Fungal Liver Abscess and Hepatosplenic Candidiasis: CT, MRI, Diagnosis, Treatment, Prognosis, and AI-Powered Medical Imaging
Keywords: Fungal Liver Abscess, Hepatosplenic Candidiasis, Liver Abscess CT, Liver MRI, Hepatic Infection, Candida Infection, Hepatic Microabscess, CT Scan Diagnosis, MRI Diagnosis, Medical Imaging AI, Radiology AI, Liver Lesion Differential Diagnosis
Abstract
A patient presenting with right upper quadrant abdominal pain, fever, and chills may initially appear to have an uncomplicated hepatobiliary infection. However, when CT or MRI demonstrates multiple small hepatic lesions, particularly in an immunocompromised patient, the diagnostic problem becomes substantially more complex. Fungal liver abscess and hepatosplenic candidiasis (HSC) must be considered alongside bacterial liver abscess, metastatic disease, hepatocellular carcinoma, lymphoma, and other infectious lesions.
The attached case describes a 48-year-old man with right upper quadrant pain, fever, and chills, with imaging demonstrating multiple hepatic abnormalities. The source material emphasizes that fungal hepatic infection should be considered particularly in patients with immunosuppression, chemotherapy, prolonged neutropenia, intensive-care admission, transplantation, central venous catheterization, or prolonged broad-spectrum antibiotic exposure.
This article reviews the pathophysiology, epidemiology, clinical presentation, ultrasound, CT and MRI findings, differential diagnosis, microbiologic diagnosis, treatment, prognosis, and emerging artificial-intelligence approaches to fungal liver infection. Particular attention is given to the radiologic interpretation of multiple microabscesses, rim enhancement, bull's-eye appearance, T1 hypointensity, T2 hyperintensity, diffusion restriction, and hepatosplenic involvement.
The most important lesson is simple:
A ring-enhancing liver lesion is an imaging pattern—not a diagnosis.
In a high-risk patient, the combination of clinical context + laboratory data + microbiology + CT/MRI + pathology when necessary provides the most reliable diagnostic framework.
1. The Clinical Problem: When Multiple Liver Lesions Are Not Cancer
The liver is one of the most frequently evaluated abdominal organs on CT and MRI. Radiologists routinely encounter focal hepatic lesions, ranging from benign cysts and hemangiomas to hepatocellular carcinoma and metastatic disease.
The diagnostic challenge becomes much greater when the patient has:
Fever
Chills
Right upper quadrant pain
Persistent inflammatory markers
Immunosuppression
Recent chemotherapy
Neutropenia
Long-term hospitalization
Central venous catheterization
Prolonged broad-spectrum antibiotic exposure
The attached case specifically emphasizes this clinical context and identifies immunocompromised and critically ill patients as major risk groups.
In these patients, multiple small hypoechoic or hypoattenuating liver lesions should not automatically be interpreted as metastases.
Instead, the radiologist should ask:
Could these lesions represent fungal microabscesses?
This question becomes particularly important when fever persists despite antibacterial therapy.
Hepatosplenic candidiasis is a classic example. It is uncommon, but it has a characteristic clinical setting: prolonged neutropenia, often associated with hematologic malignancy and intensive chemotherapy, followed by persistent fever around the time of neutrophil recovery. (PubMed Central (PMC))
2. Pathophysiology: How Does Candida Reach the Liver?
2.1 From colonization to invasive infection
Candida species can colonize mucosal surfaces without producing invasive disease. The clinical problem changes when host defenses become compromised.
Several mechanisms can facilitate invasive Candida infection:
Breakdown of gastrointestinal mucosal barriers
Neutropenia
Intensive chemotherapy
Disruption of normal microbiota by antibiotics
Central venous catheterization
Critical illness
Immunosuppressive therapy
Candida can then enter the bloodstream or portal circulation and disseminate to highly vascular organs.
The liver is particularly vulnerable because it receives a substantial proportion of portal venous blood originating from the gastrointestinal tract.
