14 Differential Diagnostic Tables

J.L. BLOEM, A. SPILT, P. VANHOENACKER, B. Op DE BEECK, J. DELANOTE, H. RIGAUTS,

L. STEYAERT, F. VANHOENACKER, A.M. DE SCHEPPER, and F. DECKERS

Table 14.1. Splenomegaly (table by J.L. Bloem and A. Spilt)

Splenomegaly with abnonnal porlal or splenic blood flow

Splenomegaly without morphological abnormalities; hematologic disorders

Splenomegaly without morphological abnormalities; infectious diseases

Common

Congestive heart failure Hepatic cinhosis

Early sickle cell anemia Nutritional anemias Leukemias Hodgkin's disease Non-Hodgkin's lymphoma

Infectious mononucleosis Acquired immune deficiency syndrome Viral hepatitis Cytomegalovirus Subacute bacterial endocarditis Malaria Sepsis Other infections (especially in children)

Splenomegaly without morphological Rheumatoid arthritis abnormalities; miscellaneous Felty's syndrome

Drug reactions

Massive splenomegaly Chronic congestive splenomegaly Chronic malaria Chronic myelogenous leukemia Myeloproliferative disorders

Uncommon

Cavernous transformation of the portal vein Splenic vein obstruction Hepatic echinococcosis Splenic artery aneurysm Hepatic vein obstruction Portal vein obstruction Other causes of portal hypertension Hepatic schistosomiasis

Ovalocytosis Spherocytosis Thalassemia major Paroxysmal nocturnal hemoglobinuria Hemoglobinopathie Immune hemolytic anemias Immune thrombocytopenias Immune neutropenias Myelofibrosis Marrow damage Marrow infiltration Myeloproliferative syndromes Langerhans' cell histiocytosis

Congenital syphilis Bacterial septicemia Histoplasmosis Leishmaniasis Trypanosomiasis Tuberculosis

Systemic lupus erythematosus Sarcoidosis Angioimmunoblastic lymphadenopathy Thyrotoxicosis Serum sickness Gaucher's disease Metastatic tumors Lymphoma

Sarcoidosis Leishmaniasis Gaucher's disease

iemann-Pick disease Longstanding thalassemia major Hairy cell leukemia Congenital syphilis

A. M. Schepper et al. (eds.), Medical Imaging of the Spleen

© Springer-Verlag Berlin Heidelberg 2000

148

Table 14.2. Solitary focal lesions (table by P. VANHOENACKER)

Cystic lesions

Solid lesions

Calcified masses or cysts

Common

Post-traumatic cyst Epidermoid Cystic degeneration of infarct Pancreatic pseudocyst Necrotic metastases Hematoma

Malignant: Metastases (melanoma, islet cell tumor, breast, lung, colon, renal cell, ovarium, pancreas) Lymphoma

Benign: Hemangioma Infarct Hematopoietic Hematoma

Abscess Tuberculous

• Pyogenic

Hematoma Vascular

Splenic artery Splenic artery aneurysm Infarct

Calcified cyst Congenital Post-traumatic Hydatid cyst Cystic dermoid

eoplasm Chondroma Osteoma Treated and aggressive lymphoma Hemangioma/lymphangioma Hamartoma

Table 14.3. Multiple focal lesions (table by B. Op DE BEECK)

Multiple splenic calcifications

Common

Phleboliths Healed granulomas (tuberculosis, histoplasmosis) Acquired immune deficiency syndrome Healed Pneumocystis infection Hemangiomas

Uncommon

Hydatid cyst Abscess Cavernous hemangioma Lymphangioma

Malignant: Angiosarcoma

. Fibrosarcoma

Benign: Hamartoma Lymphangioma Myxoma Chondroma

• Osteoma

Uncommon

Infarcts Hamartomas Brucellosis Hemosiderosis SickJe cell anemia Echinococcal cysts Epidermoid cysts Post-traumatic cysts Healed abscesses

J.L. Bloem et al.

