Infection as a Differential Diagnosis of Solid Retroperitoneal Masses: A Case Series and Review of the Literature

Abstract

The differential diagnosis of retroperitoneal masses includes a variety of benign and malignant conditions, among which infections constitute a significant subgroup. Familiarity with these infectious pseudotumours could facilitate prompt diagnosis. In this report, we describe three patients with an infectious pseudotumour, which was clinically and radiologically highly suggestive of a neoplasm. The first patient was a 62-year-old woman with a history of Richter syndrome, who seven months after allogeneic haematopoetic stem cell transplantation from an unrelated donor presented with a renal mass. A renal biopsy at that time revealed necrotic tissue. The patient displayed multiple relapses of Richter syndrome (for which she received also chimeric antigen receptor T-cell therapy salvage chemotherapy) and remissions of the lymphoma as well as an Aspergillus pneumonia for which she was treated with intravenous ambisome and afterwards oral posaconazole. Since the renal mass persisted and to exclude malignancy, nephrectomy was performed which revealed the presence of fungal hyphae. The second patient was a 51-year-old man with a history of a low-grade non-muscle-invasive bladder urothelial carcinoma, who after Mycobacterium bovis Calmette-Guerin instillation presentedwith fever and a suspicious renal mass. A partial nephrectomy was performed. Intraoperative frozen section analysis and routine histology suggested a Mycobacterium bovis-associated lesion, which was confirmed by polymerase chain reaction (PCR) analysis. The third patient was an 85-year-old man who presented with loss of appetite, fatigue, and significant weight loss (24 Kg in less than a year) as well as a travel history. The laboratory tests showed a low sodium and a high potassium level. CT scans revealed a solitary lesion in the right lung, a small liver lesion as well as bilateral adrenal lesions. A CT-guided biopsy revealed the presence of Histoplasma capsulatum, which was confirmed by PCR analysis. A retrospective review of all parameters indicates that all three patients presented with some risk factors, such as immunosuppression, travel, or clinical history that could raise the suspicion of infection in order to be included in the differential diagnosis, thus providing an additional tool for timely diagnosis.