The attached case describes this mechanism and emphasizes hematogenous dissemination, hepatic involvement, and possible simultaneous involvement of the spleen, kidney, and other organs.
2.2 Microabscess formation
Once Candida reaches hepatic tissue, inflammatory and immune responses can produce multiple microscopic foci of infection.
These lesions may initially be extremely small.
This creates an important imaging phenomenon:
The disease can be present before it becomes conspicuous on imaging.
The source case notes that hepatic lesions may become more apparent after neutrophil recovery because the inflammatory response becomes stronger.
This explains one of the most important clinical-radiologic patterns in hepatosplenic candidiasis:
Persistent fever after neutrophil recovery should trigger renewed consideration of hepatosplenic candidiasis.
This phenomenon has also been described in the radiology and infectious-disease literature. (PubMed Central (PMC))
3. Epidemiology and High-Risk Patients
Fungal liver abscess is considerably less common than pyogenic liver abscess. Hepatosplenic candidiasis is particularly associated with immunocompromised patients, especially those with hematologic malignancies receiving intensive chemotherapy.
The 2015 review by Cornely and colleagues describes HSC as a rare but important manifestation of chronic disseminated candidiasis, particularly in patients with prolonged neutropenia. (PubMed Central (PMC))
Important risk groups include:
| Risk factor | Why it matters |
|---|---|
| Acute leukemia | Intensive chemotherapy and prolonged neutropenia |
| Hematologic malignancy | High risk of invasive Candida infection |
| Neutropenia | Impaired antifungal host defense |
| Solid-organ transplantation | Immunosuppression |
| Chemotherapy | Mucosal injury and immune suppression |
| ICU admission | Multiple invasive infection risk factors |
| Central venous catheter | Potential source of candidemia |
| Broad-spectrum antibiotics | Altered microbiome and Candida overgrowth |
| Corticosteroids | Suppressed immune response |
| Severe critical illness | Increased invasive candidiasis risk |
The 2025 global candidiasis guideline developed by the European Confederation of Medical Mycology (ECMM) in collaboration with ISHAM and ASM emphasizes that invasive candidiasis disproportionately affects critically ill and immunocompromised patients and also highlights the growing problem of antifungal resistance. (ScienceDirect)
4. Clinical Presentation
The clinical presentation of fungal liver abscess is often nonspecific.
Common findings include:
Persistent fever
Chills
Right upper quadrant abdominal pain
Malaise
Anorexia
Nausea
Vomiting
Hepatomegaly
Splenomegaly
Abnormal liver enzymes
The attached case particularly emphasizes fever, chills, right upper quadrant pain, hepatomegaly, splenomegaly, and liver enzyme abnormalities.
A particularly important laboratory clue may be an increase in alkaline phosphatase, although laboratory abnormalities are not diagnostic by themselves. (PubMed Central (PMC))
The clinical red flag
A patient who has undergone chemotherapy develops prolonged neutropenia, receives antibacterial therapy, and continues to have fever after neutrophil recovery.
That scenario should immediately raise the possibility of:
Chronic disseminated candidiasis / hepatosplenic candidiasis.
The New England Journal of Medicine has described this classic pattern, including persistent fever after recovery from chemotherapy-associated neutropenia and multiple hypodense lesions in the liver and spleen. (NEJM)
5. Imaging Diagnosis of Fungal Liver Abscess
Imaging plays a central role, but no individual imaging finding is sufficiently specific to establish Candida infection.
The main modalities are:
Ultrasound
Contrast-enhanced CT
MRI
Occasionally FDG-PET/CT for selected clinical questions
The attached case contains representative ultrasound, CT, and MRI images.
Figure 1. Abdominal Ultrasound
Figure 1. Abdominal ultrasonography demonstrating a focal hepatic abnormality.
Radiologic interpretation
The ultrasound image demonstrates a heterogeneous focal abnormality within the hepatic parenchyma. In the appropriate clinical setting, multiple small hypoechoic lesions can represent hepatic microabscesses.