Armillifer armillatus infestation Collagen vascular diseases Amyloidosis Gamna-Gandy bodies

Differential Diagnostic Tables

Table 14.3. (Continued)

Multiple hypoechoic splellic masses

Multiple echogenic splenic masses

Multiple hypodense splenic lesions; 1l0n-cOlltrast scan

Multiple Iryperdense splenic lesions; non-contrast scan

Common

Lymphoma Infarcts Metastases Septic emboli Abscesses (pyogenic, fungal)

Calcified granulomas Metastases Chronic infarcts Hematomas

Lymphoma Metastases Infarcts Abscesses Granulomatous disease (tuberculosis, MAl, sarcoidosis, cat-scratch disease)

Calcified granulomas Hemorrhagic acute infarcts Acute hemorrhage (post-traumatic. spontaneous)

Multiple hyperintellse spleuic masses Infarcts on T2-weiglrted images Metastases

Multiple hypointense spleTlic masses 011 T2-weighted images

Multiple predomillantly Irypointense splenic masses on immediate post­gadolillium TI-weighted spoiled gradient-echo images

Septic emboli Abscesses (pyogenic, fungal) Subacute hemorrhage

Gamna-Gandy bodies Healed granulomas Healed infarcts

Lymphoma Infarcts Metastases Hematomas Septic emboli Abscesses (pyogenic, fungal) Healed granulomas

MAl, mycobacterium avium intracellulare.

149

Uncommon

Granulomatous disease (tuberculosis, MAl, sarcoidosis, cat-scratch disease) Cysts (simple, epidermoid, hydatid. pancreatk) Hemangiomas Hamartomas Lymphangiomatosis Disseminated Pneumocystis carinii infection Langerhans' cell histocytosis

Plasmocytomas Abscesses with air bubbles Hereditary spherocytosis Schistosomiasis Hydatid "sand" in hydatid cysts

iemann-Pick disease

Congenital or traumatic cysts Echinococcal cysts Hemangiomas Hamartomas Lymphangiomatosis Extramedullary hematopoiesis

iemann-Pick disease

Mucinous metastases (colon. stomach. pancreas) Hydatid infection Pneumocystis infection (healed) Calcified hematomas Hemangiomas complicated by rupture and hemorrhage Complicated cysts attributable to intracystic hemorrhage or infection

Cysts (posttraumatic, epidermoid. hydatid) Acute granulomatous disease Hemangiomas Hamartomas Lymphangiomas

iemann-Pick disease

Lymphoma Sarcoidosis Sickle cell disea.se

Cysts (posttraumatic, epidermoid. hydatid) Hemangiomas Lymphangiomatosis Sarcoidosis

150 J.L. Bloem et a1.

Table 14.4. Abnormal diffuse alteration of reflectivity on ultrasound (table by J. DELANOTE, H. RIGAUTS and L. STEYAER T). For abnormal reflectivity in solitary focal lesions, see Table 14.2; for abnormal reflectivity in multiple focal lesions, see Table 14.3

Increased reflectivity Diffuse small nodules with deposition of calcium or iron

Diffuse small nod Illes without deposition of calcium or iron

Diffuse or patchy

Multiple channel-like

Decreased reflectivity Diffuse small nodules

Diffuse or patclly

Common

Phleboliths; calcified hemangioma Healed granulomas (tuberculosis, histoplasmosis)

Metastases (ovary, thyroid) Inflammatory (BBS) Lymphoma

Hematoma Lymphoma

Myelofibrosis (hypersplenism) Infarction (chronic) Portal vein thrombosis

Portal hypertension [cirrhosis, congestive splenomegaly (Banti syndrome) I Arterial calcifications

Lymphoma Myeloproliferative diseases

Hematoma Lymphoma Myeloproliferative diseases Infarction Metastases

BBS, Besnier Boeck Schaumann; MAJ, mycobacterium avium intracellulare.

