PMC8666961_01
A magnetic resonance imaging of the cervical spine showing a Chiari I malformation (red arrow) with a 5.8 mm displacement of the cerebellar vermis through the foramen magnum.
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F1
A computerized tomography (CT) scan of her head and neck was unremarkable, and magnetic resonance imaging (MRI) of the cervical spine demonstrated Chiari I malformation (Figure 1).
(A) Liver ultrasound showing multiple hypo-echoic lesions ranging between 0.5 and 3.3 cm. (B) A liver computerized tomography scan showing multiple hypo-echoic lesions with peripheral rim of increased enhancement. (C) A magnetic resonance imaging (sagittal view) showing same as (A,B).
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F2
An ultrasound assessment revealed multiple bilobar hypoechoic hepatic lesions (Figure 2A) which were confirmed as multiple hypoenhancing lesions on subsequent abdominal CT and MRI (Figures 2B,C).
(A) A H&E stain of the liver biopsy (400 X) showing mixed inflammatory infiltrate composed predominantly of lymphocytes and plasma cells and smaller numbers of neutrophils and eosinophils. The bile duct (red arrows) and portal vessel (yellow arrows) are highlighted. (B) An Anti-Treponema pallidum immunohistochemical staining confirmed the presence of spirochetes and highlighted numerous microorganisms having an epitheliotropic and vasculotropic pattern. The IHC was performed on the same tissue area as for the H&E stain.
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F3
Histologic sections of the biopsy showed involvement of the liver parenchyma by a dense mixed lymphoplasmacytic and granulocytic inflammatory infiltrate associated with reactive fibrosis (Figure 3A), foci of necrosis, and clusters of epithelioid histiocytes, consistent with inflammatory pseudo-tumor. In addition, foci of vascular and biliary inflammatory injury were present (Figure 3A). Treponema pallidum (Biocare APA 135 AA) and the diagnosis of tertiary stage SH with hepatic gummas (Figure 3B). The patient's liver function tests were monitored daily and showed initial improvement (Table 1); however, she left against medical advice following completion of only 4 days of the recommended 10-14-day course of intravenous penicillin for neurosyphilis.