The attached case emphasizes:
Hypoechoic hepatic lesions
Multiple lesion distribution
Possible target or halo appearance
Potential microcalcification
Lesion size and distribution
Ultrasound is attractive because it is:
Rapid
Widely available
Radiation-free
Useful for follow-up
However, very small microabscesses can be difficult to detect, especially when located deep within the liver.
Therefore, a negative or equivocal ultrasound should not eliminate the diagnosis when clinical suspicion remains high.
6. CT Imaging: The Most Practical Initial Examination
Contrast-enhanced CT is often the most practical initial imaging study in a seriously ill patient.
In hepatosplenic candidiasis, the radiologist should not simply ask whether there is "a liver abscess."
Instead, evaluate:
Number of lesions
Lesion size
Distribution
Central attenuation
Rim enhancement
Enhancement phase
Calcification
Associated splenic lesions
Renal lesions
Extrahepatic infection
Figure 2. Contrast-Enhanced CT
Figure 2. Axial contrast-enhanced abdominal CT demonstrating multiple small hepatic lesions.
Radiologic interpretation
Multiple low-attenuation lesions are distributed throughout the hepatic parenchyma. Several lesions demonstrate relatively low central attenuation with surrounding enhancement, producing a microabscess/rim-enhancement pattern.
The attached case identifies these lesions as an important imaging pattern for fungal hepatic infection but correctly emphasizes that imaging alone cannot establish Candida infection.
6.1 The bull's-eye appearance
One of the classic CT patterns of hepatosplenic candidiasis is the bull's-eye appearance.
During the arterial-dominant phase, a small hypoattenuating center may be surrounded by a relatively hyperattenuating rim.
During the portal venous phase, microabscesses may appear as small hypoattenuating lesions.
The literature emphasizes the importance of multiphasic evaluation. The arterial-dominant phase may be particularly sensitive during the acute phase, while portal venous imaging can demonstrate small hypoattenuating microabscesses. (Wiley Online Library)
Thus:
Do not interpret a liver CT without considering which contrast phase was acquired.
The attached case specifically highlights arterial and portal venous phase differences.
7. MRI: Why It Can Outperform CT
MRI provides more detailed tissue characterization and can be particularly valuable when CT findings are equivocal.
Figure 3. Liver MRI
Figure 3. Multiparametric liver MRI demonstrating multiple hepatic lesions across different sequences.
Radiologic interpretation
The MRI series demonstrates multiple hepatic lesions with:
T1-weighted hypointensity
T2-weighted hyperintensity
Peripheral enhancement
Abnormal diffusion characteristics
The attached case emphasizes the importance of interpreting T1WI, T2WI, DWI, ADC, and contrast-enhanced sequences together rather than relying on a single image.
An important historical comparative study found that MRI detected substantially more compatible hepatosplenic candidiasis lesions than CT in a small cohort, and MRI was particularly useful for distinguishing candidal lesions from recurrent lymphoma and hepatic infarction. (Wiley Online Library)
8. DWI and ADC: The Critical MRI Combination
Diffusion-weighted imaging is especially useful for evaluating abscess-like lesions.
A typical suspicious combination is:
DWI high signal + ADC low signal
This indicates restricted diffusion.
The biological explanation is intuitive: inflammatory cellular debris, proteinaceous material, pus, and high viscosity can reduce water mobility.
However, an important caution is required.
Restricted diffusion does not equal abscess.
Necrotic tumors can also demonstrate restricted diffusion.
Therefore:
DWI must never be interpreted in isolation.
The attached case makes this distinction explicitly and recommends correlation with ADC maps and contrast enhancement.