Uncommon

Infectious (Pneumocystis carinii, hydatid cysts, brucellosis. hamartomas) Inflammatory (BB ) Hemosiderosis Gamna-Gandy bodies Transfusion related hemochromatosi Infarction Sickle cell anemia Thorotrast residuals Collagen vascular diseases (rheumatoid arthritis, systemic lupu erythematosus) Amyloidosis

Storage disease [Gaucher's disease, iemann-Pick disease (type B/C))

Hereditary spherocyto i

Opportunistic infections (Pneumocystis, cytomegalovirus, MAl. Candida albicans)

eoplasm (leukemia, metastases, angio arcoma) Hemangioma (atypical) Punctate calcifications (sickle cell anemia, thorotrast, Pneumocystis carinii, malaria) Gaucher's disease (infarction) Spherocytosis, hereditary Intrasplenic gas Extramedullary hematopoiesis (myeloproliferative disease, aplastic anemia) Spontaneous splenic rupture (mononucleosis, sickle cell disease) Oysgammaglobulinemia

Sarcoidosis Infection - Bacterial (miliary tuberculosi , MAl,

bacterial endocarditis) - Fungal (candidiasis, aspergillus.

histoplasmosis) - Parasital (echinococcus, schistosomiasis.

malaria) Metastases (melanoma, lung, breast) Storage disease (Gaucher's disease) Langerhans' cell histiocytosis Bacillary angiomatosis (cat-scratch disease)

Acute infectious diseases (viral infections) Chronic infectious diseases (tuberculosis, malaria, brucellosis) Gaucher's disease Wegener's granulomatosis

Differential Diagnostic Tables 151

Table 14.5. Abnormal diffuse alteration of attenuation on CT (table by F. VANHOENACKER and A. M. De SCHEPPER). For abnormal attenuation in solitary focal lesions, see Table 14.2; for abnormal attenuation in multiple focal lesions, see Table 14.3

High density before IV contrast administration

Low del/sity before IV contrast administration

IlIlrasplenic gas

Heterogel/eous attel/uation on pre-contrast images

Heterogeneorls 017 post-colllTast images (110 splenomegaly)

Heterogeneous on post-call trast images (witll splenomegaly)

IV, intravenous.

Common

Calcifications (Table 14.3) Hemosiderosis Transfusion-related hemochromatosis

Hematoma, subcapsular or inlrasplenic Infarction (atheromatosis, sickle cell disease) Lymphoma Metastases

Hematoma (trauma)

ormal transient heterogeneity after bolus injection of contrast medium Lymphoma Infiltrating metastatic disease Direct tumor exten ion from tumors outside the spleen Multiple infarcts Multiple absces es or septic emboli

Myeloproliferative diseases Lymphoma

Uncommon

Thorotra t exposure Pseudo-thorotrast spleen (sickle cell disease) Lymphangiogram contrast Calcified hemangiomatosis Gamna-Gandy bodies

Abscesses Angiosarcoma Peliosis

Necrosis (infarction, lymphoma, tumor, postembolization) Abscess

Spontaneous splenic rupture (Table 14.8) orne angiosarcoma

Hemangiomatosis Sarcoidosis Cat-scratch di ease BaciJlary angiomatosis Tuberculosis Wegener's granulomatosis

sequestration crisis Peliosis

of acute

Mycobacterial infection (acute) Pneumocy ti carinii Fungal infections Disseminated Kaposi sarcoma Cat-scratch di ease Gaucher's disease

iemann-Pick di ease Langerhans' cell histiocytosis Amyloidosis Other storage diseases Angiosarcoma (large) Hemangiomatosis Lymphangiomatosi

152 J.L. Bloem et al.

Table 14.6. Abnormal signal intensity (SI) on magnetic resonance imaging (table by F. DECKERS and A.M. De SCHEPPER)

