CASE 7002 Published on 20.10.2008

Periportal edema due to intense hyperhydration in a septic patient

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Noguera JJ, Vivas I, Hernandez-Sastre C, Bastarrika G, Zudaire B, Cano D, Dominguez PD.
Radiology Department, University Clinic of Navarra, Pamplona, Spain.

Patient

20 years, female

Clinical History
Patient with unknown origin sepsis arrived at the emergency department. After initial treatment, a brain and contrast-enhanced thoracoabdominal CT detected right inferior lobe pneumonia and brain and periportal edema.
Imaging Findings
We report the case of a 20 year old woman, with previous diagnosis of ganglionar tuberculosis 5 years ago and a possible diagnosis of Behçet and intestinal inflammatory disease. She was receiving cyclosporine, prednisone, isoniazide, piridoxine and folate. She came to our emergency department after 48 hours of fever, right ear supuration, caugh, purulent sputum and recent onset of severe epigastric pain.
Few minutes after her arrival hemodynamic shock developed with pallor, hypotension (80/40 mmHg), tachycardia (115 bpm), hyperventilation (25 breaths p.m.), fever (39ºC), arterial oxygen saturation of 89% and leukocytosis (18000/mm3).
After intense hydration (5 liters) arterial pressure reached 120/80 mmHg.
A brain computed tomography (CT) and contrast-enhanced thoracoabdominal CT was performed. Most salient findings included collapsed brain ventricles and effacement of sulci (Fig. 1), right middle lobe condensation with billateral interstitial peripheral densities (Fig. 2) and hepatosplenomegaly with periportal low density halo and a small amount of pericholecystic fluid (Fig. 3).
Initial diagnosis was pulmonary sepsis and cerebral, pulmonary and periportal edema due to hyperhydration. In intensive care unit bronchoscopy and bronchial lavage were performed, and afterwards corticoid suply and 10 days broad spectrum antibiotic therapy was administered. There was no growth in bronchial lavage culture after 10 days.
With clinical and analytic data improvement, she was finally discharged 16 days after admittance in our emergency set.
Discussion
Periportal space is an anatomical region that surrounds the portal vein and contains biliary ducts, arteries, lymphatic vessels and nerves. Besides, it constitutes a virtual space. Pathology of this space is very varied and includes, among others, portal cavernomatosis, hepatic artery aneurisms, biliary diseases, neurofibromatosis, lymphoma, hystiocitosis and fatty infiltration. This virtual space may also be expanded due to neoplastic or inflammatory diseases, hemorrhage or edema [1].

There are also many and varying causes of periportal edema. Up to 21% of recipients of liver transplantation show a periportal collar. Although it has been classically reported as a sign of graft rejection, it is also seen in normal recipients. It is likely to be related to impaired lymph drainage after surgical interruption of the draining lymph vessels and lymphedema [2, 3]. Also, it may be found in recipients of bone marrow transplantation with venoocclusive disease and hepatic graft-versus-host disease after hematopoietic stem cell transplantation [3, 4]. Liver trauma, hepatitis and cholangitis are other causes of periportal edema. Finally, heart failure and hypervolemia may also induce periportal edema [1, 3].

Periportal edema is hypodense in CT and hyperintense in T2-weightened MR (magnetic resonance), while in ultrasonography (US) it appears as a hyperechoic halo that surrounds portal vein. Periportal halo may mimic biliary dilatation, but its location on both sides of portal vein in CT, MR and US allowes its differentiation from biliary dilatation [1, 3].

In this case, no previous clinical data that could be responsible of periportal edema were present, except for the masive hyperhydration of shock treatment. Moreover, brain and thoracic CT showed other signs compatible with hyperhidration, as diffuse cerebral edema and billateral pulmonary interstitial densities. Differential diagnosis of brain edema in this patient included encephalitis and hyperhydration, while billateral interstitial peripheral densities are described in liver and kidney failure, hypoproteinemia or hyperhydration. Anyway, only hyperhydration was suitable with clinical status of this patient.

In summary, periportal halo is an unspecific sign with many and varied causes. Knowledge of this radiologic finding and its wide differential diagnosis may aid in the diagnosis and management patients with this finding.
Differential Diagnosis List
Periportal edema due to intense hyperhydration. Pneumonia and sepsis.
Final Diagnosis
Periportal edema due to intense hyperhydration. Pneumonia and sepsis.
Case information
URL: https://www.eurorad.org/case/7002
DOI: 10.1594/EURORAD/CASE.7002
ISSN: 1563-4086