case_images: PMC6604474_01
case_images: MRI of the brain showing hyperintense lesion in the right middle cerebellar peduncle lesion (a) and ring-shaped periatrial white matter lesion (b).
case_images: CRIRH2019-7121539.001.jpg
case_images: PMC6604474_01_CRIRH2019-7121539.001.jpg
case_images: fig1
case_images: Investigations done during the index hospitalization included brain MRI which showed T2-FLAIR hyperintense lesions in the juxtacortical, deep and periventricular white matter of the bilateral cerebral hemispheres, and infratentorial lesions in the right middle cerebellar peduncle, some with a ring-like appearance without enhancement (Figure 1).
case_images: Chest CT showing numerous small lung nodules.
case_images: CRIRH2019-7121539.002.jpg
case_images: PMC6604474_01_CRIRH2019-7121539.002.jpg
case_images: fig2
case_images: A 1.7 cm x 1.3 cm hypodense lesion was seen in the liver (Figure 2).
case_images: MRI abdomen showing 1.8 cm liver cyst (a) and 1.3 cm ovoid liver lesion (b).
case_images: CRIRH2019-7121539.003.jpg
case_images: PMC6604474_01_CRIRH2019-7121539.003.jpg
case_images: fig3
case_images: MRI abdomen noted a 2.3 cm liver lesion consistent with hemangioma, 1.8 cm cyst, and a 1.3 cm ovoid lesion (Figure 3).
case_images: PET-CT demonstrated 3 cm hypermetabolic liver mass seen on MRI.
case_images: CRIRH2019-7121539.004.jpg
case_images: PMC6604474_01_CRIRH2019-7121539.004.jpg
case_images: fig4
case_images: Due to concerns raised for abnormal liver lesions, a PET-CT done after hospital discharge demonstrated a 3 cm hypermetabolic liver mass concerning for neoplasm such as hepatocellular carcinoma, sarcoid nodule, or other granulomatous lesion and a resolution of the previously noted 1.7 cm subpleural nodule (Figure 4).
case_images: Surveillance CT abdomen/pelvis 3 months after the initial one showing numerous new tiny hepatic lesions.
case_images: CRIRH2019-7121539.005.jpg
case_images: PMC6604474_01_CRIRH2019-7121539.005.jpg
case_images: fig5
case_images: CT abdomen/pelvis 3 months after the initial one showed a resolving right hepatic hematoma but new numerous subcentimeter hypodense lesions throughout both hepatic lobes and numerous subcentimeter pulmonary nodules throughout both lungs (Figure 5). Concern for drug-related sarcoidosis or atypical mycobacterial infection was raised due to the multisystem involvement and drug exposure given reports in the literature.
case_images: (a) Lung biopsy demonstrating caseating granuloma, magnification 20x. (b). Lung biopsy demonstrating caseating granuloma, magnification 4x.
case_images: CRIRH2019-7121539.006.jpg
case_images: PMC6604474_01_CRIRH2019-7121539.006.jpg
case_images: fig6
case_images: He then underwent bronchoscopy followed by video-assisted thoracoscopic surgery (VATS) wedge resection, which revealed multiple caseating granulomas (Figures 6(a) and 6(b)).