Fungal liver infection mimicking hepatic malignant tumor on contrast enhanced ultrasound

Rational: Fungal liver infection mostly occurs in immunocompromised patients, and is often associated with delayed diagnosis and high mortality rates. Dynamic contrast enhanced imaging is crucial for the diagnosis of fungal liver infection and has been reported having variable manifestations. Patient concerns: A 38-year-old Chinese man, with a history of diabetes and chronic hepatitis B, was admitted to our hospital due to prolonged fever of unknown cause. He had a medical history of receiving broad-spectrum antibiotic treatment for pulmonary inflammation at the local hospital. The blood test results showed that the white cell count (14.0 × 10 9 /L) and neutrophil count ratio (77.0%) were subtly elevated. C-reactive protein (92.0 mg/l) and cancer antigen (CA)-125 (904.50 U/ml) were elevated. Non-small cell lung cancer antigen was within the normal limit. Hepatitis B virus DNA load was 3.28 × 10 3  IU/ml. Sputum and blood cultures were normal. Abdominal ultrasonography (US) found a large heterogeneous mass, with diffused echogenic foci without infiltrating the surrounding vascular, which exhibiting “rapid wash in and out” on contrast-enhanced ultrasound (CEUS). Diagnosis: The diagnosis of liver fungal infection was confirmed pathologically via ultrasound-guided biopsy. Interventions: Antibiotic and antifungal therapy with imipenem and voriconazole. Outcomes: The patient's body temperature had been controlled and the huge mass disappeared on follow-up ultrasound 1-year later. Lessons: This case highlights the unusual imaging features of fungal liver infection, presenting as huge heterogeneous mass with diffusive echogenic foci without infiltrating the surrounding vascular on grayscale US and the enhancement pattern of “rapid wash in and out” on CEUS. Additionally, ultrasound-guided biopsy is necessary for the correct diagnosis of suspected liver lesions.