case_images: PMC4337012_01
case_images: Axial (a), coronal (b) and sagittal (c) images of a computed tomography (CT) of the chest obtained upon the patient's second hospital admission demonstrates development of a hepatic dome fluid collection (thick arrow) associated with air foci and a right middle lobe consolidation (thin arrow). At the time of this CT, no biliptysis had been reported
case_images: WJNM-14-60-g001.jpg
case_images: PMC4337012_01_WJNM-14-60-g001.jpg
case_images: F1
case_images: Laboratory findings revealed leukocytosis of 20,700 WBC/muL and CT of the chest demonstrated a hepatic dome abscess and a right middle lobe consolidation [Figure 1].
case_images: Sagittal image of a computed tomography (CT) of the chest performed 4 days after the study in Figure 1 demonstrates development of a new right lower lobe consolidation (thin arrow). A partially visualized drain termin ates in the hepatic dome abscess. Biliptysis presented 2 days after this CT was performed
case_images: WJNM-14-60-g002.jpg
case_images: PMC4337012_01_WJNM-14-60-g002.jpg
case_images: F2
case_images: However, 4 days later, increasing leukocytosis up to 30,900 WBC/muL warranted a repeat CT of the chest, which demonstrated a new right lower lobe consolidation [Figure 2].
case_images: Planar cholescintigraphy with technetium-99m mebrofenin performed 1 day after the onset of biliptysis. Images were acquired over 60 min. Radiotracer collects in the site of the hepatic abscess (thick arrow) and then extends via the fistula into the right lung (thin arrow). There is also appearance of radiotracer in the left upper abdomen likely related to bile leak
case_images: WJNM-14-60-g003.jpg
case_images: PMC4337012_01_WJNM-14-60-g003.jpg
case_images: F3
case_images: The following day, cholescintigraphy with SPECT using Tc-99m mebrofenin [Figures 3 and 4] and bronchoscopy [Figure 5] each demonstrated the presence of a bronchobiliary fistula.
case_images: Coronal single-photon emission computed tomography images from the same cholescintigraphy study as in Figure 3, obtained following the 60-min planar images. There is an accumulation of the radiotracer in the hepatic dome abscess (thick arrow), in the fistulous tract (thin arrow) and in the right lower lobe consolidation (curved arrow). These images more accurately identify the location of the bronchobiliary fistula
case_images: WJNM-14-60-g004.jpg
case_images: PMC4337012_01_WJNM-14-60-g004.jpg
case_images: F4
case_images: The following day, cholescintigraphy with SPECT using Tc-99m mebrofenin [Figures 3 and 4] and bronchoscopy [Figure 5] each demonstrated the presence of a bronchobiliary fistula.
case_images: Photograph of yellow fluid (positive for bilirubin) aspirated from the right lower lobe during bronchoalveolar lavage on the same day as the technetium-99m mebrofenin cholescintigraphy study in Figures 3 and 4
case_images: WJNM-14-60-g005.jpg
case_images: PMC4337012_01_WJNM-14-60-g005.jpg
case_images: F5
case_images: The following day, cholescintigraphy with SPECT using Tc-99m mebrofenin [Figures 3 and 4] and bronchoscopy [Figure 5] each demonstrated the presence of a bronchobiliary fistula.