9. MRI Versus CT
The imaging strategy can be summarized as follows:
| Feature | Ultrasound | CT | MRI |
|---|---|---|---|
| Availability | Excellent | Excellent | Moderate |
| Speed | Excellent | Excellent | Lower |
| Radiation | None | Yes | None |
| Small lesion detection | Limited | Good | Excellent |
| Enhancement assessment | Limited | Excellent | Excellent |
| DWI | No | No | Excellent |
| Whole-abdominal evaluation | Moderate | Excellent | Excellent |
| Treatment follow-up | Useful | Useful | Excellent |
MRI may detect more lesions, particularly when CT is equivocal. However, critically ill patients may require rapid CT because of availability, speed, and the ability to assess the abdomen and thorax comprehensively.
The most appropriate strategy is therefore clinical-context dependent, rather than a rigid "CT versus MRI" rule.
10. Differential Diagnosis of Multiple Liver Lesions
One of the most important principles in radiology is:
Multiple hepatic lesions do not automatically mean metastases—and they do not automatically mean fungal abscesses.
The major differential diagnoses include:
10.1 Pyogenic liver abscess
Bacterial liver abscess is much more common than fungal liver abscess.
Features may include:
Fever
Right upper quadrant pain
Leukocytosis
Hypoattenuating lesions
Rim enhancement
Internal septations
Gas in some cases
Multiple lesions are possible.
Therefore:
Multiplicity alone cannot distinguish fungal from bacterial infection.
10.2 Metastatic disease
Necrotic metastases can closely resemble abscesses.
Both can demonstrate:
Central low attenuation
Peripheral enhancement
Multiple lesions
Restricted diffusion
The clinical context becomes decisive.
Evidence of a known primary malignancy, progressive tumor burden, or other metastatic disease increases the probability of metastases.
Conversely, acute fever, chills, inflammatory abnormalities, immunosuppression, and neutrophil recovery increase concern for infection.
The attached case stresses this diagnostic overlap.
10.3 Hepatocellular carcinoma
HCC typically demonstrates:
Arterial phase hyperenhancement + portal/delayed washout
However, necrotic or atypical HCC can mimic an abscess.
Underlying cirrhosis or chronic liver disease should therefore increase suspicion for HCC.
10.4 Lymphoma
Lymphoma may produce multiple hepatic and splenic lesions, particularly in patients with hematologic malignancies.
This is especially challenging because the same patient population is also at high risk for hepatosplenic candidiasis.
The attached source specifically identifies lymphoma, leukemia infiltration, and metastasis as important competing diagnoses.
11. A Practical Radiology Differential Table
| Disease | Lesions | Rim Enhancement | Fever | Major Clue |
|---|---|---|---|---|
| Fungal liver abscess | Multiple small | Common | Strong | Immunosuppression, neutropenia |
| Pyogenic abscess | Single/multiple | Common | Strong | Biliary/portal source, gas possible |
| Metastases | Often multiple | Common | Variable | Known malignancy |
| HCC | Single/multiple | Variable | Usually absent | Arterial enhancement/washout |
| Lymphoma | Multiple | Variable | Possible | Hematologic malignancy |
| Granulomatous infection | Multiple | Variable | Possible | Systemic infection |
The original case provides a similar comparison and emphasizes the importance of integrating imaging and clinical context.
12. Diagnosis: Imaging Is Essential—but Not Sufficient
A crucial principle must be emphasized:
CT and MRI cannot identify Candida albicans with certainty.
Imaging can establish a high probability of fungal microabscesses, but microbiologic and/or histopathologic confirmation may be required.
Diagnostic evaluation may include:
Blood cultures
Fungal cultures
Species identification
Antifungal susceptibility testing
Relevant fungal biomarkers
Image-guided aspiration when appropriate
Liver biopsy in selected cases
Interestingly, blood cultures can be negative in hepatosplenic candidiasis. The 2015 review notes that microbiological confirmation is often difficult and that imaging can become particularly important in establishing probable disease. (PubMed Central (PMC))
The attached case similarly emphasizes the role of microbiology and pathology when imaging alone cannot resolve the differential.
13. Treatment: Antifungal Therapy Plus Source Control
Treatment is not simply "give an antifungal drug."
