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A child with multiple liver and spleen nodules during therapy for acute lymphoblastic leukaemia
  1. Laura De Nardi1,
  2. Samuele Naviglio2,
  3. Elena Battistuz1,
  4. Valentina Kiren2,
  5. Elisabetta Cattaruzzi3,
  6. Egidio Barbi4,
  7. Marco Rabusin2
  1. 1 Clinical Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
  2. 2 Department of Oncohematology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
  3. 3 Department of Radiology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Friuli-Venezia Giulia, Italy
  4. 4 Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
  1. Correspondence to Dr Laura De Nardi, University of Trieste, Trieste, Italy; laura.denardi1993{at}gmail.com

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A 6-year-old boy affected by high-risk B cell acute lymphoblastic leukaemia (ALL) was evaluated for persistent, non-localising, abdominal pain after having successfully completed the reinduction phase of high-dose chemotherapy protocol for ALL. On admission, he was in good general condition and afebrile. Physical examination was unremarkable apart from mild abdominal tenderness on palpation at the upper quadrants. Blood tests showed increased C reactive protein (193 mg/L) and ferritin (3286 ng/mL) levels, with normal neutrophil count (2000 /µL) and normal serum transaminases and pancreatic amylase. An infectious disease workup, including blood, urine and stools cultures, blood viral PCR assay, blood galactomannan and beta-D-glucan antigens was negative. A CT of the chest and paranasal sinuses was normal. An abdominal ultrasound showed multiple hypoechoic nodules of 0.5–1 cm diameter, with a feathered border, involving both the liver and the spleen parenchyma (figure 1).

Figure 1

B-mode ultrasound shows multiple hypoechoic nodules 0.5–1 cm of maximum diameter involving hepatic and splenic parenchyma.

Test your knowledge

Question 1

What is the most likely diagnosis?

  1. Leukaemic infiltration

  2. Bartonellosis

  3. Chronic disseminated candidiasis (CDC)

  4. Tuberculosis

Question 2

What would be the next diagnostic step?

  1. Contrast-enhanced MRI

  2. Contrast-enhanced CT

  3. Liver biopsy

  4. Positron emission tomography (PET)

Question 3

How should this child be managed?

  1. Watch and wait

  2. Long-term antimycotic therapy and adjuvant corticosteroids

  3. Antibiotic therapy with doxycycline

  4. Rifampicin, pyrazinamide, ethambutol and isoniazid

Answers can be found on page 2 .

ANSWERS TO THE QUESTIONS ON PAGE 1

Answer 1. C

CDC, also known …

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Footnotes

  • Twitter @SNaviglio

  • Contributors LDN drafted the manuscript. EC performed MR and processed images. EB, VK and MR contributed to the conception of the work. SN and EB critically revised the article for relevant intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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