Unenhanced CT scan, shows a remarkably increased density of the liver and spleen.
MPR coronal view unenhanced CT scan shows moderate splenomegaly and increased, inhomogeneous density of the spleen and liver
normal aspect of liver.
Clinical photography of the hands shows typical chronic changes by rheumatoid arthritis

Gold storage

By pasquale La Pietra


Storia clinica: 73-year old man, by long time suffering from a severe form of rheumatoid arthritis, is admitted to radiology department to perform a non-Enhanced Computed Tomography (NECT) for a better assessment of several vertebral collapses, detected on the radiographs performed at another hospital following of an incidental fall.
NECT has confirmed the multiple vertebral collapses and noted an unusual appearance of liver and spleen, characterized by a remarkably rise of density of these organs with a few areas of relatively lower density.
Laboratory tests were unremarkable for liver diseases.
For further assessment of these unusual findings a ultrasounds examination was performed has showed normal aspect of spleen and liver.


Reperi:

CT 1: Unenhanced CT scan, shows a remarkably increased density of the liver and spleen. :: CT 1 ::
Unenhanced CT scan, shows a remarkably increased density of the liver and spleen.







CT 2: MPR coronal view unenhanced CT scan shows moderate splenomegaly and increased, inhomogeneous density of the spleen and liver :: CT 2 ::
MPR coronal view unenhanced CT scan shows moderate splenomegaly and increased, inhomogeneous density of the spleen and liver







Ultrasound 1: normal aspect of   liver. :: Ultrasound 1 ::
normal aspect of liver.







OP 1: Clinical photography of the hands shows  typical chronic changes by rheumatoid arthritis :: OP 1 ::
Clinical photography of the hands shows typical chronic changes by rheumatoid arthritis









Discussione:
Modifications of the density of liver and spleen are very common; especially the focal reductions of attenuation, due to presence of cysts, tumors or inflammatory lesions; much less frequent are widespread increases of their density.
This condition can be caused by some glycogen storage diseases [1] or from accumulation, in the reticuloendothelial system, of certain metals such iron (haemochromatosis and haemosiderosis) or copper as in wilson s disease [2].
Other cause can be, a previous administering of certain medications as amiodarone or gold salts.[3-4-5].
More rarely, this condition is due to previous administering of thorotrast; a contrast medium extensively used in radiologic practice until the mid-fifties.
In our case the patient had no history of metabolic disorders or of administering to amiodarone or thorotrast; but his severe rheumatoid arthritis was treated for long time, with parenteral colloidal gold therapy, in the past, commonly used to preventing joint damage of disease.
The gold particles are removed from bloodstream by the reticuloendothelial system of spleen, liver and lymph nodes and here permanently stockpiled [4].
The high atomic number of gold causes the increase of attenuation with hyperdensity on the CT scan images of the involved organs.
This iatrogenic condition is very little reported because of its rarity and the difficulty to detect this anomaly that can be detected only on computed tomography.
The other imaging modalities are unable to observe this curious, iatrogenic condition,
the conventional radiography, for la lesser contrast resolution compared to ct scan, can not detect this anomaly, the gold particles does not interfere with the ultrasounds and not being a ferromagnetic metal does not alter the signal of magnetic resonance imaging.
These imaging techniques showing hence a normal structure of the affected organs [5].
based on these findings and of history of previous treatment with colloidal gold; a diagnosis of gold storage was suggested.
In the absence of histologic proof, this diagnosis remains speculative also if probably true; but considering the risks of an invasive procedure on an elderly man, that patient have by long since discontinued the gold therapy, the absence of symptoms or alterations of laboratory tests, the liver biopsy was not performed and these incidental findings, were considered as chronic changes by the side effects of previous gold therapy.




Diagnosi differenziale: haemochromatosis and haemosiderosis, Wilson s disease, Thorotrast administration, Amiodarone administration

Comferma diagnosi: Imaging including endoscopy



categoria: Gastrointestinal

Regione/organo: Abdomen-Liver

Eziologia: metabolic

Bibliografia:
Boll DT, Merkle EM. (2009) Diffuse liver disease: strategies for hepatic CT and MR imaging.. Radiographics Oct;29(6):1591-614.

Mergo PJ, Ros PR, Buetow PC, Buck JL. (1994) Diffuse disease of the liver: radiologic-pathologic correlation.. Radiographics. Nov;14(6):1291-307.

Srinivasan R, Dean HA. (1997) Thorotrast and the liver revisited.. J Toxicol Clin Toxicol. 35(2):199-202.

De Maria M, De Simone G, Laconi A, Mercadante G, Pavone P, Rossi P. (1986) Gold storage in the liver: appearance on CT scans.. Radiology. May;159(2):355-6.

Bartalena T, Rinaldi MF. (2010) Hyperdense spleen after prolonged gold therapy.. CMAJ. Dec 14;182(18):E858.




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