Three principles should be considered:
1. Appropriate antifungal therapy
2. Identification and control of the infection source
3. Serial clinical and imaging assessment
The 2025 ECMM/ISHAM/ASM global guideline represents the most contemporary international framework for candidiasis management. (ECMM)
For candidemia and many forms of invasive candidiasis, echinocandins remain a major first-line therapeutic class.
Examples include:
Caspofungin
Micafungin
Anidulafungin
Rezafungin
The attached case identifies echinocandins as important first-line therapy and stresses the importance of species identification and susceptibility testing.
Fluconazole remains clinically important for selected patients and susceptible Candida species, but treatment should be individualized according to species, susceptibility, severity, previous antifungal exposure, drug interactions, and organ function.
14. Source Control: Look Beyond the Liver
If candidemia is present and a central venous catheter is suspected to be the source, catheter management becomes an important component of treatment.
The 2016 IDSA guideline specifically addressed early removal of central venous catheters when they are suspected to be the source and can be safely removed.
This reinforces an important radiology principle:
When you see hepatic infection, search for the source—not just the lesion.
Evaluate:
Central venous catheter
Biliary tract
Gastrointestinal tract
Bloodstream infection
Splenic involvement
Renal involvement
Other metastatic infection
15. When Is Drainage Necessary?
Not every fungal microabscess requires percutaneous drainage.
Small, multiple microabscesses are often managed primarily with systemic antifungal therapy.
Image-guided drainage or biopsy becomes more relevant when there is:
A large solitary abscess
Diagnostic uncertainty
Failure of medical treatment
Suspected bacterial superinfection
Suspicion of malignancy
A lesion amenable to aspiration
Need for microbiologic or histologic confirmation
The attached case specifically recommends selective drainage or tissue sampling rather than assuming that every lesion requires intervention.
16. Prognosis
The prognosis of fungal liver infection depends less on lesion size than on the overall host and infectious disease burden.
Important prognostic factors include:
Degree of immunosuppression
Duration of neutropenia
Neutrophil recovery
Candidemia
Multiorgan involvement
Delay in antifungal therapy
Source control
Antifungal susceptibility
Underlying malignancy
Organ dysfunction
The attached case highlights these factors and emphasizes that invasive candidiasis can carry substantial mortality in critically ill patients.
Potential complications include:
Persistent candidemia
Sepsis
Splenic infection
Renal involvement
Endophthalmitis
Central nervous system infection
Multiorgan dissemination
Prolonged antifungal treatment
Delay of cancer therapy
17. What Is New in AI for Liver Abscess Diagnosis?
This is where medical imaging is entering an important new phase.
However, an important distinction must be made:
There is currently far more evidence for AI-assisted bacterial liver abscess diagnosis than for AI diagnosis of fungal liver abscess or hepatosplenic candidiasis specifically.
Recent research demonstrates that deep learning can detect liver abscesses on contrast-enhanced CT and potentially predict causative bacterial pathogens.
A 2025 multicenter study developed a deep-learning approach for automated detection of pyogenic liver abscess and prediction of Klebsiella pneumoniae infection from contrast-enhanced CT. (ScienceDirect)
Another recent multicenter study published online in 2026 investigated CT-based deep-learning models for automatic segmentation and prediction of ESBL-producing Enterobacteriaceae liver abscesses. (ScienceDirect)
These developments suggest a future in which AI does more than identify "abnormal liver lesions."
18. Radiomics: Beyond What the Human Eye Can See
Radiomics converts medical images into quantitative features.
These can include:
Texture
Intensity
Shape
Entropy
Heterogeneity
Enhancement characteristics
Spatial distribution
A CT radiomics model has demonstrated the potential to differentiate necrotic HCC from pyogenic liver abscess, with high reported validation AUCs in that particular study. (ScienceDirect)
Other research has combined clinical variables and CT radiomics to predict Klebsiella pneumoniae liver abscess, demonstrating the potential of multimodal prediction models. (PubMed Central (PMC))
This is clinically relevant to fungal liver infection because the major diagnostic challenge is often not:
"Is there a lesion?"
but rather:
"What biological process produced this lesion?"
