient

Abstract

QUESTIONA 68-year-old male was admitted with complaints of weakness, mild right upper quadrant pain, and rightside wrist arthralgia. The medical history of the patient included hypertension and benign prostate hyperplasia, and his long-term medications were indapamide, doxazosin, alfuzosin, perindopril, and amlodipine. He also had a 20 pack-year smoking history and no history of alcohol intake. Physical examination findings were unremarkable except for tenderness in the right wrist. The laboratory test results showed hemoglobin: 8.4 g/dL (normal range [NR]: 13.6-17.2), white blood cell: 11. Negative test results were obtained for hepatitis-B surface antigen, hepatitis C antibody, antimitochondrial antibody, antinuclear antibody, rheumatoid factor, antineutrophil cytoplasmic antibodies, and quantiferon for tuberculosis. Serum angiotensin-converting enzyme (ACE), B2 microglobulin, and immunoglobulin G and M levels were within the NR. On dynamic abdominal computed tomography (CT) scan, multiple irregularly shaped, hypodense masses that were peripherally enhancing in the arterial phase were observed in all liver segments, the largest of which was 1.5 cm in size (Figure 1). Thoracic CT showed four nodules of millimetric size in the right lung parenchyma, and there was no mediastinal lymphadenopathy. Upper gastrointestinal endoscopy revealed antral gastritis, and colonoscopy revealed a polyp of millimetric size in the ascending colon. On further investigation, tests for leishmania, brucellosis, mycobacterium, aspergillus, toxoplasma, Epstein-Barr virus, and cytomegalovirus