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Abdomen » Spleen
Chronic disseminated candidiasis
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Presentation A 14 year old female patient, with confirmed acute myeloid leukaemia post chemotherapeutic treatment, readmitted to hospital because of relapse of primary illness. During another course of chemotherapy she had an abdominal ultrasound examination, which revealed changes shown in the images here.
Caption: Longitudinal sonographic image of the spleen
Description: The spleen shows the presence of multiple small, discrete, rounded hypoechoic foci. These are scattered randomly throughout the spleen.
Caption: Longitudinal sonographic image of the spleen
Description: Multiple hypoechoic foci are noted again in the spleen.
Caption: Sonographic image obtained with 8.0 MHz linear probe
Description: Color Doppler imaging demonstrated no flow inside the hypoechoic foci.
Differential Diagnosis Abscesses (fungal, pyogenic or granulomatous)
Leukemic infiltration or lymphoma of the spleen 
Gaucher's disease (splenic masses) 
Cat scratch disease
Final Diagnosis Chronic disseminated candidiasis in a patient with neutropenia
Discussion Chronic disseminated candidiasis (CDC) is a severe fungal infection that occurs mainly in patients with immunodeficiency. (1) In pediatric practice this problem usually affects children with immunosuppressive treatment of hemato-oncologic diseases. Diagnosis of chronic disseminated candidiasis is quite difficult but nowadays imaging methods seem to be very helpful.  MRI is the most specific imaging examination, but has limited utility; in contrast, ultrasound can be repeated many times and has similar specificity. There are some sonographic futures of enlarged liver and spleen which can suggest chronic disseminated candidiasis like hypoechoic irregular shaped lesions or “wheel in wheel” sign, mainly in the liver suggesting micro abscesses, or nonhomogeneous micronodular parenchymal reflex pattern  later changing into focal lesions. (2) In our case, the diagnosis of fungal abscesses was most probable, because of the changes seen in ultrasound examination ( in enlarged spleen and kidneys), blood cultures (Candida glabrata)  and improvement after intensive antifungal treatment.
Case References 1. Aisha Masood, Sabah Sallah. Chronic disseminated candidiasis in patients with acute leukemia: emphasis of diagnostic definition and treatment. Leukemia Research 2005; 29:493-501.
2. M. Karthaus, G. Huebner, C. Elser et al. Early detection of chronic disseminated Candida infections in leukemia patients with febrile neutropenia: value of computer-assisted serial ultrasound documentation. Ann Hematol 1998; 77: 41-45.
Follow Up After antifungal treatment with lipid formulations of Amphotericine B was performed, blood cultures were negative, and other laboratory tests and sonographic image improved.
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