19. AI and Hepatosplenic Candidiasis: The Current Reality
The evidence base is more limited for fungal hepatic infection.
A recent systematic review and meta-analysis evaluated AI models for early diagnosis of invasive candidiasis. Across eligible candidemia prediction studies, pooled sensitivity was approximately 81% and specificity approximately 82%, but the authors also identified moderate-to-high risk of bias and low certainty of evidence. (PubMed Central (PMC))
20. The Future: Multimodal Clinical AI for Fungal Liver Infection
Importantly, this is a future-oriented clinical AI architecture, not an established autonomous diagnostic system for hepatosplenic candidiasis.
21. AI-Assisted Treatment Monitoring
AI may become particularly valuable after treatment begins.
Instead of asking only:
"Is the abscess smaller?"
a longitudinal AI system could quantify:
Total lesion volume
Number of lesions
Enhancement changes
Diffusion changes
Calcification
New splenic lesions
New renal lesions
Resolution rate
Temporal trajectory
This could transform treatment response from a subjective visual assessment into a quantitative longitudinal biomarker.
MRI has already been used historically to monitor hepatosplenic candidiasis during therapy. (PubMed)
The future opportunity is to automate this process.
22. Figure 4 — Integrated Clinical and Imaging Pathway
Figure 4. Integrated schematic of fungal liver infection, hepatosplenic involvement, imaging, microbiology, and treatment/source control.
This schematic summarizes the central concept of the case:
Immunosuppression → Candida dissemination → hepatic microabscesses → possible splenic/renal involvement → CT/MRI detection → microbiologic/pathologic confirmation → antifungal treatment and source control.
It also highlights the importance of evaluating the liver as part of a systemic infectious process rather than treating hepatic lesions as isolated abnormalities.
23. The Seven-Point CT/MRI Checklist
When confronted with multiple small liver lesions in a febrile high-risk patient, I recommend a systematic checklist.
Liver
☑ Are the lesions multiple?
☑ What is the lesion size?
☑ Is the center hypoattenuating?
☑ Is there rim enhancement?
☑ Is there a bull's-eye appearance?
☑ Are there calcifications?
☑ How do arterial and portal venous phases differ?
Spleen
☑ Are there multiple hypodense lesions?
☑ Is splenomegaly present?
Kidneys
☑ Are there renal microabscesses?
Extrahepatic structures
☑ Lymphadenopathy?
☑ Pulmonary infection?
☑ Vascular infection?
☑ Central venous catheter?
☑ Other metastatic infectious lesions?
The source case provides this comprehensive approach essentially.
24. The Most Important Radiology Pearls
Pearl 1: Multiple liver lesions + fever = infection must be considered.
Pearl 2: Immunosuppression + persistent fever after neutrophil recovery + liver/spleen lesions = hepatosplenic candidiasis should enter the differential.
Pearl 3: Ring enhancement is a pattern, not a diagnosis.
Pearl 4: Arterial and portal venous CT phases may provide complementary information.
Pearl 5: MRI should be interpreted using T1, T2, DWI, ADC, and contrast enhancement together.
Pearl 6: Always inspect the spleen and kidneys.
Pearl 7: Radiology must be connected to microbiology and pathology.
These seven principles closely reflect the diagnostic framework provided in the source case.
Quiz
Question 1
A patient recently completed intensive chemotherapy and experienced prolonged neutropenia. After neutrophil recovery, the patient continues to have fever. CT demonstrates multiple small hypodense lesions in the liver and spleen.
What is the most likely diagnosis?
A. Hepatocellular carcinoma
B. Metastatic liver disease
C. Hepatosplenic candidiasis
D. Simple hepatic cysts
E. Acute cholecystitis
Correct Answer: C. Hepatosplenic candidiasis
Explanation
Persistent fever after neutrophil recovery in a patient with prolonged chemotherapy-associated neutropenia is a classic clinical setting for hepatosplenic candidiasis. Multiple small hepatic and splenic lesions further support this possibility.
