Drug-induced sarcoidosis-like reaction three months after BNT162b2 mRNA COVID-19 vaccination:A case report and review of literature

BACKGROUND A 70-year-old man with hepatitis C virus-related recurrent hepatocellular carcinoma was admitted for further diagnosis of a 1 cm iso-hyperechoic nodule in segment(S)5.CASE SUMMARY Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging(EOB-MRI)revealed the nodule in S5 with a defect at the hepatobiliary phase,hyperintensity on diffusion weighted imaging(DWI)and hypointensity on apparent diffusion coefficient(ADC)map.Contrast-enhanced computed tomography revealed hypervascularity at the early phase,and delayed contrast-enhancement was observed at the late phase.Contrast-enhanced ultrasound(US)revealed incomplete defect at the late vascular phase.Inflammatory liver tumor,lymphoproliferative disease,intrahepatic cholangiocarcinoma(small duct type)and bile duct adenoma were suspected through the imaging studies.US guided biopsy,however,showed a noncaseating hepatic sarcoid-like epithelioid granuloma(HSEG),and histopathological analysis disclosed spindle shaped epithelioid cells harboring Langhans-type multinucleated giant cells.One month after admission,EOB-MRI signaled the disappearance of the defect at the hepatobiliary phase,of hyperintensity on DWI,of hypointensity on ADC map,and no stain at the early phase.CONCLUSION That the patient had received BNT162b2 messenger RNA(mRNA)coronavirus disease 2019 vaccination 3 mo before the occurrence of HSEG,and that its disappearance was confirmed 4 mo after mRNA vaccination suggested that the drug-induced sarcoidosis-like reaction(DISR)might be induced by the mRNA vaccination.Fortunately,rechallenge of drug-induced DISR with the third mRNA vaccination was not confirmed.

Distant metastasis of hepatocellular carcinoma to Meckel’s cave and cranial nerves:A case report and review of literature

BACKGROUND Metastasis occurs as a late event in the natural history of hepatocellular carcinoma(HCC),and most patients die of liver failure attributed to the tumor supplanting the liver.Conversely,the brain is a less common metastatic site.CASE SUMMARY We describe a rare case of hepatitis C virus-related multiple HCC metastasizing to the cavernous sinus,Meckel’s cave,and the petrous bone involving multiple cranial nerves in an 82-year-old woman.At admission imaging studies including Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging(MRI)revealed multiple HCC nodules in both right and left lobes.Ultrasound guided biopsy of the left lobe revealed moderately differentiated HCC.Molecular targeted therapy with Lenvatinib(8 mg/d for 94 d,per os)and Ramucirumab(340 mg/d and 320 mg/d,two times by intravenous injection)were administered for 4 mo,resulting in progression of the disease.Three months after the start of molecular target therapy,the patient presented with symptoms of hyperalgesia of the right face and limited abduction of the right eye,indicating disturbances in the right trigeminal and abducens nerves.Brain MRI disclosed a mass involving the cavernous sinus,Meckel’s cave and the petrous bone.Contrast-enhanced MRI with gadolinium-chelated contrast medium revealed a well-defined mass with abnormal enhancement around the right cavernous sinus and the right Meckel’s cave.CONCLUSION The diagnosis of metastatic HCC to the cavernous sinus,Meckel’s cave,and the petrous bone was made based on neurological findings and imaging studies including MRI,but not on histological examinations.Further studies may provide insights into various methods for diagnosing HCC metastasizing to the craniospinal area.