PMC6604474_01
MRI of the brain showing hyperintense lesion in the right middle cerebellar peduncle lesion (a) and ring-shaped periatrial white matter lesion (b).
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Investigations done during the index hospitalization included brain MRI which showed T2-FLAIR hyperintense lesions in the juxtacortical, deep and periventricular white matter of the bilateral cerebral hemispheres, and infratentorial lesions in the right middle cerebellar peduncle, some with a ring-like appearance without enhancement (Figure 1).
Chest CT showing numerous small lung nodules.
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A 1.7 cm x 1.3 cm hypodense lesion was seen in the liver (Figure 2).
MRI abdomen showing 1.8 cm liver cyst (a) and 1.3 cm ovoid liver lesion (b).
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MRI abdomen noted a 2.3 cm liver lesion consistent with hemangioma, 1.8 cm cyst, and a 1.3 cm ovoid lesion (Figure 3).
PET-CT demonstrated 3 cm hypermetabolic liver mass seen on MRI.
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Due to concerns raised for abnormal liver lesions, a PET-CT done after hospital discharge demonstrated a 3 cm hypermetabolic liver mass concerning for neoplasm such as hepatocellular carcinoma, sarcoid nodule, or other granulomatous lesion and a resolution of the previously noted 1.7 cm subpleural nodule (Figure 4).
Surveillance CT abdomen/pelvis 3 months after the initial one showing numerous new tiny hepatic lesions.
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CT abdomen/pelvis 3 months after the initial one showed a resolving right hepatic hematoma but new numerous subcentimeter hypodense lesions throughout both hepatic lobes and numerous subcentimeter pulmonary nodules throughout both lungs (Figure 5). Concern for drug-related sarcoidosis or atypical mycobacterial infection was raised due to the multisystem involvement and drug exposure given reports in the literature.
(a) Lung biopsy demonstrating caseating granuloma, magnification 20x. (b). Lung biopsy demonstrating caseating granuloma, magnification 4x.
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He then underwent bronchoscopy followed by video-assisted thoracoscopic surgery (VATS) wedge resection, which revealed multiple caseating granulomas (Figures 6(a) and 6(b)).