This week’s case highlights a patient presenting with scleral icterus. The total bilirubin was elevated and imaging revealed lung nodules of unknown etiology. We discussed the differential work-up for hyperbilirubinemia in a teenager and the challenges of admission vs. discharge without a clear diagnosis. Ultimately, we came to the consensus that the patient should be admitted for additional imaging studies that may require timely intervention.

MRCP completed which did not show any stones, nut did not mildly prominent CBD (5mm) and prominence of the central intrahepatic biliary ducts without significant peripheral intrahepatic ductal dilatation. No discrete hepatic focal lesions noted but liver parenchyma commented to be very heterogenous. Unexpected lung findings noted bibasilar pulmonary nodules and CT chest/abdomen were recommended. 

CT Impression: 

1. Innumerable bilateral pulmonary nodules, some are pleural-based but most are intraparenchymal 

2. Mild hepatomegaly with diffuse low nonspecific heterogeneous hepatic parenchyma. 

3. No destructive bony lesion, intra-abdominal masses, peritoneal deposits, or pelvic masses. Symmetric prominence of both ovaries. 

Combination of findings, especially multiple lung nodules are concerning for neoplastic process of uncertain source with lung metastasis. Given heterogenous architecture of the liver the possibility of infiltrative liver neoplastic process cannot be excluded. Alternative possibilities include widespread lung granulomatous disease with a separate process in the liver like hepatitis. 

Correlation with tumor markers is recommended. Liver MRI with Eovist may be beneficial to determine if discrete liver lesions are present. 

Additional work up initiated including tumor lysis labs, AFP level for HCC tumor marker, and TB testing. MRI abdomen with Eovist also ordered to rule out HCC. 

MRI IMPRESSION: 

1. Again noted heterogeneity of liver parenchyma as described on prior studies. Current study is limited as the hepatobiliary phase is not achieved, secondary to patient’s elevated bilirubin (total bilirubin noted to be 6.8 mg/dL earlier today; hepatobiliary phase typically is difficult to reach when total bilirubin exceeds 3 mg/dL). Within this limitation, no focal lesion is appreciated. 

2. Numerous prominent porta hepatis lymph nodes are again seen, which are nonspecific but most commonly seen with infectious/inflammatory causes of hepatitis, though given presence of numerous pulmonary nodules, infiltrative neoplastic etiology can be considered. 

Remains admitted to the hospital with GI, ID, and dermatology consulted on her care. Normal AFP and absence of focal lesion on MRI encouraging against HCC. 

Quant gold also negative so TB unlikely. CMV did result positive which could explain the transaminitis, but as it would not explain the pulmonary nodules, etiology still unknown. Plan for tissue and lung biopsy. 

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