Hepatitis and a rash in an immunocompromised patient

Abstract

A 66-year-old female presented to the accident and emergency department with a rash and dull abdominal pain, predominantly in the right upper quadrant and epigastrium. She had no history of hepatobiliary or gastrointestinal disease. A background of mantle cell lymphoma was noted and at the time of presentation she was in her second remission following completed chemotherapy 4 months earlier. On examination, the rash was vesicular in nature and affected the limbs, trunk and face.A series of investigations, including plain radiography and blood tests, were performed on admission. Plain chest and abdominal radiographs were unremarkable. The blood test results confirmed a lymphopaenia 0.3 6 10 9 l -1 (normal range 1-4 6 10 9 l -1 ) and biochemical features consistent with hepatitis; alanine transaminase (ALT) 1062 IU l -1 (normal range ,55 IU l ). Hepatitis virus antibodies (hepatitis B and C) and antibody markers of autoimmune diseases were all negative. Shortly after admission, the patient's condition deteriorated and a contrast-enhanced CT scan of the abdomen and pelvis was performed (Figure 1 and 2). This enabled a specific diagnosis to be made and appropriate therapy was started. Following clinical recovery, the patient was discharged and a follow-up CT scan was obtained 3 months later. What are the abnormalities on the images and what is the cause?