Question 2
Which MRI combination is most compatible with an abscess-like hepatic lesion?
A. T1 hyperintensity and T2 hypointensity only
B. T1 hypointensity, T2 hyperintensity, and peripheral enhancement
C. Homogeneous arterial enhancement in every lesion
D. Normal DWI and ADC in all cases
E. MRI cannot distinguish infection from malignancy
Correct Answer: B. T1 hypointensity, T2 hyperintensity, and peripheral enhancement
Explanation
Abscess-like lesions frequently demonstrate T1 hypointensity, T2 hyperintensity, peripheral/rim enhancement, and potentially restricted diffusion. However, these findings are not specific for Candida infection. Clinical context and microbiologic evidence remain essential.
Question 3
Which imaging strategy is most appropriate when hepatosplenic candidiasis is suspected?
A. Noncontrast CT alone
B. Portal venous phase only
C. Evaluate the liver but ignore the spleen and kidneys
D. Consider multiphasic contrast-enhanced CT and evaluate the liver, spleen, kidneys, and extrahepatic structures
E. Use imaging alone to identify Candida albicans
Correct Answer: D. Consider multiphasic contrast-enhanced CT and evaluate the liver, spleen, kidneys, and extrahepatic structures
Explanation
Hepatosplenic candidiasis may produce lesions in several organs. Arterial-dominant and portal venous CT phases may provide complementary information, while MRI can further characterize small lesions. Imaging can strongly suggest the diagnosis but cannot identify the Candida species by itself.
Case Conclusion
The most important lesson from this 48-year-old patient's presentation is not simply that fungal liver abscesses can occur.
The deeper lesson is that radiologic diagnosis depends on clinical context.
A small hypodense liver lesion may represent:
Abscess
Metastasis
HCC
Lymphoma
Granulomatous disease
Other infectious processes
The interpretation changes dramatically when the patient has:
fever + chills + right upper quadrant pain + immunosuppression + multiple hepatic lesions.
The combination should prompt consideration of fungal liver abscess and hepatosplenic candidiasis.
The source case summarizes the diagnostic principle particularly well: clinical context, laboratory findings, microbiology, CT, MRI, and pathology may all need to be integrated.
Modern AI adds another layer.
The next generation of Medical Imaging AI will likely move from:
"Find the lesion."
to:
"Understand the lesion in the context of the patient."
That transition—from image recognition to clinical intelligence—may be particularly valuable for rare infectious diseases where the imaging appearance overlaps with malignancy.
For fungal liver infection, however, the responsible position today is equally clear:
AI can assist detection, segmentation, risk prediction, differential diagnosis, and longitudinal monitoring—but microbiology and clinical judgment remain fundamental.
Recommended Reading
O. A. Cornely, R. Sprute, M. Bassetti, et al., “Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM,” The Lancet Infectious Diseases, vol. 25, no. 5, pp. e280–e293, 2025.
DOI: 10.1016/S1473-3099(24)00749-7P. G. Pappas, C. A. Kauffman, D. R. Andes, et al., “Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America,” Clinical Infectious Diseases, vol. 62, no. 4, pp. e1–e50, 2016.
DOI: 10.1093/cid/civ933O. A. Cornely, C. Bangard, and N. I. Jaspers, “Hepatosplenic candidiasis,” Clinical Liver Disease, vol. 6, no. 2, pp. 47–50, 2015.
DOI: 10.1002/cld.491R. C. Semelka, J. P. Shoenut, H. M. Greenberg, and E. J. Bow, “Detection of acute and treated lesions of hepatosplenic candidiasis: Comparison of dynamic contrast-enhanced CT and MR imaging,” Journal of Magnetic Resonance Imaging, vol. 2, no. 3, pp. 341–345, 1992.
