0:01

So this is our companion case

0:02

to the congenital Heman Genoma case we saw earlier today.

0:05

So this was a four month old infant who had a urinary tract,

0:09

um, infection who came to imaging for renal ultrasound.

0:13

And so the tech starts off

0:14

with our typical retroperitoneal protocol

0:17

where we're looking at the kidneys.

0:19

But incidentally, when we're looking at the kidneys,

0:22

we happen to catch part of the liver parenchyma,

0:24

and we see these multiple hypo coic lesions scattered

0:28

diffusely throughout the liver parenchyma.

0:30

So everywhere we look, we start to see more

0:33

of these hypo coic liver lesions.

0:35

Um, we'll continue to follow our ultrasound protocol,

0:39

but basically normal right kidney, normal urinary bladder,

0:43

normal left kidney.

0:44

So the pertinent finding in this case is not

0:47

with the kidneys or urinary bladder at all,

0:49

but, um, incidental low density lesions scattered throughout

0:53

the liver and the text switch

0:55

to our linear high frequency transer to, to, um, better try

0:58

to see these hypo code lesions throughout the liver.

1:01

So the next thing we'll do is number one, we will, uh, look

1:05

for a primary tumor in the abdomen.

1:08

The most common, uh, uh, disease or, or,

1:12

or thing that we will see that will have multiple liver

1:14

lesions scattered throughout the liver is metastasis.

1:17

So we'll look for neuroblastoma

1:19

and wilms tumor as a primary, uh, site of cancer

1:23

that would present with liver metastases.

1:26

The good news is we don't see a primary

1:28

malignancy in this patient.

1:29

We have normal looking kidneys at ultrasound,

1:31

and we don't see any senal masses in this patient.

1:35

So the next thing we'll do is we'll ask our clinical

1:37

colleagues to do a good cutaneous examination looking

1:40

for any cutaneous infantile hemangiomas.

1:43

And then this patient, um, uh, was seen

1:45

by our vascular anomalies clinic

1:47

and went on to MRI as the next step for characterization

1:50

of these liver lesions.

1:53

So this patient went on to MRI to better characterize these,

1:56

uh, multiple liver lesions

1:57

and ensure there was no primary malignancy.

2:00

So we'll start with this, uh, axial T two fat saturated, um,

2:04

MRI sequence on the top left hand corner,

2:06

you can see normal thymus

2:08

surrounding this normal sized heart.

2:10

We do have bilateral atelectasis in this MRI

2:13

that was performed under sedation.

2:15

Um, and this is a nice correlate to

2:17

what we saw sono graphically.

2:19

So, um, at ultrasound there are a bunch

2:21

of hypo coic liver lesions scattered throughout the liver.

2:24

But on T two weighted imaging, we have T two, um,

2:27

hyper intense liver lesions in numerable of them, um,

2:32

scattered throughout all lobes of the liver.

2:35

This is helpful for us to tell.

2:36

There's no primary adrenal mass to suggest neuroblastoma,

2:41

and it's helpful for, um, confirming

2:43

that there's no primary, um, uh, liver lesion, I'm sorry,

2:47

splenic lesion to suggest this is metastatic wounds disease.

2:50

So this is the axial T two fat that, um, the coronal, uh,

2:55

the coronal T two weighted, uh,

2:57

series shows similar appearance of innumerable varying size,

3:01

but small, um,

3:03

T two hyperintense lesions scattered

3:05

diffusely throughout the liver.

3:07

On our post contrast, which is this, uh,

3:09

bottom right hand side, I'm gonna blow it up.

3:11

We did dynamic post contrast to be able

3:13

to look at the vascular enhancement of this.

3:15

So we'll start with your arterial phase

3:17

or aorta is enhancing first,

3:20

and we have just very subtle hyper enhancement of,

3:24

of these lesions scattered

3:25

throughout the, throughout the liver.

3:27

Um, it's, they're pretty hard to tell that,

3:29

that there indeed are lesions here,

3:32

but here, here for an example is one such lesion

3:35

that is hyper enhancing subtly compared

3:37

to the background liver parenchyma.

3:40

And as we continue through our dynamic post con, um,

3:43

post contrast series axial, um, the really,

3:47

now the liver just looks very heterogeneous,

3:49

looks homogeneously enhancing.

3:51

Um, I don't really see any lesions as we go on

3:54

through portal venous and late portal venous phase

3:57

of imaging, but we did this

3:59

with a hepatocyte specific contrast agent, um, to be able

4:03

to help characterize these lesions.

4:05

And so on our hepatobiliary phase MRI, we see

4:08

that there is low signal

4:10

or no contrast retention

4:12

of these innumerable lesions scattered throughout the liver.

4:16

So this is a classic appearance for infantile hemangiomas

4:20

and, um, when you have such diffuse involvement,

4:23

you could consider this to be hemangiomatosis,

4:26

so innumerable infantile hemangiomas throughout the liver.

4:30

So in contrast to congenital hemangiomas,

4:33

infantile hemangiomas are usually multiple, um,

4:37

when there is liver involvement

4:38

and they are associated

4:40

with the q the identical lesion on the surface of the skin.

4:43

So cutaneous, infantile hemangiomas also pathologically,

4:48

these are vascular tumors.

4:49

They stay glute one positive at pathology

4:53

and it is important to make this diagnosis

4:55

because infantile hemangiomas are sensitive

4:58

to beta blocker therapy.

5:00

So they treat these infants with propanolol if,

5:03

if there is such extensive involvement such as this case,

5:06

because that will cause the infantiles to involute.

5:11

Um, so they'll shrink

5:12

and they all, they, they won't cause problems anymore.

5:15

Um, one other interesting thing about infantile hemangiomas

5:18

is that they are a vascular tumor that express type three,

5:22

um, dia oto sase.

5:24

So it's a, it's a enzyme

5:26

or a a, it's a, a substance that these tumors express

5:30

that inactivate thyroid home hormone.

5:33

So this is the other reason it's important to distinguish

5:36

between congenital hemangiomas and infantile heman is

5:39

because these patients might have problems related

5:41

to hypothyroidism.

5:43

So that's another thing you can tell your clinicians

5:45

to be on the lookout for when you make the diagnosis

5:48

of infantile hemangiomas.

5:50

So congenital, hes present at birth or large

5:54

and cause problems related to vascular shunting,

5:57

Infantile hemangiomas present within the few,

6:00

the first few weeks to months of life.

6:02

So not present at birth, but rather they develop later on

6:05

and they cause issues not only related to shunting, but also

6:09

because of, um, hypothyroidism.

6:11

They can also cause mass effect.

6:12

And if they're on the surface

6:13

of the skin in an important area, they can grow, um,

6:17

as the child grows

6:19

and they can cause issues related to ulceration

6:22

or, um, as they enlarge they might cause compression

6:25

of important vascular structures.

6:27

Um, so a case of companion case of infantile heman illness.