Br. J. Surg. Vol. 62 (1975) 236
Gumma of the liver R O G E R PARNTS* SUMMARY
A misdiagnosed case of girmmatoirs disease of the liver is described. Case report An ex-Army clerk, aged 64 years, who had served in North Africa for some time was admitted to St Luke’s Hospital, Malta, o n 28 March 1974 o n account of epigastric pain of 3 days‘ duration. There were n o other recent symptoms and the pain was not related to food intake, but over the previous 6 months there had been a steady loss of appetite and of weight. In 1959 the patient had had indigestion for a few weeks and 3 years later an antral ulcer had perforated. The perforation was closed and the patient was put on an ulcer regimen. Since then he had not complained of indigestion. He had lived apart from his wife, who had borne him 10 healthy children, for the past 8 years. The cause of the separation, according to him, was loose living on her part. He smoked 20 cigarettes a day but did not touch alcohol. When examined the patient was seen to be very thin but was otherwise in good shape. His temperature, pulse rate, respiratory rate a n d blood pressure were normal. He was not anaemic o r jaundiced and his fingers were not clubbed. The pupillary reflexes were normal and his tongue was clean. Abdominal examination showed a tender firm liver containing two nodules and extending three fingers’ breadth below the costal margin. No other abnormality was detected and CNS examination was negative. A provisional diagnosis of carcinoma of the stomach with liver metastases was made. Barium meal examination showed narrowing of the antropyloric region of the stomach. A significant amount of barium was retained after 24 hours. The appearances were suggestive of pyloric obstruction which was probably neoplastic in nature. At operation two swellings were present in the liver, one in each lobe, measuring about 3 cm in diameter. They were firm but not stony hard and were in the substance rather than o n the surface of the liver. The liver was not cirrhotic. The site of [he old perforation in the antrum was seen, with adherent omentum, hut a thorough examination of the stomach revealed
236
no other abnormality. Liver biopsy was carried out and the abdomen closed. The postoperative course was satisfactory apart from a wound infection which caused a small skin breakdown. Histological examination revealed gummatous fibrosis; there was a fibroblastic reaction with plasma cell and lymphoid cell infiltration and necrosis. Parenchymal tissue was replaced by the fibrosis. No tumour cells were present. Further questioning and examination of the patient yielded no history or evidence of a chancre or of other manifestations of syphilis. Serological tests were performed: I . V D reference laboratory test: strongly positive up to 1 : 16. 2 . Reiter protein complement fixation test: strongly positive up to I : 640. 3. Kahn test: positive up t o 0.0125. A 3-week course of crystalline penicillin, 1 million units 6-hourly, was given with very good results: the liver swelling markedly decreased, the appetite improved a nd the patient’s weight went up. N o Jarisch-Herxheimer reaction was noted. He was discharged 4 weeks after admission and was last seen in September 1974 when the liver was not palpable.
Gumma of the liver is today a very rare condition. The predominant symptoms of loss of weight and of appetite plus the presence of an epigastric tumour make a diagnosis of carcinoma of the stomach almost inevitable.
Acknowledgement I should like t o thank Professor G. P. Xuereb for the biopsy examination. Reference and N i c o L c. (1964) Venereal Di,smses. London, Cassell.
KING A,
*
Dar-il-Hena, San Gorg. Birzebbuga, Malta.
Gumma of the liver R O G E R PARNTS* SUMMARY
A misdiagnosed case of girmmatoirs disease of the liver is described. Case report An ex-Army clerk, aged 64 years, who had served in North Africa for some time was admitted to St Luke’s Hospital, Malta, o n 28 March 1974 o n account of epigastric pain of 3 days‘ duration. There were n o other recent symptoms and the pain was not related to food intake, but over the previous 6 months there had been a steady loss of appetite and of weight. In 1959 the patient had had indigestion for a few weeks and 3 years later an antral ulcer had perforated. The perforation was closed and the patient was put on an ulcer regimen. Since then he had not complained of indigestion. He had lived apart from his wife, who had borne him 10 healthy children, for the past 8 years. The cause of the separation, according to him, was loose living on her part. He smoked 20 cigarettes a day but did not touch alcohol. When examined the patient was seen to be very thin but was otherwise in good shape. His temperature, pulse rate, respiratory rate a n d blood pressure were normal. He was not anaemic o r jaundiced and his fingers were not clubbed. The pupillary reflexes were normal and his tongue was clean. Abdominal examination showed a tender firm liver containing two nodules and extending three fingers’ breadth below the costal margin. No other abnormality was detected and CNS examination was negative. A provisional diagnosis of carcinoma of the stomach with liver metastases was made. Barium meal examination showed narrowing of the antropyloric region of the stomach. A significant amount of barium was retained after 24 hours. The appearances were suggestive of pyloric obstruction which was probably neoplastic in nature. At operation two swellings were present in the liver, one in each lobe, measuring about 3 cm in diameter. They were firm but not stony hard and were in the substance rather than o n the surface of the liver. The liver was not cirrhotic. The site of [he old perforation in the antrum was seen, with adherent omentum, hut a thorough examination of the stomach revealed
236
no other abnormality. Liver biopsy was carried out and the abdomen closed. The postoperative course was satisfactory apart from a wound infection which caused a small skin breakdown. Histological examination revealed gummatous fibrosis; there was a fibroblastic reaction with plasma cell and lymphoid cell infiltration and necrosis. Parenchymal tissue was replaced by the fibrosis. No tumour cells were present. Further questioning and examination of the patient yielded no history or evidence of a chancre or of other manifestations of syphilis. Serological tests were performed: I . V D reference laboratory test: strongly positive up to 1 : 16. 2 . Reiter protein complement fixation test: strongly positive up to I : 640. 3. Kahn test: positive up t o 0.0125. A 3-week course of crystalline penicillin, 1 million units 6-hourly, was given with very good results: the liver swelling markedly decreased, the appetite improved a nd the patient’s weight went up. N o Jarisch-Herxheimer reaction was noted. He was discharged 4 weeks after admission and was last seen in September 1974 when the liver was not palpable.
Gumma of the liver is today a very rare condition. The predominant symptoms of loss of weight and of appetite plus the presence of an epigastric tumour make a diagnosis of carcinoma of the stomach almost inevitable.
Acknowledgement I should like t o thank Professor G. P. Xuereb for the biopsy examination. Reference and N i c o L c. (1964) Venereal Di,smses. London, Cassell.
KING A,
*
Dar-il-Hena, San Gorg. Birzebbuga, Malta.