DOI: 10.1002/jmri.1880020315S. Sallah, R. Semelka, N. Kelekis, S. Worawattanakul, and W. Sallah, “Diagnosis and monitoring response to treatment of hepatosplenic candidiasis in patients with acute leukemia using magnetic resonance imaging,” Acta Haematologica, vol. 100, no. 2, pp. 77–81, 1998.
DOI: 10.1159/000040869J. Rudolph et al., “Unusual enhancement pattern of liver lesions in hepatosplenic candidiasis,” Acta Radiologica, vol. 45, no. 5, pp. 499–503, 2004.
DOI: 10.1080/02841850410006191A. Shirkhoda, “CT findings in hepatosplenic and renal candidiasis,” Journal of Computer Assisted Tomography, vol. 11, no. 5, pp. 795–798, 1987.
DOI: 10.1097/00004728-198709000-00010P. H. Lawrence, S. C. Holt, C. S. Levi, and J. C. Gough, “Ultrasound case of the day. Hepatosplenic candidiasis,” RadioGraphics, vol. 14, no. 5, pp. 1147–1149, 1994.
DOI: 10.1148/radiographics.14.5.7991822M. J. Hu, Y. X. Yu, Y. F. Fan, and C. H. Hu, “CT-based radiomics model to distinguish necrotic hepatocellular carcinoma from pyogenic liver abscess,” Clinical Radiology, vol. 76, no. 2, pp. 161.e11–161.e17, 2021.
DOI: 10.1016/j.crad.2020.11.002J. Zhou, X. Peng, Y. Yang, et al., “Automated detection of pyogenic liver abscess and diagnosis of Klebsiella pneumoniae infection based on CECT images with deep learning: A multicenter study,” European Journal of Radiology, vol. 193, 112462, 2025.
DOI: 10.1016/j.ejrad.2025.112462
The 2025 global guideline is particularly useful for current candidiasis management, while the classic imaging literature remains valuable for understanding the characteristic CT/MRI evolution of hepatosplenic candidiasis. (ScienceDirect)
Recommended Internal Links for This Blog: Related Medical Imaging Cases
1. Klebsiella pneumoniae Liver Abscess
Suggested anchor text: Klebsiella pneumoniae Liver Abscess: CT Imaging Findings and Diagnosis
Read: Klebsiella pneumoniae Liver Abscess – CT Imaging and Diagnosis
Recommended placement: In the Differential Diagnosis section immediately after discussing pyogenic liver abscess.
2. Comprehensive Klebsiella pneumoniae Liver Abscess Review
Suggested anchor text: Comprehensive Liver Abscess Imaging and Treatment Review
Read: Comprehensive Klebsiella pneumoniae Liver Abscess Review
Recommended placement: In the Treatment or Differential Diagnosis section.
3. Pott Disease With Bilateral Psoas Abscesses
Suggested anchor text: CT and MRI Diagnosis of Deep Infectious Abscesses
Read: Pott Disease With Bilateral Psoas Abscesses – CT & MRI Diagnosis
Recommended placement: In the broader Medical Imaging section discussing infection and abscess imaging.
4. Acute Gangrenous and Emphysematous Cholecystitis
Suggested anchor text: CT Diagnosis of Severe Hepatobiliary Infection
Read: Acute Gangrenous and Emphysematous Cholecystitis – CT Imaging
Final Clinical Take-Home Message
Fever + right upper quadrant pain + multiple hepatic lesions should never be interpreted from imaging alone.
In an immunocompromised patient, especially after prolonged neutropenia, the combination should raise concern for fungal liver abscess and hepatosplenic candidiasis.
CT identifies the distribution and enhancement pattern. MRI adds tissue characterization and diffusion information. Microbiology and pathology establish the etiologic diagnosis. AI is emerging as a powerful tool for lesion detection, segmentation, radiomics, risk prediction, and longitudinal monitoring—but it is not yet a substitute for clinical and microbiological diagnosis.
That is the central lesson of this case: the radiologist should not merely identify what is visible in the liver; the radiologist should explain why those lesions are occurring in that particular patient at that particular time.
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