PMC3056368_01
Contrast-enhanced CT scan of the abdomen (A) and pelvis (B) shows irregular wall thickening in the neck of the gallbladder (arrow in A), with multiple, enlarged inguinal lymph nodes (arrows in B) showing relatively preserved fatty hila. CT scan of the chest (C) shows multiple, well-defined, small, subcentimetre nodules (arrows), in both lower lobes
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An initial contrast-enhanced abdominal CT scan showed several gallbladder stones and diffuse wall thickening of the gallbladder, especially with irregular thickening in its neck [Figure 1A], suggesting possible malignancy. Several enlarged lymph nodes with relatively preserved fatty hilum were seen in both inguinal regions [Figure 1B], along both iliac vessels, and in the portocaval space (not shown). A subsequent chest CT scan revealed multiple, small, well-defined nodules (<1 cm in diameter), in the right upper lobe (not shown) and both lower lobes [Figure 1C], suggesting possible metastatic disease.
FDG PET/CT shows increased uptake in the inguinal lymph nodes (arrow in A) with no significant uptake in the lung nodules (arrow in B)
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An 18F FDG PET/CT scan showed hypermetabolic enlarged nodes (standardized uptake value - SUV of 10) in both inguinal regions [Figure 2A], along both iliac vessels and the portacaval space (not shown). However, there was no significant hypermetabolism (maximum SUV: 1.2) in the small pulmonary nodules [Figure 2B].
Histopathology of the inguinal lymph node shows marked hyperplasia of secondary lymphoid follicles and extensive plasma cell proliferation (inset) in the interfollicular areas (H and E, x20)
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The histologic examination of a left inguinal lymph node specimen showed a negative Warthin Starry silver stain, but revealed hyperplasia of secondary lymphoid follicles and extensive plasma cell proliferation on hematoxylin-eosin stain, suggesting possible syphilis [Figure 3].
Follow-up FDG PET/CT (A) after penicillin therapy shows decreased FDG uptake in the right inguinal lymph node (arrow). Follow-up CT scan of the chest (B) obtained 2 months after discharge shows complete disappearance of the pulmonary nodules
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After 1 week, PET/CT scan showed a decrease in the FDG uptake (max SUV - 5.2) in the involved lymph nodes [Figure 4A]. Two months after discharge, the patient returned for a follow-up evaluation and a CT scan showed complete disappearance of the pulmonary nodules [Figure 4B] with a further reduction in the size of the involved lymph nodes.