1. Case Report # 1 Submitted By: Samuel Oats, MSIV Radiological Category: Body Principal Modality (1): Principal Modality (2): PET/CT CT Faculty Reviewer: Sandra Oldham, MD Date accepted: August 28, 2014

2. Case History 75 year old female with intermittent fever, headache, arthralgia, night sweats, and weight loss since March 2014

3. Radiological Presentations

5. Histoplasmosis Lymphoma Metastases Tuberculosis Splenic Infarction Hydatid Cyst Sarcoidosis Which one of the following is your choice for the appropriate diagnosis? After your selection, go to next page. Test Your Diagnosis

6. On CT, there are multiple splenic hypodensities, the largest of which measures 1.6 by 1.5 cm. There is bilateral adrenal enlargement and an enlarged left iliac lymph node measuring 19 mm (normal <15 mm in the pelvis). On PET-CT, there is increased FDG uptake in the aforementioned splenic lesions, bilateral diffuse uptake in the adrenal glands, and scattered FDG uptake throughout the abdomen, pelvis, and bone marrow. Histoplasmosis Lymphoma Metastases Tuberculosis Splenic Infarction Hydatid cyst Sarcoidosis Findings: Differentials: Findings and Differentials

7. Splenic Infarction -May occur due to atherosclerotic emboli, Sickle cell disease, endocarditis, ateritis, hypercoagulable states, etc.. Wedge-shaped defects extending to the intact splenic capsule Often occur in the setting of splenomegaly Multiple infarcts may fuse, resulting in loss of the wedge shape Discussion

8. Hydatid Cyst -Echinococcus granulosis aka dog tapeworm -Splenic lesions found in only 2% of patients with hydatid disease -In spleen involved, cysts are also usually present in the liver or lung -Calcified rim in chronic lesion Discussion

9. Splenic Granulomas May be seen with histoplasmosis, TB, or sarcoidosis May be calcified but not necessarily so Discussion

10. Metastases Rare: only 7% of autopsied cancer patients have splenic involvement Most commonly seen with melanoma, lung, ovarian, gastric, and prostate cancer Usually splenic metastases are microscopic and not detectable on imaging Discussion

11. Non-Hodgkin’s lymphoma is the most common hematological neoplasm, with 85% of B-cell origin. The median time of diagnosis is during the sixth decade. Symptoms may include painless peripheral adenopathy, fever, fatigue, etc. The most common malignant tumor of the spleen is lymphoma. CT is 65% sensitive for splenic involvement, and patterns seen can include splenomegaly, miliary nodules, or a single large mass. Importantly, when the spleen is involved in lymphoma, adenopathy is often seen elsewhere in the abdomen. In this case, a right iliac wing biopsy was obtained, and the pathology work-up revealed diffuse large B-cell lymphoma. Discussion

12. Non-Hodgkin Lymphoma (Diffuse Large B Cell) Diagnosis

13. 1. Brant, W.F. Helms, C. A. Fundamentals of Diagnostic Radiology. Fourth Edition. Lipincott Williams and Williams. 2012. 2. Abdominal lymphadenopathy: Spectrum of CT findings. Radiographics. 1991 May; 11(3):457-72 3. Isolated splenic tuberculosis: A case report. World J Gastrointest Pathophysiol. 2010 Aug 15;1(3):109-11. doi: 10.4291/wjgp.v1.i3.109. 4. Non-Hodgkin Lymphoma. http://emedicine.medscape.com/article/203399-overview July 21, 2013. 5. Whole body FDG PET and Staging of Non-Small-Cell Lung Cancer. http://www.med.harvard.edu/JPNM/TF99_00/Jan18/WriteUp.html. January 18 th, 2000. 6. Splenic lesions and anomalies. http://radiopaedia.org/articles/splenic-lesions-and- anomalies August 26 th 2014 References