Common

High-SI TI, high-Sl T2

High-51 TI, low-51 T2

Low-Sl TI, high-51 T

Isointense-SI TI, high- I T2

Low-Sl TI, low-Sl T2

Isoilltense-SI TI, low-51 T2

Uncommon

Subacute hematoma Hemorrhagic infarction Hemorrhagic metastasis

Lymphoma Infarction Abscess Meta tasis

Lymphoma Metastasis

Lymphoma Abscess Fungal absces , acute Fungal abscess, treated Metastasis

Lymphoma Metastasis

Hemosiderosis Lymphoma Gamna-Gandy body Fungal abscess, healed

ormal neonate spleen Chemotherapy

Lymphoma Chemotherapy

Hemorrhagic cyst Splenic sequestration Hemorrhagic lymphangioma Hemorrhagic angiosarcoma Melanoma metastasis Hemorrhagic lymphoma

iemann-Pick disease

Inflammatory pseudotumor

Cyst, primary Cyst, secondary Hemangioma Lymphangioma Wegener's disease

Hamartoma Lymphangioma

iemann-Pick nodule

Sickle-cell disease Angiosarcoma Epithelioid vascular tumor Littoral cell angioma Sarcoidosis

Inflammatory pseudotumor Gaucher's-disease nodule

Table 14.7. Abnormal patterns on Gd-enhanced magnetic resonance imaging (table by F. DECKERS and A. M. DE SCHEPPER)

I o enhancement

Laceration Infarction (rim sign) Gamna-Gandy body Cyst Subcapsular hematoma Lymphangioma

Early enhancement

Inflammatory pseudotumor Hemangioma (persistent) Hamartoma (persistent)

No enhancement, obscured on late images

Lymphoma Meta tasis

Late enhancement

Hemangioma (centripetal) Abscess (rim) Lymphangioma (septae) Angiosarcoma (persistent)

Differential Diagnostic Tables

Table 14.8. Spontaneous (non-traumatic) splenic rupture (table by F. VANHOENACKER and A.M. De SCHEPPER)

Illfectiolis disease

Neoplastic disease

NOIHleoplastic /temat%gic disease

(Cardio)vasClilar disease

Systemic disease

M iscellaneolls

Reference

Common

Infectious mononucleosis Malaria

Acute leukemia Lymphoma

Splenic vein thrombosis Congestive splenomegaly Splenic infarcts

Uncommon

Typhoid fever Typhus Influenza Viral hepatitis Tuberculosis Actinomycosis Brucellosis Tularemia AspergiUosis Syphilis Kala-azar Meningococcal septicemia Virus-associated hematophagocytic syndrome Yaws

Metastases Hemangioma Angiosarcoma Myeloproliferative di ease Plasmocytoma Plasma cell leukemia

Congenital afibrinogenemia Hemophilia Hemolytic disease of the newborn Autoimmune hemolytic anemia Congenital hemolytic anemia

Infectious endocarditis Mycotic aneurysms Peliosis

Crohn's disea e Rheumatoid arthritis Felty's syndrome Systemic lupus erythematosus Polyarteritis nodosa Wegener's granulomatosis Amyloidosis arcoidosis

Gaucher's disease Glycogen storage di ease Langerhans' cell histiocytosi

pontaneous rupture in normal spleen Ectopic pregnancy Pregnancy or during labor

153

Dachman AH, Coldwell DM (1993) Trauma and nontraumatic rupture. In: Dachman AH, Friedman AC (eds) Radiology of the spleen. Mosby Year Book, SI. Louis, pp 88-90

J.1. BLOEM, A. SPLIT; Department of Radiology, Leiden University Medical Center, Rijnsburgerweg 10,2300 RC Leiden, The Netherlands P. VANHOENACKER; Department of Radiology, O. 1. V. Ziekenhuis, Moorselbaan 164, B-9300 Aalst, Belgium B. OP DE BEECK; Department of Radiology, Academisch Ziekenhuis-Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium J. DELANOTE, H. RIGAUTS; Department of Radiology, Algemeen Ziekenhuis SI. Jan Brugge, Ruddershove 10, B-8000 Brugge, Belgium 1. STEYAERT; Department of Radiology, Algemeen Ziekenhuis SI. Jan Brugge, Ruddershovelaan 10, B-8000 Brugge, Belgium F. V ANHOENACKER, A.M. De Schepper; Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium F. DECKERS; Department of Radiology, SI. Augustinusziekenhuis, Oosterveldlaan 24, B-261O Wilrijk, Belgium