PMC3298010_01
Abdominal CT and MRCP images at 1st admission. A) Thicken cystic neck, cystic duct and CBD (red arrowheads) on plain scan. B) CBD contrast enhancement in a pattern of concentric circles. C) Axial T1-W image showing moderate dilatation of intrahepatic biliary radicals in both lobes of the liver with extrahepatic bile ductal thickening. D) Axial T2-W image showing hypointense gross circumferential mural thickening of the CBD. E) The first MRCP performed before ERCP showing dilated intrahepatic ducts with abrupt cut-off of their lumens in the hilum (green arrowheads). The main pancreatic duct is not observed. F) Second MRCP after ERCP showing more dilated intrahepatic ducts with hilar discontinuity. The proximal main pancreatic duct is also observed, whereas the distal duct is not indicated.
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F1
Furthermore, an abdominal contrast-enhanced CT scan and an MRCP produced similar findings, i.e., a hilar biliary stricture with no evidence of abdominal masses or lymphadenopathy (Fig. 1). At that time, a repeat MRCP revealed a more indistinct biliary bifurcation and CHD, which was pathognomonic for malignancy (Fig. 1F).
ERCP and postoperative T-tube cholangiography. A) ERCP showing an irregular CBD stricture (red arrowheads) with dilated intrahepatic biliary trees (green arrowheads). B) Intrahepatic bile duct dilatation resumed, but no definite bile duct stricture was observed.
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F2
Accordingly, an ERCP was performed, which revealed an isolated irregular proximal CBD stricture with dilated intrahepatic biliary trees and no duodenal or ampullary tumors as well as negative brush cytology (Fig. 2A). Moreover, her T-tube was removed after a cholangiography (Fig. 2B).
Abdominal CT and MRCP at 2nd admission. A) Arterial phase and B) Venous phase CT scan demonstrating apparently normal intrahepatic and extrahepatic bile ducts (red arrowheads denoting CBD). C) Fast-echo MRI hydrography demonstrating slight dilatation of the intrahepatic bile duct. D) Compared to Fig. 1C, the axial T1-W image shows no clear extrahepatic bile duct thickening.
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F3
Radiologic exams at this time revealed a thickened CBD wall, narrow CBD lumen and moderately dilated intrahepatic bile ducts, which were also similar to but slightly less severe than her initial presentation (Fig. 3).
Microscopic examination with India ink staining (400x magnification). Numerous encapsulated yeast-like organisms measuring 7-10 mum in diameter were scattered in multinucleated giant cells (green arrowheads) and fibrous tissue throughout the entire CBD.
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F4
The periodic acid methenamine silver stain, periodic acid Schiff stain and India ink stain were all positive (Fig. 4), whereas the pathogen identified by polymerase chain reaction from the paraffin-embedded gallbladder was Cryptococcus neoformans (VNI type1).