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Abdomen » Spleen
Splenic and hepatic abscesses in a child with acute lymphocytic leukemia
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Presentation A 2 year old child underwent treatment for acute lymphoid leukemia. Subsequently, the child presented with fever and abdominal tenderness.
Caption: Sagittal image of the spleen and left kidney.
Description: The spleen is enlarged and multiple, small hypoechoic masses are present in the spleen.
Caption: Color Doppler image of the spleen.
Description: Several of the hypoechoic masses show peripheral color Doppler signals.
Caption: Sagittal sonogram of the liver.
Description: Multiple hypoechoic lesions are identified, similiar to the splenic masses.
Differential Diagnosis Leukemic infiltration or lymphoma of the spleen 
Abscesses (fungal, pyogenic or granulomatous) 
Gaucher's disease (splenic masses) 
Final Diagnosis Hepatic and splenic microabscesses.
Discussion In the setting of acute lymphoid leukemia, infiltration of the spleen by leukemic cells can result in multiple hypoechoic masses. However, the differential diagnosis includes infection, with abscesses due to bacteria, fungus or granulomatous infection. The definitive diagnosis may require ultrasound guided aspiration, which in this case confirmed an infectious etiology. Color Doppler may be helpful, as the presence of vascularity (demonstrated in this case), favors an inflammatory or infectious etiology.

In the liver and spleen, an abscess may present as a solitary lesion, or multifocal masses may be identified. In immunocompromised patients, fungal abscesses are more commonly multifocal, like this case. Abscesses due to fungal infection (Candida albicans, Aspergillus fumigatus, Cryptococcus neoforms) are usually very small, with a 'bull's eye' or 'target' configuration. The differential diagnosis of multiple small hypoechoic masses in the liver and spleen includes Mycobacterial infection and Pneumocystis Carinii, particularly in immunocompromised patients.

Less common diseases which can present with multiple splenic masses include Gaucher's disease and sarcoidosis, as well as Cat Scratch Fever.
Case References Paterson A, Frush DP, Donnelly LF et al. A pattern-oriented approach to splenic imaging in infants and children. Radiographics 1999; 19: 1465-1485.
Technical Details ATL HDI 3000 7-4 MHz convex transducer
Follow Up Percutaneous aspiration confirmed an infectious etiology and antibiotics were administered.
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